Biden’s Inaction Moves Health Care Fight To States
by Julie Rock - Daily Poster.com - June 19, 2021
Editor’s note: In response to subscribers’ requests, this is the first in a multi-part series on state-level health care reform.
On the campaign trail, Joe Biden promised to create a nationwide public health insurance option that would lower patient costs, improve medical care, and help small businesses deal with soaring health care costs.
While a Medicare-for-All, single-payer health care system would be simpler, cheaper, and guarantee universal coverage, Biden and Democrats in competitive Senate races pitched a public option as a way to expand and improve coverage without fundamentally changing how most people get health insurance today. And the Congressional Budget Office recently reported that a robust public option could reduce premiums and save Americans big money.
So far, however, President Biden and Democrats in Congress have made little effort to follow through on the pledge, instead opting to funnel tens of billions of dollars to private health insurance companies to put people on expensive insurance exchange plans known for large out-of-pocket costs and high rates of denied claims.
Amid the leadership vacuum in Washington — and as premiums and insurance profits continue to skyrocket — state lawmakers have been frantically working to develop their own alternatives to try to help Americans combat increasingly costly medical coverage. Their efforts spotlight the challenges and opportunities for states trying to offer their citizens a public health insurance option.
While such state-level public option programs are no replacement for a national Medicare for All program, many see them as tangible and constructive health care reform for budget-strapped states barred from deficit spending.
Washington state led the way in 2019, establishing the nation’s first public insurance option. The program was supposed to provide a cheaper alternative that people would choose on the state’s insurance exchange. But so far, enrollment has only reached about 1 percent of the population, largely because the program does not require hospitals to accept the insurance and most have chosen not to.
As the state’s lawmakers prepare to pass a much-needed fix, the battle over a public option is heating up in Colorado for the second year in a row. This time, legislators are hopeful they can overcome a swarming lobbying effort and propaganda campaign to derail the bill.
Lawmakers in Connecticut and Oregon are also considering legislation to establish a public option.
A Faulty First Attempt In Washington State
In 2019, the Washington state legislature passed a bill creating a new state health insurance program, Cascade Care, with two elements: new standardized plans that private insurers were required to offer, as well as a public option.
Both the private, standardized plans and the public option are administered by private insurers, and are required to offer a standard set of benefits such as primary care visits, generic drugs, and mental health care services.
The main difference between the standard option and the public option is that the public option plans reimburse providers at a rate of up to 160 percent of the Medicare reimbursement rate, which is lower than what private insurers typically pay. Employer-based plans, for example, pay an average reimbursement rate of 240 percent of Medicare.
The lower reimbursement rate is supposed to keep costs down. While premiums for the Cascade Care plans were higher than the average plan offered on the exchange, Cascade Care options had deductibles that were, on average, $1,000 lower than other plans.
But the bill had a significant loophole that made the plans inaccessible: Hospitals successfully lobbied to ensure they were not compelled to accept the insurance, due to the public option’s lower reimbursement rates than private insurance. Cascade Care’s public option plans, as a result, were only available to Washingtonians in half of the state’s counties.
“Hospitals were opposed to it, and they never moved off of their opposition,” said the bill’s lead sponsor, Democratic Rep. Eileen Cody.
When the public option launched during the 2021 enrollment period, about 15 percent of people buying health insurance on the state exchange opted for Cascade Care plans, but fewer than 5 percent of the people who bought those plans actually chose the state’s public option plans.
As a result, only 1,872 people are currently utilizing the state’s public option, or less than 1 percent of people who get health insurance through the state exchange. That percentage is slightly higher — about 2.5 percent — when taken just as a percentage of people who enrolled on new plans in 2021 as opposed to keeping their old plans.
In order to solve this problem, the state Senate passed a fix earlier this year, requiring hospital systems to accept the public option plans. The fix was then modified and passed by the state House. Now, the senate needs to concur on the modified legislation.
“The trigger is that any hospital that contracts with Medicaid or the state employee health care plans would have to accept a public option plan,” said Cody, adding, “Everybody takes Medicaid.”
Cody expects the state Senate to concur on the legislation this week, and Gov. Jay Inslee is expected to sign it into law. She has one piece of advice for lawmakers in Colorado working on public option legislation: “Prepare for a fight.”
