Letter to the editor: Maine should move toward universal care
Gov. Mills must sign L.D. 1045, which would provide publicly funded
coverage for all Mainers, and champion a federal bill that would let
states use federal funds for their own single-payer plans.
Gov. Mills must sign L.D. 1045, which would provide publicly funded
coverage for all Mainers, and champion a federal bill that would let
states use federal funds for their own single-payer plans.
The pandemic has taught us the importance of a government willing to take responsibility for the health of the governed.
At the national level, Rep. Ro Khanna’s State-Based Universal Care Act
(HR 5010) would allow states to use federal funds to support their own
universal health care plans. Rep. Chellie Pingree is an original
co-sponsor of this “states’ rights” bill.
In Maine, the Maine Health Care Act (L.D. 1045),
which would provide publicly funded health care coverage, was passed,
contingent on enabling federal legislation. Resulting cost savings would
allow provision of the plan’s comprehensive care while reducing total
state health care expenditures and most individuals’ health care costs.
The Legislature also drafted a Joint Resolution addressed to Maine’s
congressional delegation, stating that “every person in the State should
have access to affordable and high-quality health care,” and it urges
congressional support for HR 5010.
Gov. Mills’ health care focus has been on establishing a state-based
Affordable Care Act marketplace. But the sad truth is that the vast
majority of policies carry with them imposing deductibles, which leave enrollees functionally uninsured,
and do not reduce insurers’ administrative overhead. Only by the payer
consolidation can we put these dollars toward the care of all Maine
residents.
As a primary care physician, I implore Gov. Mills to join the states
seeking to establish well-funded, less-expensive medical care for their
residents by signing L.D. 1045, and that she advocate for the federal
legislation that can make state-based universal coverage a reality.
Thomas Sterne, M.D. member, Maine AllCare Bridgton
BY DAVID SIROTA,JULIA ROCK – The Daily poster - June 29 - 2021
In mid-June, Democratic congressional candidate Nina Turner launched a
television ad campaign promoting her support for Medicare for All. Less
than two weeks later, the pharmaceutical industry’s lobbyists and its
bankrolled lawmakers on Capitol Hill are trying to block her election to
Congress through an opponent who has been publicly vilifying Medicare
for All amid the pandemic.
A 2018 poll
showed that Medicare for All is wildly popular in Northeast Ohio — and
Turner is running in a district that has been represented for nearly 30
years by lawmakers who havesupportedlegislation
to create a government-sponsored single payer health care system. That
includes Marcia Fudge, who left Congress to serve in President Joe
Biden’s cabinet.
Pledging to carry on that legacy, Turner on June 15th launched her television spot
entitled “Worry,” in which she talks about how her family’s struggle to
pay health care bills led her to support Medicare for All.
The fundraiser was also headlined by a CVS Health lobbyist, as well as seven Democratic lawmakers
who have raked in more than $5 million from donors in the
pharmaceutical and health care sectors — including two whose top
donating sector is the pharmaceutical industry.
The fundraiser followed Brown slamming Medicare for All, amid a pandemic that has seen more than 1 million Ohioans lose their employer-sponsored health care. Brown told Cleveland.com
that while she would not oppose the legislation if it ever came to a
vote on the House floor, “Medicare for All would eliminate employers
from providing care for their employees. I know when I’m out in the
community there are some people who are satisfied with the health care
they’re being provided. I certainly don’t want to be the person to end
that.”
Brown then rolled out an endorsement from Hillary Clinton,
who infamously used her 2016 presidential campaign to declare that
Medicare for All would “never, ever happen.”
Now, U.S. Rep. James Clyburn — one of the Democratic Party’s most outspoken opponents of Medicare for All — is intervening to try to halt Turner’s rise in the polls.
Clyburn has vacuumed in more than $1 million
from donors in the pharmaceutical industry — and he previously made
headlines vilifying Medicare for All during the 2020 presidential
primary.
When a Medicare for All bill was first introduced in 2017, Clyburn signed on as a co-sponsor. But two years later, Clyburn removed himself as a sponsor and turned against single-payer health insurance, arguing that it would hurt the party in congressional elections.
Days before the South Carolina primary, Clyburn endorsed Biden, arguing that Democrats who supported Medicare for All had not helped the party win back its House majority in 2018. (Exit polls showed that a majority of South Carolina primary voters supported Medicare for all.)
After
Democrats lost a dozen House seats in the 2020 election, Clyburn blamed
progressive policies, including Medicare for All. “[If] we are going to
run on Medicare for All, defund the police, socialized medicine, we're
not going to win," Clyburn said on a call with Democrats about the upcoming Georgia senate special election.
Obamacare’s Survival Is Now Assured, but It Still Has One Big Problem
Twelve
states have refused to expand Medicaid, leaving millions of poor
Americans without health coverage and Democrats divided over how to
respond.
by Sarah Kliff - NYT - June 28, 2021
Some Democrats are eager to build on
their Affordable Care Act victories in the Supreme Court by filling a
gaping hole created along the way: the lack of Medicaid coverage for
millions of low-income Americans in 12 states.
But so far,
Republican leaders in those states are refusing to use the health law to
expand Medicaid, despite considerable financial incentives offered
under the law and sweetened under the Biden administration. Some are
trying to defy the will of their own voters, who passed ballot
initiatives calling for expansion.
And in Washington, Democrats who want to act are divided about when and how.
Democratic
House members from states that have not expanded have begun to push for
the federal government to intervene and provide coverage to the four million Americans shut out of Medicaid expansion.
“We
cannot wait anymore,” said Representative James Clyburn, Democrat of
South Carolina, one of the holdout states. “The states didn’t do it. We
in Congress have got to move.”
But some Democrats
quietly express reluctance about spending billions to fix a coverage gap
created by Republican governors and legislatures when that money could
go to other health care priorities. Democrats are also considering expanding Medicare,
which provides coverage to older Americans, by lowering the eligibility
age to 60 and covering additional benefits. For middle-class Americans,
Democrats want to make Obamacare subsidies more generous in a coming legislative package.
“There
are many competing priorities,” said Representative Lloyd Doggett,
Democrat of Texas, who introduced Medicaid expansion legislation this
month.“I’m not opposed to doing the other things, which
are also very expensive, but just saying don’t leave out the
economically disadvantaged.”
Fixing the Medicaid expansion gap may
face long political odds because it targets benefits to a smaller group
of people in states that typically vote Republican. Only three
Democratic senators — Jon Ossoff and Raphael Warnock, both of Georgia,
and Tammy Baldwin of Wisconsin — represent a state that hasn’t expanded
Medicaid.
“If you were thinking in strictly political terms,
advocating for Medicare expansion has a lot more political gold than
Medicaid expansion,” said Joaquin Castro, a Democratic congressman from
Texas, which has nearly 1.5 million people shut out of Medicaid
eligibility, the most of any state. “But that is why we as Democrats
need to redouble our efforts to focus on this vulnerable population.”
How
to bring coverage to Americans in those 12 states is a problem that the
creators of the Affordable Care Act never anticipated. The original law
expanded Medicaid in all states to cover Americans earning less than
138 percent of the federal poverty line ($17,420 for an individual as of
2021) and required states to provide some funding. In 2012, the Supreme Court ruled that provision unconstitutional and instructed the government to make the program optional.
Eighteen
states and the District of Columbia, all with Democratic leadership,
joined the program when it began in 2014. Twenty more states have since
joined, including six that used ballot initiatives to circumvent
Republican legislatures and governors opposing the program. That
includes Oklahoma, which will begin enrolling patients into Medicaid
expansion this Thursday.
A recent study found that people 55 to 64 living in states that chose to expand Medicaid coverage were less likely to die in the four years after expansion than people with similar demographic characteristics in states that did not expand.
Yet
recent efforts to bring the expansion to more states have struggled.
After Medicaid voter initiatives succeeded in a few states, some other
holdout states changed their process to make it harder to secure spots on the ballot. In Mississippi, ballot efforts were recently abandoned
after the state’s Supreme Court stopped the ballot initiative process
until legislators and voters changed the state’s constitution.
Missouri voters passed a Medicaid expansion ballot last summer,
but the state’s Republican-led legislature refused to appropriate
funding. A state judge ruled in the Missouri government’s favor on
Wednesday, meaning the program will not go forward as planned on July 1.
Medicaid expansion supporters plan to appeal.
Republican
governors and legislators have often cited the potential costs of the
program — states are responsible for 10 percent of the new spending, and
the federal government 90 percent — as why they resist.
“It’s a
terrible time for Medicaid expansion, when we still have an economy that
is failing,” said Troy McKeown, a Republican state senator in Wyoming
who voted against Medicaid expansion in March.
Mr.
McKeown is, like many other Republicans, opposed to the idea of
enlarging the role of public health insurance. He also worries that
providing free government health insurance will discourage adults in
Wyoming from working — and that those who do work will have to cover the
new Medicaid enrollees’ costs in the form of higher taxes.
“We’d
be penalizing hardworking Americans to make sure everyone gets on a
program,” Mr. McKeown said. “I think it’s terrible, and gets us closer
to one-payer health care.”
To allay cost concerns, the federal government included incentives in the most recent stimulus package. The funding would more than cover
the holdout states’ share of the expansion costs for the next two
years. It has not yet enticed any states to join, but some top Biden
officials say they still hold out hope.
“States have additional
time to take advantage of the significant funding included in the
American Rescue Plan,” Chiquita Brooks-LaSure, who oversees Medicaid for
the Biden administration, told reporters, noting that the
administration has been in conversation with multiple states.
Some in Congress contend that they have waited long enough, and don’t believe states will step forward.
“Anything
that is based on what I’d call the ‘states will see the light’ approach
is a false hope,” said Mr. Doggett, the Texas congressman.
The bill he introduced, the COVER Now Act,
would allow cities and counties to work with the federal government to
expand Medicaid locally. The bill has faced criticism that it would
still leave large areas of the country uncovered.
Others
have suggested that the federal government ought to intervene and
directly provide coverage to those shut out of Obamacare. The
Congressional Black Caucus, the Congressional Hispanic Caucus and the
Congressional Asian Pacific American Caucus have sent a joint letter to Democratic leadership and the White House asking for “federal intervention.”
Black and Latino Americans represent more than half of the Americans in poverty who are affected by states deciding not to expand coverage.
Senators Ossoff and Warnock wrote to Senate leadership in late May asking that it “close the coverage gap in Medicaid nonexpansion states through federal action.”
It’s not clear what this would look like. President Biden’s budget proposed
using a public option, allowing Americans to buy into Medicare, to
solve the problem. That policy was not included in the $1.8 trillion
American Families Plan he proposed in April, however.
Christen
Linke Young, deputy director of the White House Domestic Policy Council,
said President Biden “wants to work with Congress this year to close
the coverage gap.”
In Congress, health policy aides are exploring
whether the federal government could run Medicaid expansions in the 12
holdout states, or if it could provide better insurance subsidies that
customers could use to buy private coverage on the Obamacare
marketplaces.
Devising such a policy is hard because legislators
do not want to encourage current Medicaid expansion states to switch to a
new, federal option — or penalize them for having signed up sooner.
Health
policy aides envision incentives to ensure that current Medicaid
expansion states stay in the program, which would probably raise the
cost of any proposal. They also described possibly penalizing states
that do not expand, but they have concerns that this could face a legal
challenge if it looks too much like a requirement.
One Democratic aide described the Medicaid expansion gap as one of the hardest policy issues they had ever encountered.
Still,
experts say federal action will be necessary if Medicaid expansion is
to reach all states. They don’t see why states that have rejected
expansion for years would change their minds now.
“This is a case
where federal intervention seems to be especially important, but it’s a
hard lift politically,” said Jamila Michener, co-director of the Cornell
University Center for Health Equity. “I don’t know that it will
materialize as a real political possibility.”
Walking
into a doctor's office or hospital can be intimidating. But when you go
armed with the right tools and frame of mind, you can walk out of that
appointment or hospital stay feeling more confident and satisfied. Learn
how to ask your questions, either for yourself or a loved one, figure
out your various medical options and determine the best course of
action. Just having that knowledge in your pocket can help you feel
better.
When You're Healthy
It
can be hard to think about dealing with a medical emergency when you
are well, but the things you do now can really pay off later.
Pete Gamlen
Get Your Paperwork in Order
As
much as we don’t want to think about the end of our own lives, it’s a
good idea to get a head start while you’re still relatively young and in
good health. Don’t just assume your partner or family can read your
mind about whether or not you’d want to be put on a feeding tube or be
resuscitated if something went wrong. Yes, that means having an advancecaredirective on hand. This also means appointing a proxy granting him or her power-of-attorney to make your medical decisions if you’re not able to do so.
If you are fortunate enough to have some form of health insurance,
always have your current policy information handy and organized in case
you need it. In fact, keep it in an easily accessible folder, along with
an updated list of all the medications you’re taking — prescribed,
over-the-counter and supplements — and a record of your personal and
family medical history.
Regardless of whether you’re going to see your general practitioner
about a viral infection or end up in the E.R. with a broken foot, you’re
going to be asked about your medical history, so it’s best to come with
as much detail as possible.
Know Your Rights
In the United States, we have various sources setting forth our rights as patients. HIPAA, for example, guarantees on a federal level
a patient’s right to get a copy of his medical records, as well as the
right to keep them private. There is also the Patient’s Bill of Rights
that is part of the Affordable Care Act, though it primarily deals with insurance-specific rights, rather than general health care. Some states, like New York,
do have a Patients’ Bill of Rights which grants additional protections,
like receiving an itemized bill and explanation of all charges, as well
as a right to get emergency care if you need it, meaning that hospitals are not permitted to turn away a patient requiring emergency care, regardless of where they live and regardless of whether they can pay the bill. In addition, some organizations, like the American Hospital Association, have their own guidelines outlining the rights of patients.
