In some cases, provocative new research shows, some people — men in particular — succumb because their immune systems are hit by friendly fire.

This article was published on Friday, November 13, 2020 in Kaiser Health News.

By Liz Szabo

Dr. Megan Ranney has learned a lot about COVID-19 since she began treating patients with the disease in the emergency department in February.

But there's one question she still can't answer: What makes some patients so much sicker than others?

Advancing age and underlying medical problems explain only part of the phenomenon, said Ranney, who has seen patients of similar age, background and health status follow wildly different trajectories.

"Why does one 40-year-old get really sick and another one not even need to be admitted?" asked Ranney, an associate professor of emergency medicine at Brown University.

In some cases, provocative new research shows, some people — men in particular — succumb because their immune systems are hit by friendly fire. Researchers hope the finding will help them develop targeted therapies for these patients.

In an international study in Science, 10% of nearly 1,000 COVID patients who developed life-threatening pneumonia had antibodies that disable key immune system proteins called interferons. These antibodies — known as autoantibodies because they attack the body itself — were not found at all in 663 people with mild or asymptomatic COVID infections. Only four of 1,227 healthy individuals had the autoantibodies. The study, published on Oct. 23, was led by the COVID Human Genetic Effort, which includes 200 research centers in 40 countries.

"This is one of the most important things we've learned about the immune system since the start of the pandemic," said Dr. Eric Topol, executive vice president for research at Scripps Research in San Diego, who was not involved in the new study. "This is a breakthrough finding."

In a second Science study by the same team, authors found that an additional 3.5% of critically ill patients had mutations in genes that control the interferons involved in fighting viruses. Given that the body has 500 to 600 of these genes, it's possible researchers will find more mutations, said Qian Zhang, lead author of the second study.

Interferons serve as the body's first line of defense against infection, sounding the alarm and activating an army of virus-fighting genes, said virologist Angela Rasmussen, an associate research scientist at the Center of Infection and Immunity at Columbia University's Mailman School of Public Health.

"Interferons are like a fire alarm and a sprinkler system all in one," said Rasmussen, who wasn't involved in the new studies.

Lab studies show interferons are suppressed in some people with COVID-19, perhaps by the virus itself.

Interferons are particularly important for protecting the body against new viruses, such as the coronavirus, which the body has never encountered, said Zhang, a researcher at Rockefeller University's St. Giles Laboratory of Human Genetics of Infectious Diseases.

When infected with the novel coronavirus, "your body should have alarms ringing everywhere," said Zhang. "If you don't get the alarm out, you could have viruses everywhere in large numbers."

Significantly, patients didn't make autoantibodies in response to the virus. Instead, they appeared to have had them before the pandemic even began, said Paul Bastard, the antibody study's lead author, also a researcher at Rockefeller University.

For reasons that researchers don't understand, the autoantibodies never caused a problem until patients were infected with COVID-19, Bastard said. Somehow, the novel coronavirus, or the immune response it triggered, appears to have set them in motion.

"Before COVID, their condition was silent," Bastard said. "Most of them hadn't gotten sick before."

Bastard said he now wonders whether autoantibodies against interferon also increase the risk from other viruses, such as influenza. Among patients in his study, "some of them had gotten flu in the past, and we're looking to see if the autoantibodies could have had an effect on flu."

Scientists have long known that viruses and the immune system compete in a sort of arms race, with viruses evolving ways to evade the immune system and even suppress its response, said Sabra Klein, a professor of molecular microbiology and immunology at the Johns Hopkins Bloomberg School of Public Health.

Antibodies are usually the heroes of the immune system, defending the body against viruses and other threats. But sometimes, in a phenomenon known as autoimmune disease, the immune system appears confused and creates autoantibodies. This occurs in diseases such as rheumatoid arthritis, when antibodies attack the joints, and Type 1 diabetes, in which the immune system attacks insulin-producing cells in the pancreas.