A New Strategy In Colorado
Colorado has been a major health care battleground since 2016, when activists ran a single-payer ballot measure that prompted Democratic consultants to help the insurance industry crush it at the polls.
Following that defeat, state lawmakers went to work on public option legislation last year, with the support of Democratic Gov. Jared Polis. They passed a bill out of a House committee just two days before the legislature shut down due to the COVID-19 pandemic. The private health insurance industry aggressively opposed the bill, arguing it was better to let the industry lower costs voluntarily rather than by government mandate, according to state Rep. Dylan Roberts, one of the leading public option advocates in Colorado.
“What we heard continuously during the bill debate was that insurance companies know health care costs are too high, and that they would like the opportunity to lower costs without strict government intervention, or any type of government intervention, actually,” Roberts said.
This year, Colorado Democrats are trying a new strategy by calling the private health care industry’s bluff. Their revised public option bill would give private insurers the opportunity to significantly reduce costs over two years before a public option is introduced.
The bill would require insurers offering plans on the state individual or small group marketplace to offer a new standardized insurance plan, which will be designed by the state health insurance commissioner.
If insurers manage to reduce premiums and deductibles on their standardized plans by 10 percent each year in 2023 and 2024, then the state won’t set up its public option plan.
“We built in the first phase of the bill to take the insurance companies at their word and allow them two and a half years to get costs down,” said Roberts. “If they do, great, we all benefit from lower health insurance costs.”
But if they fail to do so, then the state will apply for a waiver from the Biden administration, a so-called “Innovation Waiver” created under the Affordable Care Act, and use the money from the waiver to set up a public option. The public option, or “Colorado option,” would be the state’s version of a standardized plan.
About 15 percent of the state’s population is projected to be offered the public option plans. These are people who either don’t get health insurance through their employer and buy it on the state’s exchange, or people who work for small businesses that opt for their employees to be covered under the public option.
The Colorado legislation also integrates lessons learned from the effort in Washington state.
For example, the bill is designed to align cost-cutting measures with the introduction of standardized plans, said Adam Fox, Deputy Director of the Colorado Consumer Health Initiative, a consumer advocacy group supporting the public option legislation.
“In the Colorado option legislation, we're essentially requiring insurance carriers to offer the standardized plan. And those are the plans that they have to meet these target reductions on,” Fox told The Daily Poster.
In Washington, Fox said, the standardized plans were separate from the cost-cutting elements of the legislation. That resulted in higher premiums, even though Cascade Care plans did have lower deductibles than other private insurance plans.
The bill also creates a fee schedule for provider reimbursement rates, which are slightly higher for rural hospitals and lower for highly profitable hospitals that are part of larger networks. The reimbursement rates would be set through a public rulemaking process, Fox said.
Perhaps most importantly, the Colorado legislation is statewide, meaning providers can’t refuse the insurance as they have in Washington state. And, unlike the Washington plans which are administered by private insurers, Colorado’s public option will be operated by a nonprofit entity set up by the state.
Roberts said that while the bill would only make modest changes to the state’s health care system, especially during the first stage, it could have important reverberations across the country, showing people how government action can reduce health care costs and improve care.
“It's not a total overhaul of our health care system in Colorado or in the United States by any means,” he said. “However, we would be the first state in the country that would do something like this, where it would be truly a statewide plan that's available to every Coloradan that wants to purchase it. I would love to see it trickle out across the country, and hopefully show Congress in Washington, that this is something that they should pursue on a national level.”
https://www.dailyposter.com/bidens-inaction-moves-health-care/
Health Insurer Pressured Employees To Fight State Public Option
Health insurance giant UnitedHealth Group held a webinar to pressure its rank-and-file employees to mobilize against efforts in Connecticut to create a state-level public health insurance option, according to a video of the presentation obtained by The Daily Poster.
“It does sound like it’s just an option. But the problem is that it would exist on an unlevel playing field with private insurance,” Mishael Azam, a UnitedHealth Group vice president of external affairs, told employees on the February 24 webinar. “The public option really is the path to single-payer, where there is really no private option left.”
Azam slammed the public option proposal for potentially providing Connecticut residents “artificially low premiums.” She encouraged employees to call their legislators and express their concerns about Connecticut’s public option proposal, which is designed to create more insurance competition and reduce health insurance premiums for consumers.