All patients also have the right of informed consent,
meaning that if you require any sort of treatment or procedure, your
physician should explain what will happen to you in a way you
understand, which allows you to make an educated decision. Being
familiar with informed consent before needing medical treatment can help
you achieve the best outcome possible.
Schedule Regular Appointments
Read More
Seeing a Medical Professional
Being a patient is stressful. These strategies will keep your mind clearer when you are dealing with a medical diagnosis.
Prepare for Your Appointment
To
ensure you have the best possible experience with your doctor, it’s
best to come prepared. Ideally, you’ll already have your medical history
and list of current medications ready to go, but there are a few more
steps that could make your visit even more productive.
Set goals of what you’d like to address with your doctor.
Make a list of all your symptoms and concerns about your health scare
Try not to overdo internet research before you get to the doctor’s office.
Keep in mind that your doctor is only human, and has probably worked a long day. Advocate for yourself, but also be respectful of your medical team and their time.
Ask Questions
We’re taught
to listen to what the doctor says, and while in most cases that’s a
good idea, in order to be our own advocates, we also have to speak up
and ask questions. Remember: There is no such thing as a stupid question. If something comes up that you hadn’t considered, ask about it. If you don’t understand something, say so. This includes having the doctor explain any complex medical terminology.
But direct your questions appropriately.
Questions about scheduling appointments? Ask the front desk.
Getting ready for a hospital stay? Ask the nurse (not the doctor) about what clothes to bring.
Have a specific medical questions about your diagnosis or
treatment? Ask your doctor. Chances are you’ll come up with additional
questions as soon as you leave the appointment. Ask the doctor or nurse
for the best way to contact them with these follow-up queries.
Keep Track of the Answers
When you’re in the doctor’s office because of a health problem, you may feel anxious or rushed — either way, it’s helpful to record the answers
to the questions you ask your medical team, as well as the other
information they give you. Bring paper to your appointment (or if you
forget it or a pen, just ask the receptionist) to take notes of
everything that is said during the appointment. If you’d feel more
comfortable having an audio recording of the appointment, ask your
doctor if you have their consent to record the office visit. There’s no
need to purchase any equipment: most smartphones come with a free
recording app, like Voice Memo. Depending on the nature of the
appointment, it may be helpful to have a family member, friend or
partner either go with you for a second set of ears, or call in on
speakerphone so they can hear and take notes on everything being
discussed.
Make Sure You Are Heard
A
doctor’s appointment should feel like a conversation, and it’s
important for both you and your physician that your voice is heard.
Asking questions is one thing, but it’s also necessary to speak up when
you don’t think you’re being heard or understood. There is no rule
saying that the doctor’s opinion is the be-all and end-all. They are
capable of making mistakes or, in some cases, simply ignoring patients
and their concerns, which can be especially true when the patients are women or people of color. Therefore, it’s very important that you leave the appointment believing that your doctor is taking your pain seriously.
Be as specific about your symptoms as possible. The more information
you’re able to provide to your medical team, the better your chances are
of getting an accurate diagnosis. If the doctor is still being
dismissive, calmly and respectfully express your concerns, and let them
know that you don’t feel as though you’re being fully heard. If this
doesn’t work, it may be time to change doctors or get a second opinion.
Make Sure You Understand
If
the doctor ends up making a diagnosis in the appointment and you don’t
understand what it is or what it means, feel free to ask additional
questions. Don’t hesitate to ask the doctor to refrain from using
medical jargon when explaining what is happening to you. Some medical
professionals will even draw pictures or diagrams to help illustrate
exactly what is going on in your body. If you’d like more information
than the doctor is able to provide during the appointment, ask them
where you can read more about the condition. This way, they’ll point you
to a reputable book or website, so if you’re going online for information, it will be accurate. You can also ask if there are any online resource groups for people with the condition.
Making decisions regarding your health care or treatment can be difficult.
If you are faced with having to choose from multiple options, you can ask to speak with a bioethicist or counselor. While not all medical facilities have them on staff,
your medical team should be able to point you in the direction of
someone who can help walk you through the decision-making process.
Make a list of the risks and benefits of each option, taking into
consideration what is best for treating your current medical issue, as
well as what would be best for your health in the long run.
Once you understand your diagnosis and treatment plan, it may be helpful to let trusted family members or friends know that you’re sick
so they are aware and can check in periodically. You can also ask them
to weigh in on the decision you have to make regarding your treatment if
you’d like additional opinions.
When You Need (or Want) a Second Opinion
Some
medical conditions have routine, straightforward treatment procedures.
Other times, there are multiple ways to treat a patient, and it can be
difficult to determine which option would be most beneficial. That may
mean it’s time to get a second opinion.
Moreover, if your doctor recommends a procedure that is invasive or
your diagnosis is severe, that’s another good time to get a second opinion.
This is true for diagnoses and treatment for both your physical and
mental health. Doctors should not be offended if you ask for a second
opinion, and may even recommend other physicians they trust.
When it comes to selecting a doctor for a second (or even first) opinion, don’t be afraid to shop around. If you’re going in for surgery,
ask potential surgeons how frequently they perform a specific
procedure. Even if it’s something basic that you assume all doctors know
how to do, ask if the procedure is a regular part of their practice.
During a Hospital Stay
Advocating for yourself while in the hospital requires additional considerations and planning.
Understand How (and What) the Bill Will Be
When
you’re admitted to the hospital, your focus should be on getting the
treatment you need and healing, but that can be challenging if you’re
worried about how you’re going to pay
for it. Even if you are fortunate enough to have health insurance, that
doesn’t mean that all of the members of your medical team — which may
include out-of-network specialists — are covered by your plan. Bills can add up quickly
over a multiple-day (or week) stay. Keep in mind that in addition to
the cost of your medical care, your bill will likely include administrative fees
that can significantly increase the cost of your hospitalization. If
you have questions or are confused about your insurance or payment
process, you can ask to speak with someone on the hospital staff who
specializes in billing.
Know Your Team
Depending
on the condition that put you in the hospital, you may be assigned a
team of medical professionals, including doctors, nurses, physical
therapists, physicians’ assistants and social workers.
Take the time to learn each of their names — write them down if it
helps. Caregiving can be a very intimate act, so developing a rapport
with your medical team — especially the nurses who oversee your
day-to-day care — is important.
Don’t forget about the nonmedical personnel, like the
environmental services staff, who are in charge of disinfecting your
room and potentially other tasks like changing your linens or bringing
fresh towels. They are an essential part of your care, can be
instrumental in getting you basic necessities and helping with
logistics, like fixing a broken TV or getting an extra chair for
visitors.
Keep Asking Questions
It’s
your body, and you should know what’s happening to it. If there’s
something you’re unsure about or don’t understand, never hesitate to
ask. Hospital stays can be particularly tricky because patients interact
with many people during a hospital stay and you may hear conflicting
advice or information. For instance, a doctor who only sees you once a
day may have one opinion on your treatment, while a nurse who spends
long shifts monitoring your vital signs may have a different suggestion.
Either way, keep asking questions to ensure you’re doing what’s best
for your health, recovery and treatment. While you’re at it, continue to
write down the answers. It may be helpful to keep a notebook next to
your bed so you can record your questions and the answers, and keep a
journal of your progress, treatment and notes from your medical team.
Leave With a Plan
Before you are released from the hospital, doctors and nurses should provide you with a discharge plan. Your medical team should walk you through any specific instructions you should follow once you are discharged. If this doesn’t happen, you as the patient should initiate the conversation:
What medications do you need to take? When? How long?
Do you have to do physical therapy?
Do nurses or health care providers make home visits?
What should you do if something goes wrong?
Start by assembling your team of people who can assist with your care once you’re home. Depending on
your needs, you should have a list of dependable caregivers or people to
help with different facets of your recovery, like driving you to and
from follow-up appointments, preparing meals, helping you sort out
medications, and checking in on your mental health.
Back at Home
The right mindset is needed to help you get back to your old routines.
Once
you’ve been discharged, follow your doctor's instructions, and ease
back into life outside the hospital. Don’t be afraid to ask for help
when you need it. Develop a relationship with your pharmacist;
you’ll likely be seeing him or her a lot, and he or she can be a wealth
of information on everything from adjustments in your medication to
potential contraindications. She may also be able to answer other
medication-related questions. Along the same lines, do not hesitate to
follow up with your doctor or other members of your hospital medical
team if you have any questions or concerns about your recovery. Lastly,
even though you’re out of the hospital and in recovery mode, be sure to finish all your medication and any prescribed therapy sessions, even if you start to feel better.
Advocating for Others
When
looking out for other family members or friends, many of the same
tactics apply, but there are other things to keep in mind, too.
For a Child
Caring
for a sick child is challenging not only because your baby doesn’t feel
well and it hurts your heart, but also because, depending on their age,
they may not be able to fully express their symptoms.
The best way to start is by listening to them if they say they don’t feel well.
Ask detailed follow-up questions so you and your child can present
the doctor with as much information as possible to make an informed
diagnosis.
Encourage your child to tell the doctor how they’re feeling. An
important lesson to impart is that doctors are there to help, so they
should try not to be afraid.
Explain to your child what’s on going during the appointment as
thoroughly and appropriately as possible, according to their level of
understanding.
Allow them to participate
in the discussion whenever possible, including speaking up if they
don’t think the doctor truly understands why they don’t feel well.
Keep in mind that you are your child’s primary caregiver and
decision-maker, and ultimately have the final say. This may involve some
necessary but unpleasant responsibilities, like making sure your child has all their vaccinations, even if they are afraid of shots.
Interacting with a doctor is also a good time to talk to your child about consent.
For instance, you can ask the doctor to explain what he or she is doing
during each part of the physical examination, including why they’re
touching any private parts. Use this as a teachable moment to explain
that it’s not O.K. for anyone else to touch them, and that even a doctor
isn’t allowed to touch them there if a parent or guardian isn’t present
and has given their permission.
For a Parent
Today, many people find themselves part of the sandwich generation,
taking care of themselves, their children and their parents. Acting as a
patient advocate for a parent comes with its own particular set of
challenges. While young children, for the most part, understand that
their parents make their decisions for them, that may not be as easy for
aging parents to accept. After all, they were the ones who raised us,
and this role reversal can be jarring. In some circumstances, your
parents may not even want your help, insisting that they can look after
themselves. While this may be the case, you can explain to them that
it’s always helpful to have a second pair of ears at a doctor’s
appointment and someone with whom to discuss potential treatment
options. Emphasize that this has nothing to do with their capability to care for themselves.
Part of advocating for a parent may include having difficult
conversations with them on end-of-life decisions. Work with them to
create an advance care directive, if they don’t have one already. Even
if you think you know their views on palliative care, it’s important to ask and have these conversations before the onset of any sort of cognitive decline.
From a logistical perspective, if you are acting as a patient
advocate for a parent, attend as many of their important doctor’s
appointments as possible in-person. If that’s not feasible, see if you
can make arrangements to call into their appointment so you can be part
of the discussion. If neither of these options work and you still want
someone there, look into getting an outside patient advocate or hiring a firm that specializes in it. Keep in mind that if you are a long-distance caregiver,
there are ways to advocate for your parents even if you don’t live in
the same city, like utilizing shared calendars or apps designed to
coordinate schedules, and checking in with them regularly.
Finally, don’t forget to keep an eye on your parent’s mental health.
If they are part of the generation that avoids talking about feeling
anxious or depressed, they may be reluctant to seek out professional
assistance. You can talk to them about the importance of looking after
mental health and its connection to physical health. Alternatively, if
you are in touch with their physician or hospital medical team, you can
reach out to them to suggest setting up an appointment for your parent
with a counselor or social worker.
For a Nonfamily Member
You may find yourself needing to act as an advocate for someone who is not a part of your family. This can present a new set of challenges, beyond those associated with routine caregiving and patient advocacy, as it may be difficult to obtain access
to the medical team. Attending appointments with the person should not
be difficult, but doctors may be hesitant to disclose personal medical
information over the phone to a nonfamily member. In these cases, the
patient can request authorization for you to receive this information
either in-person or over the phone, or can appoint you to be their proxy if they’d like you to be in charge of their medical decisions.
A newly approved drug
to treat Alzheimer’s disease is expected to become a
multibillion-dollar expense for Medicare. By one projection, spending on
the drug for Medicare’s patients could end up being higher than the
budgets for the Environmental Protection Agency or NASA.
There’s
little evidence that the drug, Aduhelm, slows the progression of
dementia, but the Food and Drug Administration approved it this month.
Analysts expect that Medicare and its enrollees, who pay a share of
their prescription drug costs, will spend $5.8 billion to $29 billion on
the drug in a single year.
“It’s
unfathomable,” said Tricia Neuman, executive director of the Kaiser
Family Foundation’s program on Medicare policy. “These are crazy
numbers.”
Plenty of other drugs cost
more than Aduhelm, which is made by Biogen and will be priced at $56,000
annually. What makes it different is that there are millions of
potential customers, and the drug is expected to be taken for years.
Spending
on this scale, so suddenly, could have far-reaching impacts for
Medicare, its users and taxpayers. The addition of $29 billiona
year to Medicare’s budget would be paid for by increases in both
taxpayer spending and in the premiums paid by all Medicare users.
Premiums might also go up for supplemental plans many Medicare
beneficiaries buy to offset costs the program doesn’t pay directly. And
the costs are likely to spill over into state budgets, where Medicaid
pays premiums for low-income Medicare enrollees.
Congress,
budget experts and several White Houses have spent years suggesting
ways to trim spending in Medicare, a large and growing share of the
federal budget. But many of these proposals are politically difficult to
achieve — and most would save less than the projected cost of Aduhelm.