Although doctors don't know the exact causes of autoimmune disease, they've observed that the conditions often occur after a viral infection. Autoimmune diseases are more common as people age.

In yet another unexpected finding, 94% of patients in the study with these autoantibodies were men. About 12.5% of men with life-threatening COVID pneumonia had autoantibodies against interferon, compared with 2.6% of women.

That was unexpected, given that autoimmune disease is far more common in women, Klein said.

"I've been studying sex differences in viral infections for 22 years, and I don't think anybody who studies autoantibodies thought this would be a risk factor for COVID-19," Klein said.

The study might help explain why men are more likely than women to become critically ill with COVID-19 and die, Klein said.

"You see significantly more men dying in their 30s, not just in their 80s," she said.

Akiko Iwasaki, a professor of immunobiology at the Yale School of Medicine, noted that several genes involved in the immune system's response to viruses are on the X chromosome.

Women have two copies of this chromosome — along with two copies of each gene. That gives women a backup in case one copy of a gene becomes defective, Iwasaki said.

Men, however, have only one copy of the X chromosome. So if there is a defect or harmful gene on the X chromosome, they have no other copy of that gene to correct the problem, Iwasaki said.

Bastard noted that one woman in the study who developed autoantibodies has a rare genetic condition in which she has only one X chromosome.

Scientists have struggled to explain why men have a higher risk of hospitalization and death from COVID-19. When the disease first appeared in China, experts speculated that men suffered more from the virus because they are much more likely to smoke than Chinese women.

Researchers quickly noticed that men in Spain were also more likely to die of COVID-19, however, even though men and women there smoke at about the same rate, Klein said.

Experts have hypothesized that men might be put at higher risk by being less likely to wear masks in public than women and more likely to delay seeking medical care, Klein said.

But behavioral differences between men and women provide only part of the answer. Scientists say it's possible that the hormone estrogen may somehow protect women, while testosterone may put men at greater risk. Interestingly, recent studies have found that obesity poses a much greater risk to men with COVID-19 than to women, Klein said.

Yet women have their own form of suffering from COVID-19.

Studies show women are four times more likely to experience long-term COVID symptoms, lasting weeks or months, including fatigue, weakness and a kind of mental confusion known as "brain fog," Klein noted.

As women, "maybe we survive it and are less likely to die, but then we have all these long-term complications," she said.

After reading the studies, Klein said, she would like to learn whether patients who become severely ill from other viruses, such as influenza, also harbor genes or antibodies that disable interferon.

"There's no evidence for this in flu," Klein said. "But we haven't looked. Through COVID-19, we may have uncovered a very novel mechanism of disease, which we could find is present in a number of diseases."

To be sure, scientists say that the new study solves only part of the mystery of why patient outcomes can vary so greatly.

Researchers say it's possible that some patients are protected by past exposure to other coronaviruses. Patients who get very sick also may have inhaled higher doses of the virus, such as from repeated exposure to infected co-workers.

Although doctors have looked for links between disease outcomes and blood type, studies have produced conflicting results.

Screening patients for autoantibodies against interferons could help predict which patients are more likely to become very sick, said Bastard, who is also affiliated with the Necker Hospital for Sick Children in Paris. Testing takes about two days. Hospitals in Paris can now screen patients on request from a doctor, he said.

Although only 10% of patients with life-threatening COVID-19 have autoantibodies, "I think we should give the test to everyone who is admitted," Bastard said. Otherwise, "we wouldn't know who is at risk for a severe form of the disease."

Bastard said he hopes his findings will lead to new therapies that save lives. He notes that the body manufactures many types of interferons. Giving these patients a different type of interferon — one not disabled by their genes or autoantibodies — might help them fight off the virus.

In fact, a pilot study of 98 patients published Thursday in the Lancet Respiratory Medicine journal found benefits from an inhaled form of interferon. In the industry-funded British study, hospitalized COVID patients randomly assigned to receive interferon beta-1a were more than twice as likely as others to recover enough to resume their regular activities.