“If you agree with anything that you’re hearing today, taking action and contacting your legislator really makes a difference. It did make a difference in 2019,” she said, referring to when the insurance industry successfully killed a previous public option effort in Connecticut.
UnitedHealth spokesperson Eric Hausman told The Daily Poster that employees’ attendance at the February webinar was voluntary. “While we do not discuss internal meetings, educational webinars on issues of importance to our industry and our communities, such as the proposed public option in Connecticut, are completely voluntary,” he said.
“They Think They Are Screwed”
The nation’s largest health insurer, UnitedHealth saw its profits boom last year during the COVID-19 pandemic, as people largely avoided going to the doctor and put off elective procedures, activities that cost insurers money.
The company reported more than $15 billion in profit in 2020, an 11 percent increase over the previous year. In the year prior to that, the company made headlines after its CEO netted more than $50 million. Now, UnitedHealth is taking action to protect its windfall, as lawmakers around the country weigh reforms to address soaring health care costs.
In Connecticut, where UnitedHealth asked regulators to approve large increases in premiums for this year, the company and other major insurers have undertaken a massive campaign to block a new legislative attempt at passing a state-level public option.
Hartford, the state capital, is a major hub for health insurers, which account for 25,000 jobs, according to the industry. The state has long been a battleground between the health insurance industry and those fighting for reforms.
In 2009, Connecticut passed a law that paved the way for the state to establish a public option. Six months later, though, Congress passed the Affordable Care Act (ACA), and the state never set up its own insurance option. Former Connecticut Sen. Joe Lieberman played a key role in killing the public option provision in the ACA, refusing to support the bill if it included a public option.
Connecticut lawmakers proposed public option plans in 2019 and 2020. Once again, legislators in the Democratic-held state house are considering public option legislation, backed by state Comptroller Kevin Lembo, and the chair of the Senate insurance committee Sen. Matthew Lesser. The bill passed the Senate finance committee on Thursday, and will receive a vote on the floor of the Senate before going to the assembly.
The legislative proposal to create a public option in Connecticut would authorize the state comptroller to offer the state’s current health care plan for public employees to certain individuals, small businesses, and non-profit employers. The so-called Connecticut Partnership Plan is currently administered by Anthem.
Additionally, the proposal would raise funds for subsidies for those people by instituting a tax on health insurance companies, similar to the Affordable Care Act’s Health Insurance Tax. The Health Insurance Tax, which cost Connecticut health insurers $300 million annually, was repealed in 2019, and the repeal took effect earlier this year. The new tax would cost insurers in the state $50 million.
Democratic Gov. Ned Lamont opposes the legislature’s bill, and has instead proposed his own health insurance reform plan, which would tax insurance companies to fund more subsidies to buy health insurance on the state exchange.
Front group campaigns backed by the health insurance industry are working to kill the legislation, and they are spending millions of dollars to kill state-level public option legislation being considered in Colorado, too. They argue that if states set up even modest public option plans, it could be the start of a slippery slope towards a single-payer system where there’s no need for health insurance companies.
Hausman, the UnitedHealth Group spokesperson, additionally argued in an email that “public option proposals will disrupt current coverage platforms by reducing access to providers, shifting costs to small businesses, increasing taxes, and eliminating jobs.”
Tom Swan, the executive director of the Connecticut Citizen Action Group, a group advocating for the public option legislation, told The Daily Poster that health insurers “are so threatened by this because if a public option passes in the insurance capital of the United States, they think they are screwed. And we hope that’s true.”
“Really Grassroots”
During the webinar, Azam, the UnitedHealth Group vice president, claimed that a state-run health insurance option would create an “unlevel playing field” in competing against private insurers, claims that have been widely repeated in the industry’s campaign.
When asked by an employee attending the webinar what it means for the premiums to be artificially low, she responded, “When I say artificially low, I mean that we wouldn’t even be allowed to have premiums that low because we are required to have revenues match claims. Whereas the state is not requiring itself to do so. And taxes have been increased to cover those state costs.”
Azam was repeating the false claim propagated by the Connecticut Business & Industry Association that the state’s Connecticut Partnership Plan does not charge high enough premiums to cover costs.