“It’s
so much work to get savings that are really much smaller than this one
drug would cost,” said Joshua Gordon, the director of health policy at
the Committee for a Responsible Federal Budget, who says he has found
himself thinking nonstop about the challenges raised by Aduhelm since
its approval.
Cost
predictions vary because analysts aren’t sure how many patients will
ultimately use the new drug. The F.D.A.’s approval could apply to
everyone diagnosed with Alzheimer’s disease. But the drug was developed
for a smaller group of around 1.5 million patients who are in the early
stages of the disease. Analysts aren’t yet sure whom doctors will
recommend the treatment for, and which families will want to try it. The
F.D.A. has asked Biogen to continue studying the drug until 2030, but
prescribing could become widespread before there are any further public
results on how well it works.
Allison
Parks, a Biogen spokeswoman, said in an email that the company would
focus on reaching the type of patients who were studied in the company’s
clinical trials, “in the early symptomatic stage of the disease.”
The range reflects a variety of reasonable expert estimates. The high estimate, drawing on a Kaiser paper,
assumes that about a quarter of the two million Medicare enrollees who
currently take an Alzheimer’s treatment will take this one. The low one
is based on a Cowen and Company analyst estimate of $7 billion in total
sales by 2023.
Estimating how many patients will use the
drug is challenging. Aduhelm is not just expensive, but also somewhat
hard to take, requiring monthly in-person visits to an infusion center
for treatment. Patients who take it will be required to get multiple
brain scans during their treatments to look for side effects.
And the side effects themselves — about 40 percent
of patients in one clinical trial showed signs of brain swelling — may
discourage some patients from trying the drug, and prompt others to stop
taking it. (The many scans — and treatments for more serious side
effects — would also be covered by Medicare.)
There
are six million Medicare enrollees who do not purchase supplemental
coverage who could have to pay 20 percent of the drug’s cost, in this
case $11,200 a year.
Demand may
nevertheless be high from families who see an opportunity to intervene
when faced with a devastating diagnosis. Until now, there have been few
treatment options available for patients hoping to forestall cognitive
decline from the disease.
“There is
something intrinsically hard about having a loved one, seeing the clock
ticking, and saying, Well, let’s just wait,” said Dr. Steven Pearson, a
primary care physician and the president of the Institute for Clinical
and Economic Review (ICER). “It’s very hard to ignore the drive to do
something.”
Doctors, who would administer this drug
and be paid a percentage of the drug’s high price by Medicare for that
work, may face financial incentives to say yes when patients ask for it.
“The
implications of this one drug and the associated set of procedures are
enormous,” said Rachel Sachs, a law professor at Washington University
in St. Louis and an author of a recent essay in The Atlantic asserting that the drug could “break American health care.
Private insurers
may erect roadblocks to treatment, requiring patients to get additional
tests or prove that other options haven’t worked. But in normal
circumstances, Medicare covers drugs that are approved by the F.D.A.
Medicare decides what drugs to cover based on whether they are
“reasonable and necessary,” not on how much they cost.
Medicare
is initially required to pay for this type of drug at its list price in
addition to a 3 percent fee to the doctor who gives it. And then, after
about a year on the market, it pays the average sales price plus 6
percent. For drugs with competition, that average price can be
substantially lower than the sticker price. But for a drug like Aduhelm,
which is the first of its kind, the drugmaker may not offer doctors
discounts.
Medicare, which covers 61
million Americans 65 and over, does have some tools to contain costs. It
could decide to cover the drug in a way that is more limited than the
F.D.A. approval, a break from its normal practice.
Or it could do something even more unusual: An unexpected alliance of advocates has suggested
that Medicare put the drug into a randomized experiment to evaluate how
well it works — paying to cover the drug in some parts of the country,
but not others. Such policy experiments were authorized under the
Affordable Care Act, but one has never been used to limit coverage of a
drug in this way.
Other countries will
most likely control the cost of Aduhelm by negotiating with Biogen for a
lower price, or simply decline to buy it at all. Most will consider the
drug’s effectiveness when deciding what they are willing to pay. So
far, the drug has not been approved for use anywhere else in the world.
Medicare
can’t do that. Because of the way it pays for drugs under current law,
it has no way to bargain down the price. Democrats increasingly support
legislation to change that. The House passed legislation
in 2019 that would give Medicare the authority to negotiate some
prices, but it died in the Senate. Legislators reintroduced the same
bill in the House in April.
President
Biden supports allowing Medicare to negotiate drug prices but did not
include the policy in his proposed American Families Plan.
Dr. Pearson of ICER has estimated that if the new drug’s effectiveness were taken into account, a fair price would be $2,500 to $8,300.
“It
will be interesting to see if this starts a discussion about fair
pricing in the United States,” he said. “To most people’s eyes, this
looks like an outstanding example of a price that just does not match up
with the evidence.”
Ezra Sassaman - Maine Allcare Newsletter - June 12, 2021
On May 12th, the Maine State Legislature held a public hearing on LD
1045, An Act to Support Universal Health Care. LD 1045 aligns completely
with Maine AllCare’s key principles for health care legislation. It
includes universal coverage, public funding, comprehensive care, and
coverage independent from employment. It chooses public good over
profits.
In around two hours of oral testimony, over twenty people presented
personal stories and strong arguments in favor of universal health care
in Maine. They included legislators, active and retired physicians,
psychiatrists and mental health counselors, small business owners, a
veteran, and members of the Unitarian Universalists.
Some testimonials went as I expected: horror stories of patients
navigating the minefield of private health insurance companies in our
country. What I did not expect was how many doctors and other caregivers
feel the exact same way.
Here are four of the most common themes that arose during the testimony:
Employer-based health care is a bad idea
During the financial crisis in 2007, many people lost their jobs and,
with them, their health insurance. Over a decade later, the U.S. still
had not taken steps from preventing this tragedy from repeating itself.
During the COVID-19 pandemic in 2020 and continuing into 2021, tens of
millions of people lost their jobs, and, again, their health insurance.
Many testified that losing insurance during a pandemic hurts gravely. A
global public health crisis is exactly when it makes the most sense to
have people insured and unafraid to seek medical treatment.
Lynn Cheney, an Affordable Care Act (ACA) Navigator and board member
of Maine AllCare, asserted, “COVID-19 has provided the ultimate reason
that health care should not be tied to employment.”
We need dramatic change, not tinkering around the edges
Many testified that small fixes to our current health care system
would not be enough to get Mainers the kind of health care they deserve.
Even many people who are covered with high deductible health insurance
are afraid to risk bankruptcy by seeking needed care. The status quo in
this country means that those who do not have enough money do not have a
consistent relationship with doctors. Instead, they only visit the
hospital when something goes very wrong.
Valerie Dornan, a member of Maine AllCare, shared a heartbreaking
story about her mother dying in the hospital with “no confidence in a
health care system she never had access to.” Dornan said about her
mother, “by the time she was eligible for Medicare, going to the doctor
was as alien to her as it would be to a martian.”
Private health care hampers caregivers’ ability to treat their patients
Several active and retired physicians and mental health professionals
testified in favor of universal health care in Maine. Many described
how their work was made more difficult by insurance companies. They
disliked being forced to double-check whether a certain procedure or
prescription drug was covered by the insurance companies. They instead
wanted more freedom to focus on their patients’ health. Like patients,
doctors and psychiatrists find it difficult to navigate the bureaucracy
of health insurance companies.
Caryl Heaton, DO, a family physician and board member of Maine
AllCare, described her time working in a large group medical practice.
She explained, “I found we had not had an increase in payment from Aetna
Insurance in nine years. And we could not cancel Aetna, because, in one
form or another, it covered about 30% of our patients. But during that
same time… premiums went up every year. Physicians need to understand
how and why they are paid. That’s impossible when you take 27 different
payers.”
Humans have inherent worth and dignity, so stop treating them like disposable products
A veteran described how the publicly-funded Veterans Affairs (VA)
health insurance program saved his life. When a routine annual checkup
found a suspicious spot on his body, he did not have to worry about
costs when he got an x-ray. He explained that a private system would
contain no incentive for him to get an expensive scan nor for an
insurance company to pay. But this would have likely cost him his life:
the x-ray revealed a cancerous spot that needed to be removed
immediately.
On a similar note, many others testified about the overwhelming focus
on money in our current system. Under the status quo in this country,
profits are too often seen as more important than human lives.
Members of the Unitarian Universalists shared their belief in the
inherent sense of worth and dignity of each human. They see a moral
imperative for all people to be healthy and cared for regardless of
their level of wealth.
Testimony against universal health care in Maine
Although testimony on LD 1045 was overwhelmingly in favor, two
speakers, Kristine Ossenfort and Katherine Pelletreau, argued against
the legislation. Both women have a direct connection to the health care
industry.
Ossenfort works for Anthem Blue Cross and Blue Shield in Maine. She
argued that universal health care is too expensive and difficult for a
single state to implement.
Pelletreau is the Executive Director of Maine Association for Health
Plans, which represents clients such as Aetna, Anthem, and Cigna. She
made similar arguments as Ossenfort and especially emphasized the failed
attempt to achieve universal health care in Vermont.
Closing
The testimony showed overwhelming support for universal health care
in Maine, from legislators and their constituents alike. For too many,
our current health care system is too expensive, confusing, and
inhumane. Mainers from a variety of backgrounds understand that the
status quo is unacceptable for many reasons and they want big changes.
But the end of the public hearing showed that health insurance
corporations won’t go away without a fight. Proponents of universal
healthcare must understand the types of arguments these companies make
to avoid giving up their power. That way, we can address their talking
points head-on and respond with more convincing arguments of our own.
Medicaid Enrollment Surpassed 80 Million, a Record, During the Pandemic
The increase points to the program’s growing role not just as a safety net, but also as a foundation of U.S. health coverage.
by Sarah Kliff - NYT - June 21, 2021
Medicaid enrollment rose sharply
during the pandemic, with nearly 10 million Americans joining the public
health program for the poor, a government report released Monday showed.
Eighty
million people were covered under Medicaid, a record. It reflected an
increase of nearly 14 percent over the 12-month period ending Jan. 31.
The figure also includes enrollment in the Children’s Health Insurance
Program, which covers children whose parents earn too much for Medicaid,
but too little to afford other coverage.
The spike in enrollment
demonstrates Medicaid’s increasingly important role not just as a safety
net, but also as a pillar of the American health system, with fully a
quarter of the population getting coverage through it.
“This
tells us that Medicaid is a critical program for American families,”
said Chiquita Brooks-LaSure, the Biden administration official who
oversees Medicaid. “What we’ve seen during this pandemic is that people
want access to affordable health insurance, and how important it is
during a public health crisis.”
The Affordable Care Act
transformed Medicaid from a targeted health care benefit meant to help
certain groups — expectant mothers, for example, and those with
disabilities — to a much wider program providing largely free coverage
to most people below a certain income threshold. A notable exception is
the 12 states — mostly in the South — that have declined to expand Medicaid under the A.C.A.
Medicaid,
in which states and the federal government share the cost, covers all
adults with income up to 138 percent of the poverty level, which would
be about $17,420 for an individual to qualify this year.
The
expansion of Medicaid in most states since the bulk of the A.C.A. took
effect in 2014 provided a public source of coverage for the newly
unemployed that did not exist a decade ago. Adult enrollment in Medicaid
grew twice as fast as child enrollment, suggesting that widespread job
loss related to the pandemic created a huge group of newly eligible
adults.
“In past economic downturns, there has been substantial
growth in Medicaid enrollment, but it was concentrated among children,”
said Rachel Garfield, co-director of the Kaiser Family Foundation’s
program on Medicaid and the uninsured. “This time, it’s interesting
we’re seeing much of the enrollment happening among adults.”
She also noted that Medicaid enrollment has increased much faster during the pandemic downturn than in previous downturns. Fewer than four million Americans joined the program in 2009, at the beginning of the Great Recession.
There may also have been
increased interest among uninsured Americans who were already eligible
for Medicaid, but who decided to enroll because of heightened health
concerns during the pandemic.
“When we look at who remains
uninsured, so many times it’s people who are eligible but unenrolled,”
Ms. Brooks-LaSure, the Medicaid official, said. “Right now, we’re seeing
that when we make it easy for people to enroll, they do it.”
Medicaid enrollment had been declining in the years leading up to the pandemic. More than a million children
lost coverage between December 2017 and June 2019, a trend that rattled
health care advocates. Many attributed the changes to new rules during
the Trump administration that made it harder to sign up and remain
signed up.
That changed last spring, as the pandemic took hold and
Congress gave states extra money to fund their Medicaid programs.
Congress gave a 6.2 percent spending bump on the condition that states
not disenroll patients or tighten eligibility requirements.
A
woman who gave birth, for example, would normally have lost coverage 60
days after delivery, but because of the legislation, she could stay on
Medicaid for the length of the pandemic. Those rules remain in effect
until the federal government declares the public health emergency over.
Three
states — Utah, Idaho and Nebraska — expanded Medicaid last year after
voters approved ballot initiatives; those states saw especially large
enrollment surges. A fourth, Oklahoma, will expand Medicaid to most
low-income adults starting next month.
Even after its
growth under the Affordable Care Act, the Medicaid program has holes
that are hard to fix. The 2012 Supreme Court decision that upheld the
law’s individual insurance mandate also made expanding Medicaid optional
for states.
As a result, millions of low-income adults in the 12 holdout states, which include Florida and Texas, still have no coverage. A recent study
in JAMA found that Medicaid enrollment increased faster during the
pandemic in the states that participated in the expansion, most likely
because many more people were eligible for coverage.