Researchers need to confirm these findings in a much larger study, said Dr. Nathan Peiffer-Smadja, a researcher at Imperial College London who was not involved in the study but wrote an accompanying editorial. Future studies should test patients' blood for genetic mutations and autoantibodies against interferon, to see if they respond differently than others.

Peiffer-Smadja notes that inhaled interferon may work better than an injected form of the drug because it's delivered directly to the lungs. While injected versions of interferon have been used for years to treat other diseases, the inhaled version is still experimental and not commercially available.

And doctors should be cautious about interferon for now, because a study led by the World Health Organization found no benefit to an injected form of the drug in COVID patients, Peiffer-Smadja said. In fact, there was a trend toward higher mortality rates in patients given interferon, although this finding could have been due to chance. Giving interferon later in the course of disease could encourage a destructive immune overreaction called a cytokine storm, in which the immune system does more damage than the virus.

Around the world, scientists have launched more than 100 clinical trials of interferons, according to clinicaltrials.gov, a database of research studies from the National Institutes of Health.

Until larger studies are completed, doctors say, Bastard's findings are unlikely to change how they treat COVID-19.

Dr. Lewis Kaplan, president of the Society of Critical Care Medicine, said he treats patients according to their symptoms, not their risk factors.

"If you are a little sick, you get treated with a little bit of care," Kaplan said. "You are really sick, you get a lot of care. But if a COVID patient comes in with hypertension, diabetes and obesity, we don't say, 'They have risk factors. Let's put them in the ICU.'"

Liz Szabo: lszabo@kff.org, @LizSzabo

Lags could have devastating consequences, because even one undetected infection can quietly but rapidly trigger a broad outbreak.

This article was published on Thursday, November 12, 2020 in Kaiser Health News.

By Jordan Rau and Lauren Weber and Rachana Pradhan

Nursing homes are still taking days to get back COVID-19 test results as many shun the Trump administration's central strategy to limit the spread of the virus among old and sick Americans.

In late summer, federal officials began distributing to nursing homes millions of point-of-care antigen tests, which can be given on-site and report the presence or absence of the virus within minutes. By January, the Department of Health and Human Services is slated to send roughly 23 million rapid tests.

But as of Oct. 25, 38% of the nation's roughly 15,000 nursing homes have yet to use a point-of-care test, a KHN analysis of nursing home records shows.

The numbers suggest a basic disagreement among the Trump administration, state health officials and nursing home administrators over the best way to test this population and how to strike the right balance between speed and accuracy. Many nursing homes still primarily send samples out to laboratories, using a type of test that's considered more reliable but can take days to deliver results.

As a result, in 29% of the approximately 13,000 facilities that provided their testing speed to the government, results for residents took an average of three days or more, the analysis found. Just 17% of nursing homes reported their average turnaround time was less than a day, and the remainder tended to get results in one or two days. Wait times for test results of staff members were similar.

Those lags could have devastating consequences, because even one undetected infection can quietly but rapidly trigger a broad outbreak. It's especially concerning as winter sets in and the pandemic notches daily records of infections.

In the meantime, the coronavirus continues its march through institutions. Nursing homes have reported more than 262,000 infections and 59,000 deaths since the government began collecting the information in May. Even without estimating how many residents died from COVID-19 before then, reported nursing home deaths amount to more than a quarter of all COVID-19 fatalities in the U.S. so far.

During the week ending Oct. 25, the most recent period for which data is available, a third of skilled nursing facilities reported a new suspected or confirmed coronavirus infection of a resident or staff member.

Many state public health authorities and nursing homes have ongoing reservations about the rapid tests. They are considered less accurate than the more expensive ones sent out to laboratories, which are known as polymerase chain reaction, or PCR, tests and identify the virus's genetic material but often take days to complete. And their manufacturers say the rapid tests are designed for people with symptoms — not for screening a general population.