Lembo, the state comptroller, debunked that claim in a February letter, explaining that a 2019 legislative fix had brought premiums on par with the cost of care. The actual reason the Partnership’s premiums are lower is that the difference between claims and premiums is not used to generate profits, according to a March report from the comptroller’s office.
In the presentation, Azam also laid out the company’s strategy for tanking the public option proposal. “We have three major coalitions in Connecticut in addition to our grassroots efforts,” she said.
The presentation slide listed the Stop The HIT national coalition, a group that was formed to push for the repeal of the original Health Insurance Tax in the ACA; Insurance Matters to Connecticut, a coalition of insurers, businesses, and trade groups in the state organizing against the public option; and Connecticut’s Health Care Future.
Connecticut’s Health Care Future is a campaign from the Partnership for America’s Healthcare Future Action, a state-focused affiliate of the health care industry front group set up to oppose Medicare for All and a public option at the federal level.
“This national group has major members including the American Hospital Association, AHIP [America’s Health Insurance Plans], physician groups, business groups, and the Connecticut arm of it is really grassroots,” Azam said.
Connecticut’s Health Care Future has made radio ad buys, and Azam said during the February webinar that it is also “aggressively engaged in letter writing campaigns.”
She added: “There are over 10,000 members of ‘My Care, My Choice,’ a grassroots platform in Connecticut, that are engaged in letter writing, and we also have a targeted letter writing campaign to key members of the Insurance Committee in the legislature.”
Azam said that other insurers and trade groups are working to deploy their employees against the Connecticut legislation.
“We also have trade groups doing employee engagements like this and member engagements. And the other carriers in Connecticut, the other major health insurance carriers, are doing engagements like we are today as well,” she said.
Azam noted that Connecticut’s Health Care Future had recently done polling in the state and found that “consumers are very concerned about a government takeover of health care.”
The group’s polling was conducted by Locust Street Group, a public relations and grassroots consulting firm. They claimed that only 36 percent of respondents support a Connecticut public option, and only 40 percent support the idea of a national public option plan.
Meanwhile, a Fox News Voter Analysis survey of the American electorate, conducted just before the 2020 election, found that 74 percent of Connecticut voters support the idea of “changing the health care system so that any American can buy into a government-run health care plan if they want to.”
While Azam had previously said that Connecticut’s Health Care Future is “really grassroots,” when an employee asked how they can get involved with the group, she responded: “I don't know that individuals can join the Connecticut for Health Care Future coalition. I think it's mostly businesses.”
https://www.dailyposter.com/health-insurer-pressured-employees/
Big Money v. The Public Option
In response to subscribers’ requests, this is the third in a multi-part series on state-level health care reform. Read the other stories here and here.
When President Joe Biden outlined his legislative priorities during his first address to Congress last month, notably absent was a major campaign promise: a public health insurance option. Instead, his current health reform proposal will funnel $200 billion more to private insurance companies to subsidize premiums, without any requirement that they cap out-of-pocket costs or eliminate them altogether.
As a result of Biden’s approach, states have been left to introduce public option legislation themselves, in the process taking on some of the nation’s largest and most politically organized businesses. From coast to coast, health insurance companies, hospitals, and pharmaceutical companies are colluding and using every tactic at their disposal to block states from passing public option legislation.
Such efforts hint at just how far the industry will go to block any sort of reform that threatens its massive profits.
In particular, the Partnership for America’s Health Care Future Action (PAHCF Action), the state arm of the dark money group that has opposed Medicare for All and a public option at the federal level, has spent millions of dollars on TV ads and mailers in Colorado, Connecticut, and other states where public option bills are being considered. The group has spent more on lobbying in Colorado in 2021 than any other organization since 2011, and possibly ever.
As a result, the actual public option component of the Colorado legislation was removed in an agreement made with the hospital industry. What’s left of the bill is a requirement that private insurers offer so-called “standardized” health insurance plans and cut premiums on those plans by 18 percent over three years. Despite the overhaul, the industry has continued to oppose the plan.
“It’s a little intriguing to me that this is becoming such a big deal, because the bill is actually very narrow,” Rep. Dylan Roberts, the lead sponsor of the Colorado legislation, told The Daily Poster, before the bill was watered down. He added, “It’s not a total overhaul of the health care system in Colorado or in the United States by any means. So the opposition to me is a little intriguing on that front.”