Generous
financial incentives offered through the most recent stimulus package
have not been enough to persuade any of the 12 states to expand
Medicaid, but top Biden administration officials say they remain hopeful
that some will come on board.
“We hope we can encourage them,”
Xavier Becerra, the Health and Human Services secretary, said in a call
with reporters last week. “We want to make sure they’re expanding care
and it’s affordable.”
Three years later, after a second ruling in which the court declined to gut the law,
Republican candidates were noisily outraged and quietly relieved. They
could keep the law as a rhetorical device to stoke support but escape
any political backlash from millions losing health insurance.
“Every
G.O.P. candidate for the Republican nomination should know that this
decision makes the 2016 election a referendum on the full repeal of
Obamacare,” said Senator Ted Cruz of Texas, one of more than a dozen Republicans running for president at the time.
“I think three times the Supreme Court’s upheld the Affordable Care Act, and I think we need to move on,” said Senator John Cornyn, whose home state, Texas, led the lawsuit.
For
six election cycles, Republicans and Democrats have wielded the health
care law as a political cudgel, battering their opponents over an issue
that consistently topped the list of concerns for American voters. But
now, after more than 70 efforts to repeal or modify the law in Congress,
three Supreme Court rulings and nearly a dozen years, Republicans may
have finally run out of firepower.
The closest Republicans came to
dismantling major parts of the law came in 2017, when legislation
passed the House but crashed in the Senate after Senator John McCain flashed a famous thumb-down during the vote on the floor.
That
failure to overturn the law after Republicans had gained control of
Washington altered the political dynamics of the issue, reflecting
growing support for a health care system that had become deeply embedded
in American life.
Republicans lost the 2018 midterm
elections after Democrats flipped their strategy from deflecting attacks
on the law to defending its most popular provisions. A year later,
supporting an expansion of Medicaid, a signature piece of the law,
helped Democrats win governors’ races in deep-red Louisiana and
Kentucky.
“Hopefully, this will be the end of the line,” said Brad
Woodhouse, the executive director of the liberal group Protect Our Care
and one of many Democrats who took a victory lap after the Supreme
Court’s ruling on Thursday. “If Republicans continue to do this, they
are likely to continue to lose elections on this issue.”
The
changed politics reflect a policy that has become part of the American
social fabric. As of this month, a record 31 million people receive
insurance through its plans. And nearly every American is touched by
programs mandating things like calorie counts on menus, expanded
services for disabled people, free breast pumps for nursing mothers and a
host of other benefits.
Last year, the law became more popular than ever,
with 55 percent of people expressing a positive view of it — the
highest rating since the Kaiser Family Foundation began tracking
opinions of the act in 2010. More than 70 percent of Americans and 67 percent
of Republicans believe it is important that popular provisions
protecting Americans with pre-existing conditions remain in place.
This kind of deep rooting in American life is exactly the outcome many Republicans
feared after the law was passed. Ever since President Franklin D.
Roosevelt’s New Deal during the Great Depression, lawmakers have rarely
shown the ability or the will to pare back major entitlements — the term
for government assistance programs that are open to all who qualify and
are not subject to annual budget constraints. After periods of bitter
political controversy, Social Security, Medicare and Medicaid all became
widely accepted — and popular with voters.
Although the court, in
its latest ruling, rejected the plaintiffs’ claims based on legal
standing, not substance, some scholars believe that the conservative
majority on the Supreme Court was sending a message about future
constitutional challenges to the law.
“You have to look at that
increased support and say that the court is making clear that the time
for legal challenges to the Affordable Care Act is over,” said Andrew J.
Pincus, a partner at Mayer Brown and experienced Supreme Court
litigator, pointing to the 7-to-2 ruling in the case.
For
Republicans, there’s reason to expect Obamacare to linger as a kind of
zombie issue, used by conservative politicians to rally the base with
little actual expectation of eliminating the law. And in the dozen
states that have refused to expand Medicaid, fights over the law will
certainly continue. But other issues, like culture-war battles over race and transgender rights, have already supplanted health care as the party’s preferred red meat.
“I
don’t know what the next step is” on health care, Representative Nancy
Mace, a Republican from South Carolina, said in an interview on MSNBC.
“I hope it’s not the end of the road.”
Yet the political battle
over the future of the law could become more contentious for Democrats,
who disagree on how to tackle problems like large deductibles, high
premiums and the holdouts on Medicaid expansion.
In 2020,
questions of how to build on the law dominated the Democratic Party
primary race, which ended poorly for liberal politicians. Senator
Elizabeth Warren’s campaign tanked after she was pressed on the details
of her sweeping health care alternative. In a book released last month about her campaign,
Ms. Warren largely attributed her defeat to her fumbling effort to
explain how she would pay for her health care policies. Joseph R. Biden
Jr., who argued for bolstering the health care law instead of scrapping
private insurance, beat out Ms. Warren and several other more
progressive rivals, including Senator Bernie Sanders.
Mr. Sanders,
whose plan to nationalize American health care has long been a core
part of his political message, welcomed the court’s decision this week
but said it was not enough. As the chairman of the Senate Budget
Committee, he’s pushing to lower the Medicare eligibility age from 65 to
60 and expand the range of health services the entitlement covers.
“We
are the only major country, as you know, not to guarantee health care
to all,” he said on Capitol Hill this week. “There are millions of older
workers who would like to get Medicare who today can’t, which is why
we’ve got to lower the age, and there are millions more walking around
who cannot hear, can’t afford eyeglasses and dental.”
President Biden signaled little new interest in changing his position from the campaign.
“The
Affordable Care Act remains the law of the land,” he said in a White
House statement, adding that it was time to “move forward and keep
building on this landmark law.”
Covid Proved the C.D.C. Is Broken. Can It Be Fixed?
by Jeneen Interlandi, Brian Rea -NYT - June 20, 2021
In November, an independent team of academics and
public-health experts who called themselves the Covid Rapid Response
Working Group gathered on Zoom to puzzle over what had by then become
the pandemic’s most vexing challenge: how to make all schools safe for
full-time, in-person learning as quickly as possible. Schools had not
proved to be a hotbed of coronavirus transmission, but beyond that the
research was complicated, and communities were divided about how to
balance the risks. Some people wanted a full reopening, immediately, no
exceptions. Others were terrified to return at all.
So far,
there was no national plan for how to move forward. The Centers for
Disease Control and Prevention was advising everyone to wear masks and
remain six feet apart at all times. But that guidance was a significant
impediment to any full-bore reopening, because most schools could not
maintain that kind of distance and still accommodate all their students
and teachers. It also left many questions unanswered: How did masks and
distancing and other strategies like opening windows fit together? Which
were essential? Could some measures be skipped if others were followed
faithfully?
The C.D.C. seemed incapable of answering these questions. From the pandemic’s earliest days, the agency had been subject to extreme politicization and
troubled by what looked, at least from the outside, like pathological
clumsiness. Scientists there had been far too slow to detect the virus,
to develop an accurate diagnostic test for it or to grasp how fast it
was mutating. Their advisories on mask-wearing, quarantine and
ventilation had been confusing, inconsistent and occasionally dead
wrong. And during the Trump administration, agency leaders stood by
while politicians and political appointees repeatedly undermined the
agency’s staff. Scientific reports were blocked or altered. Quarantine
powers were used to achieve political goals. Dangerous strategies for
controlling the virus were not only promoted but actively employed. And
state and local leaders were left to fend for themselves — to decide
which of the agency’s recommendations to follow or modify or ignore.
The
Covid Rapid Response Working Group, at the Edmond J. Safra Center for
Ethics at Harvard, was one of several independent organizations that
stepped in to help fill the gap. In the last year, these groups, run
mostly out of academic centers and private foundations, have transformed
reams of raw data — on transmission rates and hospitalization rates and
death tolls — into actionable intelligence. They have created county-by-county risk-assessment tools, devised national testing strategies
and mapped out national contact-tracing programs. In many if not most
cases, they have moved faster than the C.D.C., painting a more accurate
picture of the pandemic as it unfolded and offering more feasible
solutions to the challenges that state and community leaders were
facing.
When it came to the question of school reopenings, the
Covid Rapid Response Working Group found itself going in circles. It was
possible to control the spread of infections indoors; hospitals did it
all the time. But when it came to schools, where the risk was much
lower, everyone seemed to be at a loss. Why was that? What, exactly,
made hospitals so different? “It makes no sense,” Thomas Tsai, a surgeon
in the group, said. “Hospitals are not special. We don’t use magic. We
just use basic infection control.” He explained what that meant: Teams
of specialists create detailed protocols based on what the risks are and
what the evidence says about how to avoid those risks. They update and
adjust their practices as information evolves, and they conduct routine
trainings with all hospital staff members (not just doctors or
administrators) so that everyone knows exactly what to do. It was all
very standard, he said. It did not even require an advanced degree, just
a basic understanding of disease transmission, an awareness of a given
hospital’s particular situation and a few people who knew how to connect
the two and could train others to do the same. School systems did not
have any of those tools, Danielle Allen, head of the Safra Center,
pointed out. Nor did they have a clear path to making those connections.
But maybe the group could chart that path for them? What would that
take?
From the pandemic’s earliest days,
the C.D.C. was subject to extreme politicization and troubled by what
looked, at least from the outside, like pathological clumsiness.
Allen
and her colleagues had already published at least one report on school
safety, but when the Biden administration set a national goal of opening
most schools by May 1, they partnered with a larger initiative, the
Covid Collaborative, and formed a task force to address the issue of
infection control. They parsed research, brought educators and other
stakeholders together for sustained dialogue and, by late April,
produced a detailed road map:
Most schools could remain open for full-time in-person instruction even
when the virus was circulating at high levels in the community, as long
as they had good infection-control programs. Beyond a few key elements —
including masks, proper ventilation and contact tracing — the contours
of such programs would depend almost entirely on the individual school.
What was the ventilation system like? How many students did it have? Did
its windows open easily?
The road map explained how to devise and
implement an infection-control plan, making clear who should take
charge of what and how to get federal funding and offering suggestions,
like establishing “situation rooms,” for managing challenges on the
ground. It was, in short, everything that the C.D.C. guidance was not.
And it was the product of a strategy that felt obvious and simple: The
task force engaged stakeholders in a sustained dialogue, incorporated
input from schools and factored practical realities, like the need to
move quickly, into its recommendations.
Allen disputes the notion
that she and her colleagues are doing work that the C.D.C. itself should
be doing; in fact, she says, the task force and the federal agency have
worked closely together. But she acknowledges that the
interdisciplinary approach of the collaborative — it consists not only
of doctors and public-health professionals but also of political
scientists, economists, lawyers and M.B.A.s — enables it to spot
problems that the federal institution can’t necessarily see. Infection
control is a good example. “This is not a public-health problem, or even
a medical one,” she says. “It’s an issue of organizational capacity.”
The C.D.C. is not equipped to identify organizational issues, let alone
resolve them.
The agency has made clear improvements under the Biden administration. Among other things, the incoming director, Rochelle Walensky,
has made a point of bringing agency guidelines back under the exclusive
domain of agency staff members. But those guidelines are still
confusing, the agency’s messaging is still deeply muddy and communities
across the country — and school districts, especially — are still
struggling with next steps. Schools are reopening, but vaccines have yet
to be approved for children younger than 12. No one can say for sure
how long immunity to the virus might last, or what will happen when it
fades.
What is clear, as the second pandemic spring
tilts into the second pandemic summer, is that efforts like the Covid
Collaborative will be needed for some time to come. “We did not expect
to be doing this work once the new administration took over,” Stefanie
Friedhoff, a professor of public health at Brown University and a member
of the collaborative, told me recently. But as the rest of the nation
is learning, the former president was not the C.D.C.’s only — or even
its biggest — problem.
For most of
the last seven decades, the C.D.C. has stood as the world’s premier
public-health institution — so much so that counterpart agencies in
other countries are often called C.D.C.s, even when the abbreviation
means nothing in their native languages. The agency invented disease
surveillance as we know it, helped lead the (successful) quest to
eradicate smallpox, initiated the (ongoing) fight against H.I.V. and
beat back Ebola — more than once. Its heroics have been the stuff of
novels and movies and harrowing nonfiction best sellers. Americans took
for granted that the C.D.C. would be engaged and quick in a crisis; that
it was well funded and equipped with modern technology; that it had, or
could quickly get, comprehensive data on diseases of concern; and that
it knew how to translate that data into sound guidance in a crisis.
Wasn’t that, at least partly, how bird flu, swine flu and a thousand
other nameless plagues were prevented from decimating the American
masses?
The agency may be just one cog in the nation’s
public-health apparatus, but it is a crucial one. In an ideal world, its
edicts would hold sway not only over schools but also nursing homes,
prisons and meatpacking plants. It would guide elected officials and
private institutions alike through not just global pandemics but all
manner of public-health threats: food-borne pathogen outbreaks, the
opioid crisis, gun violence. In an ideal world, its efforts would
succeed, more often than not, at keeping people safe and helping them
stay healthy. This is the C.D.C. we need. But as the last year has made
clear, it is not the C.D.C. we have.
The C.D.C. we have is hardly a monolith: Some of its many pockets are
bursting with innovation; others are plagued by inertia. But scientists
and administrators who have spent decades working with and for the
agency say that three problems in particular affect the whole
institution: a lack of funding, a lack of authority and a culture that
has been warped by both. Some of these problems come down to politics,
but most are a result of flaws in the agency’s very foundation.
From
its inception in 1946, the agency’s existence hinged on its officers’
ability to sell its services to state leaders who were leery of federal
interference, and to lawmakers who often struggled to appreciate the
point of epidemiology. They did this by taking on the jobs that no other
agency wanted, quickly developing a reputation for being the first to
arrive at any given emergency, the last to leave and the one with the
most cutting-edge technology. But with each success, a pattern emerged.
