June 28

Ehelp

Covid-19andtheNeedforHealthCareReform-1-1.pdf

Home >English homework help >June 28

Perspective

T h e N EW ENGL A N D JOU R NA L o f M EDICI N E

June 25, 2020

n engl j med 382;26 nejm.org June 25, 2020 e104(1)

The Covid-19 pandemic has brought into sharp focus the need for health care reforms that promote universal access to affordable care. Although all aspects of U.S. health care will face

incredible challenges in the com- ing months, the patchwork way we govern and pay for health care is unraveling in this time of crisis, leaving millions of people vulner- able and requiring swift, coordi- nated political action to ensure access to affordable care.

About half of Americans receive health coverage through their em- ployer, and with record numbers filing for unemployment insur- ance, millions find themselves without health insurance in the midst of the largest pandemic in a century. Even those who main- tain insurance coverage may find care unaffordable.

Before the pandemic, research showed that more than half of Americans with employer-spon- sored health insurance had de- layed or postponed recommend-

ed treatment for themselves or a family member in the previous year because of cost.1 The loss of jobs, income, and health insur- ance associated with the pandem- ic will greatly exacerbate existing health care cost challenges for all Americans. For instance, in a re- cent poll, 68% of adults said the out-of-pocket costs they might have to pay would be very or somewhat important to their de- cision to seek care if they had symptoms of Covid-19.2 Failure to receive testing and treatment because of cost harms everyone by prolonging the pandemic, in- creasing its morbidity and mor- tality, and exacerbating its eco- nomic impact.

To address myriad issues raised by Covid-19, Congress has passed two significant pieces of legisla-

tion, with more likely to come. The Families First Coronavirus Response Act (FFCRA) requires all private insurers, Medicare, Medicare Advantage, and Medic- aid to cover Covid-19 testing and eliminate all cost sharing (copay- ments, deductibles, and coinsur- ance payments) associated with testing services during the public health emergency. It also appro- priated $1 billion for the Public Health and Social Services Emer- gency Fund to cover testing for uninsured individuals under state Medicaid plans. Although the FFCRA assists with testing costs, patients remain vulnerable to cost- sharing expenses associated with treatment (such as hospitaliza- tion) until they reach their yearly out-of-pocket maximum, which can exceed $8,000 for an indi- vidual and $16,000 for a family.

The Coronavirus Aid, Relief, and Economic Security (CARES) Act, a $2.2 trillion pandemic-relief bill, requires all private plans to cover Covid-19 testing and future

Covid-19 and the Need for Health Care Reform Jaime S. King, J.D., Ph.D.

Covid-19 and the Need for Health Care Reform

The New England Journal of Medicine Downloaded from nejm.org on August 22, 2021. For personal use only. No other uses without permission.

P E R S P E C T I V E

e104(2)

Covid-19 and the Need for Health Care Reform

n engl j med 382;26 nejm.org June 25, 2020

vaccines, but it stops short of elim- inating cost sharing for Covid-19 treatment. Nonetheless, many pri- vate insurers, including Humana, Cigna, UnitedHealth Group, and Blue Cross Blue Shield, have agreed to waive cost-sharing payments for plan members treated for Covid-19. The CARES Act appropriated $100 billion for hospitals and health care providers, which Health and Human Services Secretary Alex Azar later conditioned on provid- ers’ agreement not to bill insured patients more than their in-net- work cost-sharing amounts and not to bill uninsured patients at all for Covid-19 treatment. The federal government will reimburse providers at Medicare rates for treating uninsured patients. The CARES Act also provided substan- tial tax credits, emergency grants, and loans to help businesses keep employees on the payroll or on furlough through June 2020, while extending and increasing unem- ployment benefits for those who lost their jobs.

Though these laws provide crit- ical assistance, additional policies are needed to ensure that Ameri- cans can continue to access af- fordable care as the crisis contin- ues. First, I believe policymakers should freeze people’s insurance status as of April 1, 2020, to keep as many people as possible in their existing plans and with their current providers. People who had employer-sponsored in- surance or an Affordable Care Act (ACA) marketplace plan as of that date should be able to re- main on that plan through the end of the public health emer- gency, even if they lose their jobs or cannot pay their premiums. As an initial step in this direction, several states have instituted grace periods on insurance-premium payments for all policies.3 For ex-

ample, the Ohio Department of Insurance ordered all insurers to offer employers a 60-day grace period for premium payments, enabling them to retain employ- ees and their health benefits for an extended period.4 Premium payments could be paused, subsi- dized, or paid directly by federal disaster-relief funds.

Second, policymakers should secure coverage for people who have already lost their jobs by ex- panding access to ACA market- place plans and Medicaid. Eleven states and the District of Colum- bia have opened new open enroll- ment periods for their state ACA marketplaces to encourage enroll- ment.3 Despite President Donald Trump’s announcement that he would not open enrollment in the 38 states with ACA plans hosted on the federal marketplace, peo- ple who have lost their jobs with- in the past 60 days or who expect to lose their job in the next 60 days can apply to enroll in an ACA marketplace plan during a special enrollment period (just as one can after a life event such as marriage or the birth of a child).