Lobbyists Gut Colorado Option
In Colorado, PAHCF Action is smashing state lobbying records by spending millions of dollars to kill its public option proposal. The organization is running a full-scale advocacy campaign, blanketing the television airwaves and filling people’s mailboxes with propaganda.
While PAHCF Action’s donors are not public, its board includes top executives from lobbying groups for investor-owned hospital chains and health insurers.
The organization’s president is Chip Kahn, who leads the Federation of American Hospitals. His group lobbies for hospital chains like HCA Healthcare and Tenet Healthcare.
HCA reported $3.5 billion in profit last year, and its CEO made $83.6 million, according to Axios. The hospital chain owns seven hospitals in Colorado, including one that drew national headlines in 2019 for billing an emergency room patient more than $12,000 to treat a hangover after his bachelor party.
While HCA does not disclose its political contributions, Tenet has reported donating nearly $2.9 million to PAHCF between 2018 and 2020, according to company political spending disclosures. Tenet has a dozen surgery centers in Colorado, according to its website.
PAHCF Action’s secretary is David Merritt, a senior executive at America’s Health Insurance Plans (AHIP), which lobbies for big health insurers like Aetna.
CVS Health, which owns Aetna, donated $5 million last year to the national Partnership for America’s Health Care Future (PAHCF), according to reporting by The Intercept.
The dark money group isn’t alone — 149 individual lobbyists in the state are registered as opposing the legislation. These lobbyists represent AHIP, Anthem Blue Cross and Blue Shield, Cigna, UnitedHealth Group, and Kaiser Permanente, among other corporate interests. Americans for Prosperity, the Koch network’s political advocacy arm, has 16 lobbyists alone registered in opposition of the bill.
These influence peddlers have already had significant success.
Last year, lobbyists helped kill a public option proposal in the state. This year, legislators proposed a scaled-down version of the public option plan, one that would allow the state to set up a public option in two years if private insurers failed to set up standardized plans that meet certain cost criteria.
But even this legislation was derailed by special-interest groups. In late April, lawmakers removed the public-option component from the bill following negotiations with insurance industry lobbying groups and the Service Employees International Union (SEIU) of Colorado, which opposed the bill. The SEIU Local 105 argued that the premium-cutting measures in the legislation would lead to layoffs of health care workers at hospitals.
“Even as the bill has changed, they’ve had the same generic talking points about a government takeover of health care that doesn’t reflect what’s actually in the bill,” Roberts said.
The health care industry is still opposing the bill, even in its weakened state.
On May 12, two days after the modified bill passed the Colorado House, the Taxpayers Protection Alliance (TPA), a Koch-affiliated political advocacy group, announced an “ad blitz” to oppose the legislation as it moves forward. Their so-called “No Big Handouts for Big Insurance” campaign will involve a statewide ad campaign targeting the rate-setting element of the legislation, according to a TPA press release.
The idea that big insurers would benefit from the legislation is more than a little dubious, given that health insurance lobbyists are helping lead the campaign to kill it.
Standoff In The Insurance Capital
Connecticut has long been a flashpoint in the battle over a public option. Hartford, the state capital, is known as the “Insurance Capital of the World,” because a number of the world’s largest insurance companies — Cigna, The Hartford, Chubb, and until recently Aetna — are headquartered there, and are also major employers.
The industry has used its presence in the state as leverage to kill public option efforts. In 2019, Cigna reportedly threatened to leave if the state passed public option legislation. Between that threat and a massive lobbying effort by the insurance industry against the legislation, the bill never passed.
Now the industry is doing it again.
Last month, the CEOs of Anthem, Cigna, CVSHealth, Tufts Health Plan, Harvard Pilgrim Health Care, and UnitedHealth Group wrote a letter to Connecticut Gov. Ned Lamont, thanking him for opposing the legislature’s public option legislation and implicitly threatening to leave the state if it passes.
“The pandemic has demonstrated that employees can work virtually, making it easier for companies to choose where they are domiciled and grow,” the letter said. “As a result, it has never been more critical for the State to create a climate that retains and attracts businesses that will help stabilize the economy. All of us will have to decide where it will be best to deploy our resources long term. Private employers and taxpayers should not fund unsustainable public policy pursuits.” (When CVS acquired Aetna in 2018, it promised to keep Aetna headquartered in Hartford for at least a decade, and retain its staffing levels at least until 2022.)