In early November, the Food and Drug Administration warned of false-positive results — in which someone is told incorrectly they are infected — associated with one type of rapid COVID test, and urged providers to follow Centers for Disease Control and Prevention recommendations for using them in nursing homes. False negatives are also a concern because people who don't know they are infected can unwittingly spread the virus.

HHS bought millions of rapid tests to distribute to nursing homes as the federal government imposed new mandates for the facilities to test staffers at least once a month. Routine staff testing increases to as often as twice a week for homes in areas with the highest infection rates. The Centers for Medicare & Medicaid Services, which is part of HHS, does not recommend testing asymptomatic residents unless a new outbreak occurs or a resident routinely goes outside the facility.

Leaders in multiple states, including Nevada, Vermont and Illinois, have moved to ban antigen tests in nursing homes or limit their use.

"I thought the hard part was getting the testing to the different facilities," said David Grabowski, a health care policy professor at Harvard Medical School. Instead, he said, "the major barriers to the use of rapid testing seem to be a lack of guidance on when and how to use the tests, coupled with concerns about their accuracy."

Dr. Michael Wasserman, immediate past president of the California Association of Long Term Care Medicine, said the national effort has been chaotic and inadequate.

The federal government "just hands stuff off to nursing homes and then says, 'Hey, it's yours; go use it,'" he said. "And then when things fall apart, 'We're not to blame.'"

Nursing homes that don't trust the rapid tests are having to shoulder the higher cost of lab tests. It costs Stuart Almer, president and CEO of Gurwin Jewish Nursing & Rehabilitation Center on New York's Long Island, $125,000 a week to conduct lab tests on up to 1,500 residents and staff members.

"We embrace the testing," Almer said. "But how are we supposed to continue operating and paying for this?"

Goodwin House in Virginia, which includes skilled nursing and assisted living facilities, had performed more than 9,500 tests for COVID-19 as of late October, said Joshua Bagley, an administrator. Only 100 of them were antigen tests. "The majority of our focus is still toward the PCR testing," Bagley said.

The concerns of state health officials were perhaps most evident in Nevada, where in early October the state banned antigen testing in nursing homes. HHS said the order was illegal, and it was revoked within days.

"There is no such thing as a perfect test," Adm. Brett Giroir, a senior HHS official who leads the Trump administration's COVID testing efforts, said on a call with reporters Nov. 9. For example, Giroir said, a risk of PCR tests is that they could provide a positive diagnosis when a person is no longer "actually infectious."

Although there have been widespread accuracy concerns over antigen tests, certain tests the administration is distributing nationwide have comparable accuracy to lab-based tests, he said.

Other state responses have not been as aggressive as Nevada's but nonetheless demonstrated unease over how best to use the devices, if at all.

Vermont recommends the use of antigen tests after a known COVID exposure but says they should not be used to diagnose asymptomatic people.

Ohio was initially reluctant to deploy them after Republican Gov. Mike DeWine's false-positive result from an antigen device, although the tests have since been adopted, said Peter Van Runkle, executive director of the Ohio Health Care Association, which represents some skilled nursing facilities in the state.

Some nursing homes say relying on antigen tests has made a monumental difference. In Hutchinson, Kansas, Wesley Towers Retirement Community has used both types of tests, but it was Abbott's BinaxNOW antigen test that detected its first two asymptomatic people with COVID-19, said Gretchen Sapp, Wesley Towers' vice president of health services.

"We have more confidence that our staff are indeed COVID-free or that they are out and not exposing residents. And that is incredibly helpful," Sapp said. "The biggest challenge is I need more tests."

A total of 1,150 homes told the federal government they did not have enough supplies for point-of-care tests for all workers, the KHN analysis found. Nursing homes can go through millions of tests quickly when testing monthly or more often, depending on the level of COVID-19 in the area.