The agency received an infusion of funding in times of crises, and
praise and more responsibility when it saved the day. But it was often
starved of resources the rest of the time and rived by internal
conflicts over how to apportion the money it did receive. “Everybody was
trying to establish his own thing,” the historian Elizabeth Etheridge
writes in “Sentinel for Health,” her biography of the agency. Each
branch had strong leadership, but none of those strong leaders were
great at working together.
Today the C.D.C. is both sprawling in
its reach and extremely constrained in what it can do. It consists of
more than a dozen centers, institutes and offices and employs more than
11,000 people in all, in a gargantuan roster of public-health
initiatives — not just infectious-disease control but also
chronic-disease prevention, workplace safety, health equity and more. A
majority of that work is concentrated in the agency’s Atlanta
headquarters, but there are also C.D.C. labs and programs across the
United States and C.D.C. operations around the world. Despite that
scope, the agency has little authority. Its officers can’t compel
individual states to participate in its initiatives, for example, nor to
include C.D.C. scientists in local outbreak investigations, nor to
share much data with the agency — even in the middle of a pandemic. It
can’t force people to wear masks, or local leaders to close (or open)
schools or other establishments. The agency did try to halt evictions
during the height of the pandemic, but that edict faced such a barrage
of court challenges that its fate remains uncertain even now. Aside from
a few quarantine powers, the most the C.D.C. can do is issue guidance,
which is unenforceable and — as the past year has repeatedly shown —
just as likely to be weaponized as meaningfully employed.
Insiders
say three problems affect the institution: a lack of funding, a lack of
authority and a culture that has been warped by both.
The
C.D.C.’s multibillion-dollar annual budget is both too small — it has
barely kept pace with inflation in the last two decades — and subject to
too many restrictions. Around half of the agency’s domestic budget is
funneled to the states, but only after passing through a bureaucratic
thicket. There are nearly 200 separate line items in the C.D.C.’s
budget. Neither the agency’s director nor any state official has the
power to consolidate those line items or shift funds among them. “It
ends up being extremely fragmented and beholden to different centers and
advocacy groups,” says Tom Frieden, who led the C.D.C. during the Obama
administration. That lack of flexibility makes it extremely difficult
to adapt to the needs of individual states.
This funding system
also hobbles emergency-response efforts, because there is no real budget
for the unexpected. When something like swine flu or Zika or Covid-19
emerges, the agency must rely on Congress for additional resources —
almost always a large, one-time infusion that can’t be used for
longer-term planning — and then deploy those resources, quickly, in the
middle of the crisis. Public-health experts like to call this “building
the plane while flying the plane.” In the past, they say, it made the
C.D.C. scrappy and fostered an esprit de corps among its officers that
helped the broader operation thrive. But in recent decades, these
privations appear to have done the opposite. “I’d go into a meeting and
say, ‘What needs to be done?’” William Darrow, a former chief of the
agency’s Behavioral and Prevention Research branch, told me. “And they’d
give me a five-point chart. And then I’d ask, ‘Well why aren’t we doing
those things?’ And it was all hemming and hawing about whether we could
convince the states, or get top leadership to support it, or if it
would be controversial.”
The C.D.C. is resistant to change, slow
to act and reluctant to innovate, according to critics. The agency’s
officers are overly reliant on published studies, which take time to
produce; and are incapable of making necessary judgment calls. Agency
departments are also deeply siloed. “We are really good at drilling
down,” Darrow says. “But terrible at looking up and reaching across.”
Ongoing tensions between the C.D.C. and its parent agency, the
Department of Health and Human Services, have exacerbated these
tendencies, insiders say, and the agency is constantly fending off
H.H.S.’s efforts to usurp some of its portfolio. “There are a lot of
very good people there,” Bill Hanage, a scientist who studies the
evolution of infectious diseases at the Harvard T.H. Chan School of
Public Health, says. “But when your resources are constantly constrained
like that — when you’re constantly told no — that forces you into a
defensive crouch.”
Long before the
novel coronavirus began its march across the globe, scientists at the
C.D.C. understood that the United States was well behind where it should
have been when it came to identifying and monitoring infectious-disease
threats. In 2014, the agency created the Office of Advanced Molecular
Detection to begin closing this gap, but the effort faced several
hurdles. New technology required much more advanced computer
infrastructure than the C.D.C. or any of the nation’s public-health labs
had. It also required the kind of work force, highly skilled in
bioinformatics and genomic analysis, that you had to compete with the
private sector to get. And it necessitated a mountain of data-sharing
agreements between the C.D.C. and the states that were tricky and
laborious to negotiate. “We are talking about a 50-way dialogue,” says
Duncan MacCannell, lead scientist at the O.A.M.D. “Anything you want to
do or change has to be negotiated with each state separately, and at the
end of the day, they can still say no to you.”
Just about every
public-health lab in the nation had at least some genomic-surveillance
capacity by the time the coronavirus pandemic erupted. But most of that
capacity was concentrated in the foodborne-pathogen division, and
despite MacCannell’s best efforts, it was difficult to adapt many of
those programs to meet the new crisis. Several months into the pandemic,
when SARS-CoV-2, the virus that causes Covid-19, was well on its way to
becoming the most-sequenced virus in human history, the United States
was contributing hardly anything to that effort. And when it came to
tracking new variants in the United States, health officials were flying
blind.
MacCannell says he did everything he could
think of to get a handle on the crisis: He and his team devised
protocols to help public-health labs start new sequencing programs;
developed plans for partnering with commercial labs, which have much
greater capacity overall; and set up a consortium of scientists across
the country to collaborate and pool resources. But those efforts were
mere stopgaps, he acknowledges, and in any case the approval and funding
needed to get them off the ground was delayed for many months. “There
was a big gap between what we expected to happen and what we actually
saw unfold,” MacCannell says. “Not only at the federal level, but at
every step down from there.”
Genomic surveillance
is one of many shortcomings plaguing the disease-surveillance system
over which the C.D.C. presides. Those shortcomings have been invisible
to anyone not working in the field, because at first blush the system
makes sense. Public-health emergencies that are identified at the local
level are reported up to state health departments and then, when
necessary, passed on to the C.D.C., where officials analyze the
information, issue guidelines and coordinate federal response efforts.
There’s a special system for the 120 or so “notifiable diseases”
— like Lyme disease and hepatitis — which everyone agrees are serious
enough to warrant immediate action, and another for “syndromic
surveillance,” in which epidemiologists can search real-time
emergency-room data for symptoms of concern. But beneath that broad
structure, chaos often reigns.
As the coronavirus
grew into a full-blown pandemic, C.D.C. scientists struggled to answer
even basic questions about what the disease looked like or where or how
it was spreading.
The system itself is deeply
disjointed, and the technology that underpins it is less sophisticated
than that found in many American households. State health departments
are not connected to one another in any meaningful way, nor are
hospitals, clinics, laboratories and local health agencies. The C.D.C.
maintains more than 100 separate disease-specific computer systems (a
byproduct of the agency’s funding silos), and many of those can’t
interface with one another. Crucial data is often shepherded from health
care facilities to health departments through a tortured process that
can involve handwritten notes, manual spreadsheets, fax machines and
snail mail. It’s not uncommon for basic information like race,
ethnicity, age or address to be missing from clinical reports. It’s also
not uncommon for those reports to languish at the state or local level
without ever making their way to federal officials. Even the most
serious diseases, which are supposed to be logged within 24 hours of
detection and reported to the C.D.C. in a timely way, are not
necessarily sent up that chain in any systematic manner. “It depends on
the jurisdiction,” Janet Hamilton, executive director of the Council for
State and Territorial Epidemiologists, told me recently. “Some regions
have robust public health departments and good reporting records, and
others don’t.”
Disease monitoring is also hampered by the uneven
patchwork of surveillance programs across the country and the need to
negotiate data sharing and other agreements separately with each state.
Antibiotic resistance, respiratory infections and other pathogens are
tracked robustly in some areas and very poorly or not at all in others
(respiratory infections, for example, are more heavily monitored in the
Four Corners region than in other places), in part because the agency
does not have the ability, or authority, to get all the data it needs
from every community. Hanage likens the entire apparatus to a Rube
Goldberg machine. “There’s no central anything,” he says. “Random
patchwork collaborations were initiated and transformed and now have an
outsize impact on our understanding of public health. That’s not to
criticize the people who made those things, because the alternative
might have been nothing. But the result is something with no rational
plan behind it.”
The gaps make it difficult to track even well-known diseases and nearly impossible to get a handle on new ones. During a recent E. coli outbreak
involving romaine lettuce, officials were forced to base
billion-dollar, life-or-death decisions about which products to pull
from which shelves in which regions of the country on data that was
being screen-shotted and text-messaged to epidemiologists and health
officials. During the vaping injury (or Evali) outbreak in 2019,
doctors faxed hundreds of pages of medical records, for some cases,
directly to local health departments. Epidemiologists could barely
process the data in that format, let alone parse it for clues. “There is
no ready-made process for when something like vaping injury or Zika or
SARS-CoV-2 pops up,” Hamilton says. “There are 64 separate public-health
jurisdictions in this country, and each one will have its own ideas
about what information to collect and how to share it.”
In 2020,
as the coronavirus grew from a few isolated outbreaks into a full-blown
pandemic, C.D.C. scientists struggled to answer even basic questions
about what the disease itself looked like or where or how it was
spreading. “We were being asked who is being hospitalized, who are the
severe cases, what are the characteristics, and it was so frustrating,”
Anne Schuchat, the agency’s deputy director, told a panel of colleagues
last fall. “People were going out to manually review charts. I felt
like, well, the health care sector has this data. It’s sitting in their
system. Can we work with them?” The agency could not keep reliable track
of testing or case rates across the country. It also struggled to
update hospital data, which includes things like bed availability and
ventilator supply; the Trump administration hired a private contractor
to assemble that data, amid accusations of political favoritism. And
when multiple vaccines were finally deployed, the agency was not able to
monitor supplies or accurately keep tabs on waste.
Covid
is the biggest crisis the C.D.C. has faced, by far, in all its history.
It is exactly the kind of threat for which the agency was created in
the first place. But when it finally arrived, by most accounts,
officials there had very little to meet it with.
By mid-May of
this year, the nation had cleared what felt like a dangerous
bottleneck. The dreaded fourth surge in cases had not materialized, even
as it became clear that more-contagious variants were spreading across
the country. Vaccination rates were climbing steadily, despite
vaccine-hesitancy; and case counts, hospitalizations and daily death
counts were trending downward just about everywhere. Yet the C.D.C.
struggled to grasp this new reality. Agency officials were exceedingly
slow to update guidelines, and then conservative, awkward and confusing
when they finally did. They waited months before saying anything at all
about the impact that vaccination might have on various restrictions.
When they finally allowed that people who were fully vaccinated could resume overseas travel, Walensky, the agency’s director, undermined that advice almost immediately by saying that personally, she advised against it.
A
few weeks later the agency updated its mask guidelines: Fully
vaccinated people should wear masks in all indoor settings and in some
outdoor ones, and unvaccinated people should wear masks almost all the
time, including outside, except for when walking or jogging alone. At
summer camp, the agency said, everyone should wear a mask, at all times,
except when swimming or eating. Critics were both bewildered and
frustrated by these edicts. It had been clear for many months that
outdoor transmission was exceedingly rare, and most experts agreed that
fully vaccinated people were highly unlikely to contract the virus and
even less likely to pass it on to others if they did. Why was it taking
the C.D.C., the supposed leader in global public health, so long to
acknowledge what everyone else could see so clearly?
Lawmakers —
Republicans especially — denounced Walensky over the lag. At one
hearing, Bill Cassidy of Louisiana warned that the agency was at risk of
becoming completely irrelevant to the American public. “I always
considered the C.D.C. to be the gold standard,” Senator Susan Collins of
Maine told Walensky at the same hearing. “I don’t anymore.” A few days
later — just weeks after the C.D.C. had told everyone to keep their
masks on — the agency announced yet another update: People who were fully vaccinated could ditch their masks in most settings, including in most indoor settings.
Critics
took issue with this move too. The old guidelines were too strict, they
said, but these were too lenient and failed to factor in the realities
of human behavior. How would retail workers distinguish among vaccinated
and unvaccinated patrons? What should immunocompromised people do,
especially in workplaces where masks and distancing would not be
enforced? And what would happen now in communities with very low
vaccination rates? Even the C.D.C.’s staunchest defenders wondered aloud
why the agency had not taken a more sensible middle path between the
two extremes. Why not suggest scrapping outdoor mandates altogether,
given how rare outdoor transmission seemed to be? And then maintain
indoor masking edicts or tie them to vaccination rates, or even
transmission levels, in individual communities?
It’s unclear how or whether any of these more practical questions factored into the C.D.C.’s decision-making. The Washington Post reported that
White House officials pressed the agency about the implications such
guidelines would have for businesses and people who could not be
vaccinated, but could not get satisfactory answers. With some 35,000 new
cases and more than 600 deaths still being logged nationwide every day,
some of the agency’s own staff members had wanted to hold off on the
update, according to the paper. Many scientists and public-health
experts seemed to agree that it made sense to lift masking advisories as
the agency had done, but even to them, the agency seemed to be
operating inside a black box.
Why was it
taking the C.D.C., the supposed leader in global public health, so long
to acknowledge what everyone else could see so clearly?
Walensky
maintained that as with all of the agency’s guidelines, its position on
masks changed as the science behind them evolved. She cited a roster of
new studies that she said had tipped the balance of evidence away from
outdoor masking, and toward loosening restrictions for the fully
vaccinated. And the C.D.C. pointed out that not even President Biden had
been notified of the agency’s decision until a few hours before the
announcement — proof that it was not being swayed by political
considerations.