In response to the pandemic, nearly all states have received Sec- tion 1135 Medicaid waivers to meet the needs of their most vul- nerable residents.3 Many states sought such waivers to eliminate Covid-19–related cost sharing, fa- cilitate provider and participant enrollment, and waive preauthori- zation requirements for Covid-19– related services during the de- clared public health emergency. In addition, many states (includ- ing Iowa, which already applied for and received a Medicaid waiv- er to be allowed to maintain its enrollment) will pause disenroll- ment to receive a higher federal matching rate established by the FFCRA. Finally, no state is cur-

rently enforcing work require- ments for maintaining Medicaid eligibility.

Given the size and scope of the pandemic, state or federal government officials could also implement something similar to the Disaster Relief Medicaid pro- gram (DRM), a temporary public health insurance program creat- ed in New York after the 9/11 ter- rorist attacks.5 The DRM allowed nearly 350,000 New Yorkers to quickly and easily obtain access to Medicaid benefits by raising eligibility thresholds, excluding asset tests, and using short-form applications. The program pro- vided New Yorkers with 4 months of emergency Medicaid coverage during the most critical time of the crisis, and then helped them transition to other coverage. A similar emergency program could raise eligibility thresholds beyond Medicaid expansion levels and in- crease federal matching funds to help cover people who lost their jobs or remain uninsured during the pandemic.

Third, state and federal offi- cials should continue addressing out-of-pocket expenses, such as cost sharing and surprise medi- cal billing. Lawmakers can follow Massachusetts, New Mexico, and Washington, D.C., by eliminating cost sharing for Covid-19–related treatment. Hospital and provider reimbursement shortages can be covered by CARES Act appropria- tions.

Covid-19 also creates unique affordability challenges related to surprise medical billing, which can occur when a patient receives treatment from an out-of-net- work physician at an in-network facility. Staffing shortages and triage protocols make it more likely that patients will be sent to out-of-network facilities or be seen

The New England Journal of Medicine Downloaded from nejm.org on August 22, 2021. For personal use only. No other uses without permission.

P E R S P E C T I V E

e104(3)

Covid-19 and the Need for Health Care Reform

n engl j med 382;26 nejm.org June 25, 2020

by out-of-network providers when they cannot check providers’ net- work status. Furthermore, provid- er shortages may require provid- ers to fill in care gaps for many conditions, not just Covid-19, ex- panding the potential for out-of- network care and surprise bills during this time. Though more than half the states offer some surprise-billing protections, poli- cymakers should eliminate bills from out-of-network providers that exceed in-network cost-sharing limits for any medical treatment received during the public health emergency.

While states should continue leading the way on Covid-19 poli- cies, comprehensive protections demand federal intervention. The Employee Retirement Income Se- curity Act of 1974 (ERISA) pro- hibits state laws governing health insurance from applying to self- insured employer plans, typically offered by large employers such as Apple, Intuit, and Microsoft. As a result, current state surprise- billing protections, cost-sharing prohibitions, and coverage man- dates will not apply to nearly 60%

of Americans with employer- sponsored health insurance (near- ly 30% of the population). ERISA thus leaves millions of people un- protected by state health care re- forms. Absent a federal response, states can avoid some ERISA en- tanglements by directly prohibit- ing providers from charging cost- sharing rates for Covid-19 treatment and from surprise bill- ing, but historically this ap- proach has been politically infea- sible. Perhaps Covid-19 provides the necessary impetus for change.

Never before has the interde- pendence of all our health, fi- nances, and social fabric been so starkly visible. Never before has the need for health care reforms that ensure universal access to affordable care for all Americans been more apparent. Our policies on health and health care, both during this pandemic and in the future, should reflect this reality, and we should not let the lessons of this crisis pass us by.

Disclosure forms provided by the author are available at NEJM.org.

From the University of California Hastings College of the Law, San Francisco.

This article was published on April 17, 2020, at NEJM.org.

1. Hamel L, Muñana C, Brodie M. Kaiser Family Foundation/LA Times survey of adults with employer-sponsored health insurance. May 2019 (http://files .kff .org/ attachment/ Report - KFF - LA - Times - Survey - of - Adults - with - Employer - Sponsored - Health - Insurance). 2. The Commonwealth Fund. What are Americans’ views on the coronavirus pan- demic? NBC News/Commonwealth Fund health care poll. March 20, 2020 (https:// www .commonwealthfund .org/ publications/ surveys/ 2020/ mar/ what - are - americans - views - coronavirus - pandemic). 3. State data and policy actions to address coronavirus. San Francisco: Kaiser Family Foundation, April 14, 2020 (https://www .kff .org/ health - costs/ issue - brief/ state - data - and - policy - actions - to - address - coronavirus/ #policyactions). 4. Ohio records first COVID-19 death; sen- ior centers, adult day cares to close. News release from the office of Governor Mike DeWine, March 20, 2020 (https://governor .ohio .gov/ wps/ portal/ gov/ governor/ media/ news - and - media/ ohio - records - first - covid19 - death - senior - centers - adult - day - cares - to - close). 5. Perry M. New York’s Disaster Relief Medicaid: insights and implications for cov- ering low-income people. Washington, DC: Kaiser Commission on Medicaid and the Uninsured in Collaboration with the United Hospital Fund, August 2002 (http://files .kff .org/ attachment/ new - yorks - disaster - relief - medicaid - insights - and - implications - for - covering - low - income - people).

The New England Journal of Medicine Downloaded from nejm.org on August 22, 2021. For personal use only. No other uses without permission.