White House spokesperson Michael Bars said the administration is working "hand-in-hand with our state and local partners" and "doing more than ever to protect the health and safety of high-risk age groups most susceptible to the virus."

Janet Snipes, executive director of Holly Heights Care Center in Denver, said antigen tests have been useful to screen staff members despite a few false-positive results. One test was used on a clergy member a resident had summoned.

"We wouldn't have been able to allow him in, but we were able to do the antigen testing," she said. "With the vulnerable residents we serve, we're hoping for more antigen testing, more testing period, more testing of any type."

Jordan Rau: jrau@kff.org, @JordanRau

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Rachana Pradhan: rpradhan@kff.org, @rachanadixit

The fear and uncertainty regarding the coronavirus have made online groups targets for the spread of false information.

This article was published on Thursday, November 12, 2020 in Kaiser Health News.

By Alex Smith, KCUR

For decades, people struggling with illnesses of all kinds have sought help in online support groups. This year, such groups have been in high demand for COVID-19 patients, who often must recover in isolation.

But the fear and uncertainty regarding the coronavirus have made online groups targets for the spread of false information. And to help fellow patients, some of these groups are making it a mission to stamp out misinformation.

Shortly after Matthew Long-Middleton got sick on March 12, he joined a COVID-19 support group run by an organization called Body Politic on the messaging platform Slack.

"I had no idea where this road leads, and so I was looking for support and other theories and some places where people were going through a similar thing, including the uncertainty," said Long-Middleton, 36, an avid cyclist who lives in Kansas City, Missouri. His illness started with chest discomfort, then muscle weakness, high fever, loss of appetite and digestive problems. In addition to all the physical symptoms, the mystery weighed on him, making him feel like he and other patients "have to figure this out for ourselves."

But with the support came misinformation. Group members reported taking massive amounts of vitamins — including vitamin D, which can be harmful in excess — or trying other home remedies not backed by science.

Experts warned that such false or unverified information spread on online support groups can not only mislead patients, but also potentially undermine trust in science and medicine in general.

"Even if we're not actively seeking information, we encounter these kinds of messages on social media, and because of this repeated exposure, there's more likelihood that it's going to seep into our thinking and perhaps even change the way that we view certain issues, even if there's no real merit or credibility," said Elizabeth Glowacki, a health communication researcher at Northeastern University.

In an effort to help fellow COVID-19 sufferers, some patients, like Vanessa Cruz, spend most of their days fact-checking their online support groups.

"It's really become like a second family to me, and being able to help everybody is a positive thing that comes out of all this negativity we're experiencing right now," Cruz said.

Cruz, a 43-year-old mother of two, moderates the Facebook COVID-19 support group called "have it/had it" from her home in the Chicago suburbs. She's also a "long-hauler" who has been dealing with COVID-19 symptoms, including fatigue, fever and confusion, since March.

The worldwide group has more than 30,000 members and has recently been buzzing with reports from India about treating COVID-19 with a common tapeworm medication (it's not FDA-approved and there's little evidence it works) — as well as speculation about President Donald Trump's recent diagnosis.

Other troubling posts include people pushing hydroxychloroquine, which has not been proved effective in treating COVID-19, and sharing the viral video "America's Frontline Doctors," which promotes other unproven treatments and spreads conspiracy theories.

Cruz said supporting fellow patients can be a tricky balance of getting the facts right but also giving people who are scared the chance to be heard.

"It's like you really don't know what to question, what to ask for, how to reach for help," Cruz said. "Instead of doing that, they just write up their story, basically, and they share it with everybody."

To keep the group evidence-based, it has built up a 17-person fact-checking team, which includes two nurses and a biologist. Someone on the team reviews every post that goes up.

However, many online COVID-19 groups don't have the resources or strategy to address misinformation.

Mel Montano, a 32-year-old writing instructor who lives in New York and has also felt sick since March, said she left a large Facebook support group because she was frustrated by the conspiracy theories that filled its posts.