But even if the agency was governed exclusively by
science, at least some of that science was flawed. Far fewer than 1
percent of coronavirus cases — fewer than one-tenth of 1 percent, by
some estimates — have been contracted outdoors. The C.D.C. puts the risk
at less than 10 percent, an order of magnitude higher. Walensky says
the higher number comes from an aggregation of high-quality
peer-reviewed research. But, as The New York Times has reported,
those studies rely on an overly liberal interpretation of the term
“outdoors.” They included almost any setting that had an outdoor
component: Workplaces and educational settings counted as outdoors if
people sometimes went outside to a courtyard or play area.
It was not until late this spring that the agency finally acknowledged that the virus was airborne
and that people did not necessarily need to be in close contact to
infect or be infected by one another, something many scientists, not to
mention average citizens, had long since concluded. Here, too, the delay
came down to a flawed interpretation of published studies and a blind
eye toward real-world experience. For the better part of a year, C.D.C.
scientists relied on research that tried to culture the virus from air
samples — a notoriously difficult feat, even for viruses like measles
that are known to be airborne. In the meantime, they overlooked ample
evidence — including multiple superspreader events that its own epidemiologists had tracked — that the virus could be carried on air currents well beyond six feet.
This spring, the Biden administration issued a proposed budget that included the C.D.C.’s biggest funding increase in nearly two decades.
And in recent months, the agency received billions of dollars in
Covid-19 supplemental funding that has been used for long-overdue
data-modernization and genomic-surveillance initiatives. Since at least
February, Walensky has appeared at multiple press briefings each week,
as a key member of the president’s Covid-19 response team. She has also
held a series of “all-hands meetings” with C.D.C. staff members where
attendees say she renewed the agency’s commitment to health equity and
hinted at the need for broader reforms within the agency. “It feels like
we’re finally starting to move forward,” a senior C.D.C. official, who
asked not to be named discussing the agency, told me in April.
But
the pall of the previous year still lingered. Not only did the public
messaging flubs — and the public backlash against them — persist, but
there also seemed to be no plan to fully reckon with the agency’s
biggest missteps and mistakes, many of which were still coming to light.
In her assessment of the C.D.C.’s Trump-era coronavirus guidelines,
Schuchat identified several that were either written outside the agency or considerably
watered down before publication, or both. But her report did not say who
was responsible for that interference, nor parse the leadership
failures that allowed it to happen, nor offer any real plan for
preventing similar mistakes in the future. Those questions need to be
answered, too. “What we really need is a truth-and-reconciliation
commission,” the senior C.D.C. official told me. “But we need someone at
the very top to make that happen.”
In May, both Schuchat and Nancy Messonnier,
the long-serving director of the C.D.C.’s immunization center, resigned
from the C.D.C. Some agency staff members and alumni I spoke with
lamented these departures. Schuchat especially had attained an aura of
celebrity in her 30 years with the United States Public Health Service.
She had served as deputy director under three administrations and
presided over scores of high-profile outbreak investigations, and her
institutional memory is unrivaled. But some said that such resignations
were necessary for the C.D.C. to move forward, and that if anything, a
greater purge of top leadership was warranted. How could the agency
reform itself if the people who built its current culture and set its
institutional priorities were still running things?
Others pointed
out that personnel changes were no substitute for the much bigger fixes
that were needed — starting with the agency’s own culture. “For years,
we have managed to muddle through crisis after crisis, thanks to some
luck and to some of the truly brilliant people that we have here,” the
senior official told me earlier this year. “But those wins have been a
double-edged sword, because now our reputation exceeds our capacity, and
people think we can do all these things that we can’t actually do. And
we have sort of internalized that and become deluded ourselves, instead
of reflecting on how we need to improve.” Like other agency insiders I
spoke with, he was deeply anxious about the C.D.C.’s future and adamant
that any reckoning would have to go beyond the obvious crisis of the
previous administration. “We have a chance to rebuild this institution
so that it works the way we want it to,” he said. “But we have to start
by acknowledging what’s really broken.”
Many scientists I spoke
with insisted that the biggest barrier to modernizing the C.D.C. was the
agency’s own lack of imagination. New technologies capable of tracking
pandemic disease through wastewater, for instance, or through human
blood are promising and could revolutionize the fight against global
disease threats — if only agency scientists would open their minds and
embrace them. But such technologies are difficult to imagine in a system
that still relies on fax machines.
‘You can’t starve and neglect something over and over for decades and then expect it to function perfectly in a crisis.’
Each
fresh crisis brings new resolve to modernize the system, but that
resolve usually evaporates before progress can be made. And when funds
are available, public health tends to lose out to other interests. In
2010, for example, when Congress appropriated billions of dollars
through the Affordable Care Act to upgrade the nation’s electronic
medical record systems, just about all of the money went to health care
providers, not public-health departments. In 2019, when a consortium of
public-health groups asked Congress for $1 billion to be routed through
the C.D.C. over the next 10 years to upgrade the public-health data
system, lawmakers gave them $50 million. By then, the novel coronavirus
had almost certainly made its way into several states, but owing partly
to insufficient surveillance efforts, it would be months before anyone
realized it.
One thing most experts seem to agree on is that the
agency’s budget — both the amount of money it receives and the
mechanisms by which it is allocated — needs an overhaul. Fiscal
insecurity makes it difficult for the agency to be bold or innovative,
to build strong relationships or to lead in a crisis. But the history of
attempts to fix these problems is long and littered with failure. In
1983, William Foege, the agency’s director at the time, advised Congress
to index a portion of total health care spending and reserve it for
public health. Lawmakers did not heed his advice. In the early 2000s,
Julie Gerberding tried to change the agency’s funding structure so that
states could have more flexibility in how they spent C.D.C. dollars, to
no avail. And a decade later, Frieden tried to do the same. The only
thing he accomplished, he says, was to “make everyone really angry” with
him. “Each of those line items is protected by a fierce constituency
that fought to get it there in the first place,” Gerberding says. New
suggestions are again percolating. Almost every former director I spoke
with had at least one proposal or plan for how to fortify the agency by revising its funding structure. But it remains to be seen whether any of them can gain currency.
Many
have also argued that the agency should be granted more authority —
during public-health emergencies, at least. If the C.D.C. could compel
states to share key data through a central, standardized system, or to
sequence a certain portion of viral genomes, the nation might be able to
develop a picture of a given crisis much more quickly and accurately.
And if the agency could enforce certain edicts at the outset of an
outbreak, officials might be able to stave off a full-blown epidemic.
“We need to come up with a set of no-regret interventions,” Hanage says.
“Like, if you have credible evidence of a virus with certain
properties, you enact certain measures, like enforced quarantines,
regardless. Not to stomp it out, but to slow it down long enough to get
other measures in place.” The politics of such a shift might prove
insurmountable. “If there was a proposal to give C.D.C. all the same
powers that states have for public-health emergencies, 50 governors
would immediately oppose it,” Foege told me (in fact, several states are
pressing right now to curb the powers of public-health agencies, not
expand them). But the specter of 50 separate coronavirus responses, and
more than half a million deaths nationwide, has convinced some
public-health professionals that it’s time to give the idea serious
consideration.
In truth, the C.D.C. and the states each deserve a
share of the blame for the disconnect between them. “State and local
health departments often feel like C.D.C. is clueless about the
challenges they face and the realities of their work,” Frieden says.
“And they are not entirely wrong in that.” But while state leaders
complain that the C.D.C. is clueless, and occasionally make a show of
flouting the agency’s guidelines, some can also be obstinate about
sharing data and communicating with the agency — even when it’s in their
own best interest. “Sometimes we ask for info, and they just say they
can’t give it to us,” the senior C.D.C. official told me. “We don’t know
if they are underresourced, or they just don’t want to, or what —
because they don’t tell us.”
Frieden, who served as New York City
health commissioner before his stint as C.D.C. director, says that one
way to bridge this divide might be to create an exchange program of
sorts, where thousands of C.D.C. staff members are embedded in state and
local health departments for two-to-five-year periods. “In time, you’d
have a whole cadre of public-health experts, and a common vision between
the C.D.C. and state health departments,” he says. “You’d also have a
much stronger public-health system overall.”
Of course, true
reform will require more than money or new laws or even a revived spirit
of innovation. It will require a reconciliation of sorts: The C.D.C.
will have to regain the nation’s trust. The nation will have to
acknowledge the limits it imposed on the agency, both implicitly and
explicitly, from the outset. And both sides will have to reckon with a
fundamental but inconvenient truth: Public health can never fully
divorce itself from politics, because public health is an inherently
political endeavor. It involves more judgment calls than absolutes and
requires trade-offs and public acceptance to work.
In other words, not every failure
of pandemic response can be pinned on the C.D.C. “There has been a real
pile-on against the C.D.C. in the past few months,” Frieden told me in
early June. “Did they fall down on some things? Yes. But they have also
done a lot of good work that’s been overlooked. And you can’t starve and
neglect something over and over for decades and then expect it to
function perfectly in a crisis.”
In retrospect, it seems clear
that only a strong C.D.C. — a well-funded, well-run federal authority,
grounded in science and resistant to political pressure but also mindful
of lived reality — could have rescued American policymakers from the
worst of their Covid confusion. And only a stronger C.D.C. stands a
chance of correcting these errors when the next pandemic comes along.
But the federal agency is just one part of a much larger system, and
other components of that system must work properly — and together. For
much of the last year, they have not.
Federal agencies
like the Department of Education have not stepped in to help schools
confront the challenges of infection control, for example. And while
many communities have made heroic efforts to beat the virus back, state
and local officials have not always done as much as they could to build
trust or secure community support for needed measures. Too often, they
fell prey to political bickering and wielded data points as weapons
instead of as tools to improve safety. Fear and frustration have
prevailed as a result, even as the pandemic wanes — and especially when
it comes to schools. While some parents rage over mask mandates and
contact-tracing regimes, others say they won’t return or send their
children back, even with every precaution in place, until every last
person is vaccinated. The fault lines of this divide are familiar, but
somehow knowing where they lie has not helped the nation avoid them.
The
C.D.C.’s institutional cautiousness and muddy messaging have not
helped. “The C.D.C. is like an elephant turning around in a camp tent,”
Allen says. “It does not realize that when it turns all these other
things have to turn around it.” But the problem is much bigger than
messaging or guidelines. The U.S. public-health apparatus is vast and
unwieldy. Its components are supposed to work closely together but are
instead disconnected from one another, and there is little awareness of
this problem or of the impact it has on broader response efforts.
Neither the C.D.C. nor the entities it serves seem to have an
understanding of what federal disease control is supposed to do, or what
the limits of the current system actually are. “C.D.C. updates its
guidelines, and half of America thinks that means the rules have
changed,” Allen says. “But C.D.C. does not make the rules, states and
cities do.”’
Only a stronger C.D.C. stands a chance of correcting these errors when the next pandemic comes along.
Without
that basic understanding, nuanced discussion has been difficult, and
rare. “We’ve spent a whole year debating things like six feet versus
three feet, and masks versus no masks,” Friedhoff, from the Covid
Collaborative, told me. “But the answers to these questions are totally
context-dependent. The way you layer infection-control measures in a
school depends on what your building looks like, how many students you
have and so on.” That, she says, is the understanding that public-health
groups need to instill in educators, business owners and average
people. But so far, it has been lost in all the noise.
A perfect
case study is Manatee County, in western Florida, which decided to open
its school doors to full-time in-person instruction in January. Kevin
Chapman, the district’s strategic planning director, relied heavily on
the C.D.C.’s guidance. “It was the only thing we had to go by, the only
authority or expertise we could lean on,” he says. The guidelines were
hardly perfect: They appeared to have been written by medical
professionals who had never set foot in a school. And the district had
no meaningful support when it came to translating them. The state’s governor, Ron DeSantis,
routinely undermined the C.D.C. in his remarks, which by extension
seemed to throw the efforts of Chapman and his colleagues under
suspicion too. But the team did the best they could. They set up an
operations center, educated themselves in the delicate science of
contact-tracing and worked with their local health department to hew as
closely as possible to what the federal agency had laid out.
They
managed to keep the virus at bay. There were no school outbreaks and no
closures between January, when schools reopened, and late May, when the
school year finally ended. But even so, the district plans to abandon
almost all of its current protocols when the next school year begins: no
masks, no contact tracing and none of the other edicts that have helped
keep the virus in check. Chapman worries that this is too much, too
soon, but his team has little recourse. DeSantis has lifted the state
mask mandate, and for weeks, a contingent of vocal parents crowded into
school-board meetings to demand that the school district follow suit.
Never mind that the C.D.C. quickly clarified that its loosened
guidelines didn’t apply to schools. “They yell and threaten us,” Chapman
says. “They tell us that it doesn’t matter what the C.D.C. says. That
if DeSantis has lifted the mask mandate, schools should do the same.”
Friedhoff
worries that with schools opening or staying closed based on political
considerations, a broader opportunity is being missed. “We have a chance
right now to make good infection control and healthier buildings a part
of school culture,” she says, “the same way that mental health and
healthy eating have become part of that culture.” But that will only
happen if school officials can absorb the right lessons from the last
year.
The same is true of state and local governments,
and of lawmakers who set the C.D.C.’s funding and determine its powers.
As the pandemic fades into the background of American life, it’s unclear
whether the necessary changes will take place. Public attention and
political resolve are likely to fade quickly as vaccination rates
increase and case counts decline. That prospect troubles those who
believe in the C.D.C.’s mission and who still have hope for its future.
“I think the very worst thing that could happen now,” the senior C.D.C.
official told me recently, “is for all of this to be forgotten and for
everything to just go back to business as usual.”