"All of these conflicting theories completely took away from the focal point of it," Montano said. "It was a mess."

Montano is now a moderator of the Body Politic group on Slack.

Facebook and Twitter have made changes in their approaches toward COVID-19 misinformation, including additional fact-checking, removing posts that contain falsehoods and removing users or groups that spread them.

However, critics say more changes are needed.

Fadi Quran, director of campaigns for Avaaz, a human rights group that focuses on disinformation campaigns, said Facebook needs to revise the way it prioritizes content.

"Facebook's algorithm prefers misinformation, prefers the sensational stuff that's going to get clicks and likes and make people angry," Quran said. "And so the misinformation actors, because of Facebook, will always have the upper hand."

A study by Avaaz showed that misinformation and disinformation had been viewed on Facebook four times as often as information from official health groups, like the World Health Organization.

Facebook did not respond to inquiries for this story.

COVID-19 patient Long-Middleton thinks the problem goes deeper than getting the data right. He said a lot of bad information is spread because patients so badly want to find ways to feel better.

After nearly six months of symptoms, Long-Middleton said he's returned to better health in the past month, though he continues to check in on fellow support group members who are still struggling.

He never tried risky treatments discussed in the group himself, but he understands why someone might.

"You want to find hope, but you don't want the hope to lead you down a path that hurts you," he said.

This story is part of a partnership that includes KCUR, NPR and Kaiser Health News.

Alex Smith, KCUR: @AlexSmithKCUR

Medicare reimbursement rates for patients admitted to hospitals average half what commercial or employer-sponsored insurance plans pay.

This article was published on Wednesday, November 11, 2020 in Kaiser Health News.

By Phil Galewitz

Of his many plans to expand insurance coverage, President-elect Joe Biden's simplest strategy is lowering the eligibility age for Medicare from 65 to 60.

But the plan is sure to face long odds, even if the Democrats can snag control of the Senate in January by winning two runoff elections in Georgia.

Republicans, who fought the creation of Medicare in the 1960s and typically oppose expanding government entitlement programs, are not the biggest obstacle. Instead, the nation's hospitals, a powerful political force, are poised to derail any effort. Hospitals fear adding millions of people to Medicare will cost them billions of dollars in revenue.

"Hospitals certainly are not going to be happy with it," said Jonathan Oberlander, professor of health policy and management at the University of North Carolina-Chapel Hill.

Medicare reimbursement rates for patients admitted to hospitals average half what commercial or employer-sponsored insurance plans pay.

"It will be a huge lift [in Congress] as the realities of lower Medicare reimbursement rates will activate some powerful interests against this," said Josh Archambault, a senior fellow with the conservative Foundation for Government Accountability.

Biden, who turns 78 this month, said his plan will help Americans who retire early and those who are unemployed or can't find jobs with health benefits.

"It reflects the reality that, even after the current crisis ends, older Americans are likely to find it difficult to secure jobs," Biden wrote in April.

Lowering the Medicare eligibility age is popular. About 85% of Democrats and 69% of Republicans favor allowing those as young as 50 to buy into Medicare, according to a KFF tracking poll from January 2019. (KHN is an editorially independent program of KFF.)

Although opposition from the hospital industry is expected to be fierce, that is not the only obstacle to Biden's plan.

Critics, especially Republicans on Capitol Hill, will point to the nation's $3 trillion budget deficit as well as the dim outlook for the Medicare Hospital Insurance Trust Fund. That fund is on track to reach insolvency in 2024. That means there won't be enough money to fully pay hospitals and nursing homes for inpatient care for Medicare beneficiaries.

Moreover, it's unclear whether expanding Medicare will fit on the Democrats' crowded health agenda, which also includes dealing with the COVID-19 pandemic, possibly rescuing the Affordable Care Act if the Supreme Court strikes down part or all of the law in a current case, expanding Obamacare subsidies and lowering drug costs.

Biden's proposal is a nod to the liberal wing of the Democratic Party, which has advocated for Sen. Bernie Sanders' (I-Vt.) government-run "Medicare for All" health system that would provide universal coverage. Biden opposed that effort, saying the nation could not afford it. He wanted to retain the private health insurance system, which covers 180 million people.

To expand coverage, Biden has proposed two major initiatives. In addition to the Medicare eligibility change, he wants Congress to approve a government-run health plan that people could buy into instead of purchasing coverage from insurance companies on their own or through the Obamacare marketplaces. Insurers helped beat back this "public option" initiative in 2009 during the congressional debate over the ACA.

The appeal of lowering Medicare eligibility to help those without insurance lies with leveraging a popular government program that has low administrative costs.

"It is hard to find a reform idea that is more popular than opening up Medicare" to people as young as 60, Oberlander said. He said early retirees would like the concept, as would employers, who could save on their health costs as workers gravitate to Medicare.

The eligibility age has been set at 65 since Medicare was created in 1965 as part of President Lyndon Johnson's Great Society reform package. It was designed to coincide with the age when people at that time qualified for Social Security. Today, people generally qualify for early, reduced Social Security benefits at age 62, though they have to wait until age 66 for full benefits.

While people can qualify on the basis of other criteria, such as having a disability or end-stage renal disease, 85% of the 57 million Medicare enrollees are in the program simply because they're old enough.

Lowering the age to 60 could add as many as 23 million people to Medicare, according to an analysis by the consulting firm Avalere Health. It's unclear, however, if everyone who would be eligible would sign up or if Biden would limit the expansion to the 1.7 million people in that age range who are uninsured and the 3.2 million who buy coverage on their own.

Avalere says 3.2 million people in that age group buy coverage on the individual market.

While the 60-to-65 group has the lowest uninsured rate (8%) among adults, it has the highest health costs and pays the highest rates for individual coverage, said Cristina Boccuti, director of health policy at West Health, a nonpartisan research group.

About 13 million of those between 60 and 65 have coverage through their employer, according to Avalere. While they would not have to drop coverage to join Medicare, they could possibly opt to also pay to join the federal program and use it as a wraparound for their existing coverage. Medicare might then pick up costs for some services that the consumers would have to shoulder out-of-pocket.

Some 4 million people between 60 and 65 are enrolled in Medicaid, the state-federal health insurance program for low-income people. Shifting them to Medicare would make that their primary health insurer, a move that would save states money since they split Medicaid costs with the federal government.

Chris Pope, a senior fellow with the conservative Manhattan Institute, said getting health industry support, particularly from hospitals, will be vital for any health coverage expansion. "Hospitals are very aware about generous commercial rates being replaced by lower Medicare rates," he said.

"Members of Congress, a lot of them are close to their hospitals and do not want to see them with a revenue hole," he said.

President Barack Obama made a deal with the industry on the way to passing the ACA. In exchange for gaining millions of paying customers and lowering their uncompensated care by billions of dollars, the hospital industry agreed to give up future Medicare funds designed to help them cope with the uninsured. Showing the industry's prowess on Capitol Hill, Congress has delayed those funding cuts for more than six years.

Jacob Hacker, a Yale University political scientist, noted that expanding Medicare would reduce the number of Americans who rely on employer-sponsored coverage. The pitfalls of the employer system were highlighted in 2020 as millions lost their jobs and workplace health coverage.

Even if they can win the two Georgia seats and take control of the Senate with the vice president breaking any ties, Democrats would be unlikely to pass major legislation without GOP support — unless they are willing to jettison the long-standing filibuster rule so they can pass most legislation with a simple 51-vote majority instead of 60 votes.

Hacker said that slim margin would make it difficult for Democrats to deal with many health issues all at once.

"Congress is not good at parallel processing," Hacker said, referring to handling multiple priorities at the same time. "And the window is relatively short."

Phil Galewitz: pgalewitz@kff.org, @philgalewitz