US private hospitals eye overseas expansion in search of vast profits
by Jordan Rau - Kaiser Health News - June 22, 2021
Foreign forays prompt questions about why US non-profit health systems are indulging in such nakedly commercial ventures
Across the street from the Buckingham Palace Garden and an ocean away
from its Ohio headquarters, Cleveland Clinic is making a nearly $1bn
bet that Europeans will embrace a hospital run by one of America’s
marquee health systems.
Cleveland Clinic London, scheduled to open
for outpatient visits later this year and for overnight stays in 2022,
will primarily offer elective surgeries and other treatments for the
heart, brain, joints and digestive system. The London strategy attempts
to attract a well-off, privately insured population: American
expatriates, Europeans drawn by the clinic’s reputation, and some
Britons happy to pay. The hospital won’t offer less financially
rewarding business lines, like emergency services.
“There are very
few people out there in the world who would not choose to have
Cleveland Clinic as their healthcare provider,” said chief executive
Tomislav Mihaljevic.
Facing
the prospect of stagnant or declining revenues at home, about three
dozen of America’s elite hospitals and health systems are searching with
a missionary zeal for patients and insurers able to pay high prices
that will preserve their financial successes.
For years, a handful
of hospitals have partnered with foreign companies or offered
consulting services in places like Dubai, where western-style healthcare
was rare and money plentiful. Now a few, like the clinic, are taking on
a bigger risk – and a potentially larger financial reward.
But
these foreign forays prompt questions about why American non-profit
health systems, which pay little or no tax in their home towns, are
indulging in such nakedly commercial ventures overseas. The majority of
US hospitals are exempt from tax because they provide charity care and
other benefits to their communities. Non-profit hospitals routinely tout
these contributions, though studies have found they often amount to
less than the tax breaks.
Despite their tax designation,
non-profit hospitals are as aggressive as commercial hospitals in
seeking to dominate their healthcare markets and extract as high prices
as they can from private insurers. Though they do not pay dividends,
some non-profits amass large surpluses most years even as more and more
patients are covered by Medicare and Medicaid, the US government’s
insurance programs for the elderly, disabled and poor, which pay less
than commercial insurance.
Cleveland Clinic, one of the
wealthiest, ran an 11% margin in the first three months of this year and
paid Mihaljevic $3.3m in 2019, the most recent salary disclosed.
The
advantages of international expansion for their local communities are
tenuous. Venturing overseas does not provide Americans with the direct
or trickle-down benefits that investing locally does, such as
construction work and healthcare jobs. Even when hospitals abroad add to
the bottom line, the profits funneled home are minimal, according to
the few financial documents and tax returns that disclose details of the
operations.
“It’s a distraction from the local mission at a
minimum,” said Paul Levy, a former chief executive at Boston’s Beth
Israel Deaconess Medical Centerand now a consultant.
“People get into them at the beginning thinking this is easy money. The
investment bankers get involved because they get the financing, and the
senior faculty get on board and say, ‘This is great; it means I can go
to Italy for two years’ – and there’s not a real business plan.”
There
are financial hazards. For instance, Cleveland Clinic has warned
bondholders that its performance could suffer if its London project does
not launch as planned. There are also risks to a system’s reputation if
a foreign venture goes awry.
Finance experts temper expectations
that operations of overseas hospitals will have a major bearing on a
system’s balance sheet. “Even though they do well, they’re small
hospitals – they’re never part of the overall picture,” said Olga Beck, a
senior director at Fitch Ratings. “It does help [the US operations]
because it gives a global name and presence in other markets.”
Hospital
executives say their foreign ventures provide an additional source of
revenue, thus adding stability, and benefit the care of their hometown
patients.
“As we go to different areas around the world, we learn
and we continuously improve for all our patients,” said Brian Donley,
chief executive of Cleveland Clinic London. He said the clinic has
learned from UK practices more efficient ways to sterilize surgical
instruments and perform X-rays.
One of the oldest foreign ventures
is the organ transplant program the Pittsburgh-based non-profit system
UPMC has run in the Italian city of Palermo since 1997, when Sicily’s
government and Italian insurers realized it would be cheaper to perform
those procedures there than continue to send patients to the US. Since
then, UPMC’s Palermo facility has performed more than 2,300 transplants.
In
this initial expansion, the US hospital was providing a highly
specialized type of surgery – one that UPMC is renowned for – that was
not available locally. But UPMC, one of the most entrepreneurial US
health systems, didn’t stop there. In Ireland, UPMC owns a cancer center
and provides care for concussions through sports medicine clinics.
Since 2018, the system has acquired hospitals in Waterford, Clane and
Kilkenny. They are staffed mostly by independent Irish physicians, but
UPMC regularly sends over its leading US specialists to lend expertise,
according to Wendy Zellner, a UPMC spokesperson.
UPMC has company
in Ireland: in 2019, Bon Secours Mercy Health, a Roman Catholic system,
merged with a five-hospital Catholic system there.
Over the past
two decades, UPMC did advisory and consulting work in 15 countries but
decided to narrow its involvement to four: Italy, Ireland, China and
Kazakhstan, where UPMC is helping a university develop a medical
teaching hospital. Charles Bogosta, president of UPMC International,
said UPMC wanted to focus its efforts where it was confident it could
improve the quality of care, bolster UPMC’s reputation and earn profit
margins greater than its US hospitals do.
UPMC officials said the
economics are favorable abroad because labor is cheaper and the mix of
patients is heavily tilted toward those with commercial insurance, which
pays better than government programs.
“What we’ve been doing
overseas has been really helpful in addressing what everyone in the US
is trying to do, which is come up with diversified revenue sources,”
Bogosta said.
Even
so, that extra revenue remains a small part of UPMC’s earnings. The
health system’s foreign hospital business generated gross revenues of
$96m, or 1% of UPMC’s $9.3bn total hospital revenues in 2019, according
to a KHN analysis of a UPMC financial disclosure. Since that figure is
before accounting for the costs of running the hospitals, taxes and
other expenses, the actual profits the foreign hospitals might send back
to Pittsburgh are much smaller.
In Ireland, where corporations
are required to disclose audited financial statements, UPMC Investments
Ltd, an umbrella group that owns the Waterford hospital operation and
property, reported net profits of about a half-million dollars in 2019
on more than $47m in gross revenues.
In an email, Zellner said the
Ireland statements “do not give you the totality of the picture in
Ireland or International, where our results are far better than these
documents would suggest”. UPMC declined to provide more detailed
financial data.
But foreign ventures can misfire. “These
partnerships can turn into nightmares, as Hopkins has learned,” Steven
Thompson wrote in a 2012 article for the Harvard Business Review that
described his observations as the founder and first chief executive of
Johns Hopkins Medicine International, a for-profit venture jointly owned
by Johns Hopkins Medicine and Johns Hopkins University.
Cleveland
Clinic London is unusual in that US health systems rarely build a
hospital abroad from scratch without a local partner. The clinic chose
that more cautious approach with Cleveland Clinic Abu Dhabi, a 364-bed
hospital owned by the Mubadala investment company that the clinic
manages. It also has a consulting practice that is helping a Singapore
healthcare company build a hospital in Shanghai.
Foreign
enterprises appeal to the clinic because it has limited growth
opportunities in Ohio, where the population is growing slowly and aging,
meaning more patients are leaving high-paying commercial insurers for
lower-paying Medicare. The clinic has expanded in Florida, acquiring
five hospitals to take advantage of population increases and wealthier
patients there.
The London project will have 184 beds and eight
operating rooms. Donley said it will be staffed primarily by UK
physicians, including ones who also work for the NHS.
“The clinic
has a long track record of being able to execute on its strategies,”
said Lisa Martin, an analyst at the bond rating agency Moody’s Investors
Service. “The London project is obviously the biggest venture and the
biggest financial risk that they’ve made abroad.”
Congrats, America! Earlier this month you passed an annual milestone: Two days after Tax Day, you made it to… Deductible Relief Day!
What’s that? It’s the day where the average person with
employer-based health insurance has spent enough on health expenses to
finally meet their deductible.
Health insurance deductibles have been rising so rapidly (year after
year after year) that the Kaiser Family Foundation decided to track the
trend to show how severely Americans are getting ripped off (and sick). And it’s bad.
As you might guess, the Deductible Relief Day is being pushed further
each year. In 2005, you had to wait until February 28. By 2009, you
wouldn’t be popping champagne until March 18. In 2019, you waited two
months more than that.
As the Kaiser Family Foundation noted, in 2009, the average
deductible was $533 for a single person. In 2018, it was $1350. How? The
insurance industry strategy of moving all of us into high-deductible
plans (one of the many gross abuses I saw first-hand at Cigna) has paid
off well for my former employers.
“Average enrollee spending on deductibles more than tripled between 2007 and 2017.”
In 2018, about 85% of covered workers were enrolled in a
high-deductible plan, up from just 50% ten years earlier. Another way of
looking at this: Average enrollee spending on deductibles more than
tripled between 2007 and 2017.
And Kaiser didn’t look at people who buy their coverage on their own through the ACA exchanges. They’re in even *worse* shape. The Commonwealth Fund
found that 40% of people in ACA plans are underinsured because of high
out-of-pocket charges – and many likely never meet their deductibles.
As a result, millions of Americans are not going to the doctor or
picking up prescriptions. Insurers LOVE that. It’s far fewer claims to
pay! It’s why, when many other businesses went belly up during COVID-19,
insurers made record profits: medical treatment was less accessible!
President Biden, are you paying attention to this? You must.
Millions
of people WITH insurance who voted for you, including folks on
Obamacare, CAN’T USE IT because of deductibles! Insurers can charge
families up to $7,200 before they’ll pay a dime. It keeps going up.
Every. Single. Year.
No wonder more and more Americans with insurance are turning to
GoFundMe or bankruptcy court. It’s not just the premiums you gotta worry
about, Joe. Deductibles are eating us alive. You and Congress need to pay attention before NO Americans can meet their deductibles.
The Three Trends Fueling Health Insurers’ Frightening Growth and Profitability
The top three trends that have enabled insurers to rise to the
top tier of American corporations and report record-breaking profits
quarter after quarter.
by Wendell Potter - Tarbell - June, 2021
2020
was the year of the worst pandemic of our lifetime, and it turned out
to be the most profitable year ever for America’s health insurers, even
as many hospitals and physician practices were struggling to stay
afloat. Unless current trends change and cause some unexpected reversal
of fortune, 2021 will likely bring more of the same — if not bigger
profits — for health insurers.
In this article, I’ll identify the top three trends that have
enabled insurers to rise to the top tier of American corporations and
report record-breaking profits quarter after quarter. If you’re
wondering, those qualifiers are not meant to be compliments.
But first, here’s some context to set the stage.
If it ain’t broke…
Considering how well the status quo is working for health insurers,
you can understand why they are spending more and more of their premium
revenue on lobbying and PR efforts to kill or weaken health insurance
reform proposals, especially the one championed by President Biden
during his candidacy: establishing a public option to compete with
private insurers.
Health insurers talk a good game about “choice and competition,” but
their actions in both the marketplace, in which consolidation has
created companies far bigger than just a decade ago, and the political
arena, belie their talking points. During the first quarter of this
year, the industry’s biggest trade group, America’s Health Insurance
Plans, spent more money on lobbying in Washington than any prior 3-month
period. Centene,
one of the industry’s newest and now biggest players (thanks to a
string of acquisitions), spent a whopping 80% more between January and
March of this year than during the same period a year ago.
With diminishing competition, the big for-profit insurers have been
able to use the premium and fee increases they demand from customers to
bulk up, transform themselves to the point that the terms “insurer” and
“payor” are antiquated and no longer descriptive, and erect nearly
impenetrable barricades to keep would-be reformers and competitors at
bay. The same can be said of the 35 nonprofit Blues as many dominate
their individual markets, as well as the political landscape in their
individual markets.
These companies’ aggressive push for vertical integration (e.g.,
massive M&A activity) has catapulted half of the big six (Anthem,
Centene, Cigna, CVSHealth, Humana, and UnitedHealth Group) into the top
20 of the Fortune 500 in recent years — and two of them into the top 10.
CVSHealth, Aetna’s parent company, now ranks #5, right behind Amazon,
Walmart, Apple and Exxon Mobil. UnitedHealth Group is #7, just below
Berkshire Hathaway. Cigna, which was #141 on the list when I left the company’s employment in 2008, is now #13.
Now onto the turbo-charged, profit-enhancing business practices driving pandemic profits
The trends that have made some of the biggest contributions to health
insurers’ unprecedented growth and profitability were well underway in
2010 when Congress passed the Affordable Care Act, which conventional
wisdom (even on Wall Street) held would put a big crimp in insurers’
profit margins. While the ACA did make several common industry practices
illegal — notably their refusal to sell coverage to people with
preexisting conditions (or charging them more than most could afford)
and spending less than 80 percent of premium revenue on claims — it
didn’t deter insurers from going on buying sprees and turbocharging
other, still legal, profit-enhancing business practices.
Trend #1: Vertical Integration
When I left the industry a little more than a decade ago, most of the
companies’ M&A activity was still horizontal, meaning insurers were
buying or merging with competitors. When Humana recruited me in 1989,
it was better known in the managed care space than UnitedHealth was at
the time, even though Humana hadn’t yet shed its even better-known
hospital division. But UnitedHealth was busy quietly buying relatively
small local and regional health plans. It entered the big leagues in
1995 with its acquisition of Travelers’ and MetLife’s group health
businesses. Numerous other acquisitions followed. In more recent years,
with fewer competitors left to buy, UnitedHealth has shifted its M&A
strategy (as have most of the other bigs), making it no longer
horizontal M&A, but vertical integration, meaning the company is now
deep into healthcare delivery. It’s fastest growing and most profitable
division these days is Optum, which not only operates a huge PBM but
also outpatient facilities, including kidney dialysis giant DaVita, and
numerous physician practices. It surprised even me to learn that
UnitedHealth is now the country’s biggest employer of doctors — more
than 50,000 at last count with plans to add another 10,000 this year.
UnitedHealth’s competitors had no choice but to follow suit and go
vertical. Cigna went big with its 2018 acquisition of Express Scripts.
Aetna is now a big part of a company that operates not only a huge PBM
but 10,000 retail drug stores, many of which now employ doctors and
nurse practitioners in their walk-in “MinuteClinics.” Anthem and Humana —
and to a lesser extent Centene — have also become more diversified
companies by entering the provider space. This change in M&A
strategy obviously has enormous implications for the country’s doctors
and hospitals.
Trend #2: Changing sources of revenue
Not only have these big corporations experienced massive growth in
revenue from their non-health insurance lines of business, but their
health plan revenues have also seen a big shift in recent years. Not so
long ago, the big insurers were getting most of their health plan
revenue from private-sector customers, primarily the nation’s employers.
But after the Medicare Modernization Act of 2003, which made the
Medicare Advantage business more lucrative, insurers flocked to that
program. Now, many of the big insurers get more of their health plan
revenue from government programs — primarily Medicare and the state
Medicaid programs they manage — than from private employers and
individuals shopping for coverage on the ACA exchanges. In the first
quarter of this year, 72% of UnitedHealth’s U.S. health plan revenue
came from government payers. The shift has been almost as stark for the
other big players. Centene, which has grown rapidly through numerous
acquisitions, has very few private paying customers.
Trend #3: Barriers to care
Health insurers theoretically have two ways of managing healthcare
costs: Influencing the unit cost of goods and services and influencing
access to those goods and services. Despite their size, they have an
unimpressive track record when it comes to reducing the unit cost of
those goods and services, prescription drugs in particular. One could
argue that they have little interest in doing that. As long as there is
no competitor (as a robust public option might be), insurers can simply
raise the premiums they charge customers to account for anticipated
increases in “medical trend.” In other words, the more the prices of
goods and services increase, the more insurers can demand in premiums
from their customers. Drug rebates processed though insurer-owned PBMs
offer an entirely different set of disincentives, and massive
opportunities for payor margin growth, as well.
Where insurers excel is in restricting access to care, and in recent
years they have ramped up those restrictions to assure levels of
profitability suitable to Wall Street. Those barriers to care include
more aggressive prior authorization requirements, ever-increasing
out-of-pocket requirements of health plan enrollees, and the elimination
of doctors, hospitals and other healthcare facilities from their
provider networks. In many cases, the eliminated providers are being
replaced by the companies’ own providers.
In future articles on Un-covered, I’ll dive deeper into each of these
trends, touching on the consequences of these developments for both
healthcare providers and their patients — as well as employers and the
U.S. economy as a whole — and assess their sustainability.
Will the good times continue to roll for the bigs or will their power and reach into our lives somehow be curtailed? And what can providers, employers, and regular folks do?
Wendell Potter is a former health insurance executive, New York Times
bestselling author, health care and campaign finance reform advocate,
and authority on corporate and special interest propaganda. He leads two
health care reform advocacy nonprofits: the Center for Health and
Democracy and Business Leaders for Health Care Transformation, and is
the founder of Tarbell.org, a nonprofit journalism organization.
UnitedHealthcare recently sparked outcry by saying it
may retroactively deny ER claims — but documents suggest it’s been doing
so for years.
by Andrew Perez - Daily Poster - June 25, 2021
The man’s son had been vomiting, feeling nauseous, and experiencing
bad heartburn for several weeks. The child’s pediatrician eventually
made the call: It was time to take the boy to the ER.
The father,
who requested anonymity, wasn’t the sort of person who went to the
emergency room on a whim. He was an internal medicine physician after
all, so he tried to avoid ER visits as much as possible. But in late
2019, he listened to the boy’s doctor and took his son to the ER near
where they lived in Florida, then took him a second time when he once
again couldn’t hold down food.
The decision ultimately seemed to
make sense. Tests found the boy was suffering from a newly onset
auto-immune disorder. But the family’s insurer, UnitedHealthcare,
refused to pay the bills, which totaled $7,000 — $4,000 of which the
hospital’s physician services company has since demanded from the
family.
The insurer denied one claim, asserting it needed
additional information, and refused to consider two other charges,
saying the “documentation doesn't support the level of service billed.”
The family has tried appealing, but, according to the father, the
insurer has said the physician documentation did not support the ER trip
being an emergency.
To the father, who has been a doctor for more
than a decade, that response made no sense. “We were advised to go
there, so there's no way that it's not [an emergency],” he told The Daily Poster. “It required an ER visit and an inpatient stay to get a diagnosis.”
The Florida-based physician isn’t the only one concerned about the ER policy of UnitedHealthcare, the nation’s largest insurer which last year logged a quarter trillion dollars of revenue while its CEO made $42 million.
Health care advocates recently expressed alarm after the company
announced it was planning to more closely scrutinize emergency room
visits, and potentially deem them “no coverage or limited coverage” events.
The American College of Emergency Physicians (ACEP) warned
that “UnitedHealthcare is expecting patients to self-diagnose a
potential medical emergency before seeing a physician, and then
punishing them financially if they are incorrect.”
In response to the outcry, UnitedHealthcare hastily announced it would postpone the policy at least until the end of the COVID-19 pandemic. However, consumer complaints reviewed by The Daily Poster
— including the incident detailed above — indicate the insurance giant
has already been denying emergency room claims, asserting that patients’
medical scares weren’t real emergencies, leaving them on the hook for
massive bills.
A UnitedHealthcare spokesperson requested that we
hold this story a day for them to review the specific patient
complaints, but ultimately did not respond to our questions about their
denials.
She noted that, “Based on feedback from our provider
partners, we have decided to delay the implementation of our emergency
department program until at least the end of the national public health
emergency period. We will use this time to continue to educate
consumers, customers and providers on the new program and help ensure
that people visit an appropriate site of service for non-emergency care
needs.”
For-profit
health insurance companies regularly refuse to pay for medical services
because denials boost their profits, and they have little incentive not
to deny coverage. In 2019, health insurers rejected roughly 17 percent
of claims for in-network services involving patients on individual
Affordable Care Act health insurance plans, according to data from the Kaiser Family Foundation. Only a tiny fraction of patients appeal the denials.
In 2018, Anthem Blue Cross Blue Shield enacted a similar emergency room policy to the one announced by UnitedHealthcare. ACEP sued Anthem over the policy, and the company has quietly limited its use. Last year, California health care regulators fined health insurer Aetna for wrongfully denying members' emergency room claims 93 percent of the time, in violation of state laws protecting ER patients.
The
issue of rampant claim denials extends to Medicare Advantage plans,
coverage offered to Medicare beneficiaries by private insurers. A few
years ago, the federal Health and Human Services Department (HHS) reported
that “there are persistent problems related to denials of care and
payment in Medicare Advantage.” HHS reviewed Medicare Advantage
contracts covering 15 million beneficiaries in 2016 and found nearly 37
million claim denials — or 2.4 claim denials per customer.
“It’s Bull”
The ongoing pandemic has proven to be a jackpot for health insurance companies, as patients have avoided doctors and trips to the emergency room as much as possible.
UnitedHealthcare
took in $257 billion in revenue last year. It also reported more than
$15 billion in profit — an 11 percent increase from the previous year.
Despite its COVID profit boom, the company chose to announce a policy
likely to deter people from visiting emergency rooms.
On June 8,
UnitedHealthcare wrote: “Effective July 1, 2021, we will enhance our
capabilities to assess emergency department (ED) facility commercial
claims to determine if the ED event was emergent or non-emergent,
according to existing plan provisions, in most states.”
The
company said that emergency room claims would be evaluated based on a
number of factors including “the patient’s presenting problem” and “the
intensity of diagnostic services performed.”
“Claims determined to
be non-emergent will be subject to no coverage or limited coverage in
accordance with the member’s certificate of coverage,” the company
wrote, adding that patients would be given an “opportunity to complete
an attestation if the event met the definition of an emergency
consistent with the Prudent Layperson Standard.”
The Federal Prudent Layperson standard, enacted by Congress in 1997, defines
an emergency medical condition as “a medical condition manifesting
itself by acute symptoms of sufficient severity (including severe pain)
such that a prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of immediate
medical attention” to result in serious harm.
The point of the
Prudent Layperson Standard is to protect patients and allow them to seek
emergency care if they believe it’s necessary. ACEP said the
UnitedHealthcare policy would violate the prudent layperson standard and
“leave millions fearful of seeking medical care.”
The insurer quickly announced
it “decided to delay the implementation of our emergency department
policy until at least the end of the national public health emergency
period.”
But Karen Schapira, a Florida lawyer who often represents health care providers, told The Daily Poster that UnitedHealthcare already has a history of retroactively denying ER claims.
“They're
claiming to have put [the policy] off for now, in response to the COVID
pandemic, and they'll only begin sometime in the future,” she said.
“It's bull, because they've been doing it forever.”
“Extremely Unsettling”
Schapira
is representing the Florida physician whose son’s claims were rejected
by UnitedHealthcare. She took his case on after she was retained by a
young woman with another ER claim denial story involving the insurance
giant.
In that case, a foreign university student in Florida went
to the emergency room in the middle of the COVID-19 pandemic last spring
after she experienced severe chest pain, numbness in her left arm and
leg, and shortness of breath. She feared she was having a stroke or a
heart attack. An ER doctor evaluated her and determined she was having a
panic attack.
The woman, who recently graduated from nursing
school, was insured under a UnitedHealth Global plan through the travel
insurance company Seven Corners. But of the $16,000 she was billed in ER
charges, Seven Corners would only cover $292 — because, according to
her explanation of benefits documents, the “charges exceed [the] maximum
allowed.”
According to a complaint filed in the case, when the
woman questioned the denials, “UnitedHealthcare or its intermediary
advised the diagnosis does not fall within the definition of an
emergency.”
The Daily Poster reviewed several other
consumer complaint files where UnitedHealthcare either denied emergency
room claims as non-emergent or was accused of doing so.
In 2017,
for example, the parents of a young girl in Washington state called 911
after their daughter woke up coughing and gasping for air. Paramedics
directed the family to an emergency room. At the hospital, the child was
diagnosed with Croup, an upper airway infection, provided a nebulizer
and oral steroids, and quickly sent home.
Such an approach is not unusual; the Mayo Clinic instructs
people to seek immediate attention if their child has symptoms of Croup
and is struggling to breathe. UnitedHealthcare, however, denied the
subsequent ER claims, which totaled about $1,950, because the insurer
deemed the visit didn’t meet the definition of an emergency.
The
parents appealed and filed a complaint with the state’s insurance
commissioner’s office. “I find it extremely unsettling that when the
paramedics team that arrived at our house directed us to the nearest
emergency room that somehow that is not considered a ‘true emergency’
and is not covered by insurance,” one of the parents wrote. “Any prudent
parent seeing their child in respiratory distress would be negligent
not to take their child to the emergency room based on the paramedic's
remarks in fear that there could be a negative outcome.”
In
response, UnitedHealthcare wrote that the services provided at the
emergency room didn’t meet the definition of an emergency, and the
patient was not provided emergency services. However, the company said
it determined that “corrective steps are needed” and had “reprocessed
the claim because there was an error in the original processing.” The
company told state regulators it had decided to pay the claims in full
as “a one-time benefit exception,” but insisted that it had “correctly
denied the original claims.”
In another Washington state case, a
parent brought her young daughter, who was suffering from a severe case
of the flu, to the emergency room in 2019 after “she started to turn
purple and her level of consciousness changed,” according to a complaint
with the state insurance commissioner.
“Her hands, face and lips
turned very bluish purple and I could see the purple starting to spread
up her arms,” the parent wrote. “Her speech had changed to not make
sense, and she was quite loopy-acting. I decided to take her into the
emergency room because of these symptoms and because urgent care or
other clinics would not be open for several more hours.”
According
to the complaint, United Healthcare denied the resulting ER claims
because they did not consider the episode “to meet the definition of
emergency services, despite the CDC saying a child with flu-like
symptoms whose face or lips turn bluish is an emergent symptom."
The Centers for Disease Control and Prevention (CDC) advises that children with a bluish face or lips should obtain medical care right away.
UnitedHealthcare
had the complaint immediately thrown out, because the child was on an
employer-funded insurance plan. Such plans are regulated by the U.S.
Labor Department, not by state insurance commissioners.
According
to a different complaint, in March this year, an elderly man in Nevada
started vomiting early one morning and couldn’t stop, eventually
vomiting more than a dozen times. After his son found the man
unconscious, an urgent care center recommended he be rushed to the
hospital.
At the emergency room, medical professionals injected
the man with anti-nausea medication and performed an ultrasound. Based
on the man’s history of kidney stones and prostate cancer, a doctor also
ordered a CT scan.
But Health Plan of Nevada (HPN), a
UnitedHealthcare company, denied the man’s claims after he was billed
more than $31,000 for his care.
“Your emergency room visit has
been denied as the symptoms were not sudden or unexpected requiring
emergency attention,” the company told the man in a letter denying his
claims.
In May, after the man filed his complaint with the Nevada Division of Insurance, HPN approved the claims.
For
Schapira, such cases illustrate the dangers of UnitedHealthcare’s
emergency room denial practices, whether they are official or not.
“I
believe that a retroactive review of a patient sets a very dangerous
precedent,” she said. “You are going to dissuade people from going to
the ER, and that is huge. ERs are for emergencies, and by and large
people only go there when they have no other choice.”