UnitedHealth Group, whose CEO signed the letter to Lamont, held a webinar in February to train its employees to lobby against the legislation, The Daily Poster previously reported.
According to the PAHCF Action’s first quarter lobbying report in Connecticut, the group has spent roughly $126,000 on lobbying so far this year, including about $95,000 on compensation and $31,000 on solicitations.
Beyond PAHCF Action, health insurance companies and businesses are also engaged in lobbying through other front groups or direct lobbying on the public option legislation.
The Connecticut Hospital Association, whose members include dozens of hospitals as well as insurance companies such as Anthem Blue Cross & Blue Shield and Harvard Pilgrim Health Care, has spent $296,000 on lobbying during the first quarter of this year, according to state filings.
Meanwhile, the Connecticut Association of Health Plans has spent $133,000 on lobbying and $1,200 on paid media during the first quarter of this year, according to state filings. The group’s president is Tim Meyers of Aetna, the insurance giant owned by CVS, and its treasurer and secretary work in government relations for ConnectiCare and Harvard Pilgrim Health Care, respectively.
The opposition’s talking points don’t reflect what the bill would actually do, says Tom Swan, the executive director of the Connecticut Citizen Action Group, a group advocating for the public option legislation. “A lot of their campaign is just railing against a bill that doesn’t exist,” Swan said.
“They’re saying, ‘don’t let them do a one-size-fits-all health insurance option,’” said Swan, who added that in truth, the bill includes multiple different public-option plans and does not interfere with the private insurance industry's capacity to operate.
Without action on health care at the federal level, more states may try to take on the health care industry and its national advocacy groups themselves. Nevada, a state with one of the highest uninsured rates in the nation, recently introduced its own public option bill — and PAHCF Action immediately launched an operation to kill it.
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What I Learned in 33 Years at the C.D.C.
by Ann Schuchat - NYT - June 10, 2021
Dr. Schuchat is the principal deputy director of the Centers for Disease Control and Prevention. She’s retiring from the agency at the end of June after 33 years.
Nearly 15 years ago, during a ceremony in the Centers for Disease Control and Prevention’s Atlanta campus auditorium, I was promoted to rear admiral in the Commissioned Corps of the U.S. Public Health Service. My father, a veteran of World War II and the Korean War, positioned my new gold epaulets on the shoulders of my service dress blue uniform while my mother, a cultural anthropologist, observed the ritual from the audience. I said to the people gathered, “Public service is a privilege. For me, it has also been a joy.” Thirty-three years later, I’m retiring from the agency, and that’s the same message I would like to send to the American public.
My father, like many in his generation, enlisted in the U.S. Navy after the attack on Pearl Harbor. Another call to national service, for another generation, followed President John F. Kennedy’s inaugural address. My route to public service was more private and less intentional than those. I initially planned to apply my medical training to clinical practice. But the C.D.C.’s disease detective program — the Epidemic Intelligence Service — got me hooked on public health.
Public service is difficult. The past year and a half left many among our ranks exhausted, threatened, saddened and sometimes sidelined. The Covid-19 pandemic is not the first time the U.S. public health system has had to surge well beyond its capacity, but with the worst pandemic in a century and, initially, a heavily partisan political context, the virus collided with a system suffering from decades of underinvestment. A recent report from the National Academy of Medicine revealed that state and local public health departments have lost an estimated 66,000 jobs since around 2008.
With prior responses — including the hantavirus outbreak and bioterrorist anthrax, pandemic H1N1 influenza and the Ebola and Zika epidemics — the public health front line has been the little engine that could. For each of those responses, state and local public health departments absorbed the initial shock until emergency funding came through — and then repeatedly watched resources ebb as the crisis abated. Over the past few decades, public health experienced a progressive weakening of our core capacities while biomedical research and development accelerated into the future. With Covid-19, we were the little engine that couldn’t.
Infections, hospitalizations and deaths are declining in the United States, thanks to extraordinary vaccination efforts. These recent improvements might make it too easy to forget just how much we have collectively been through. But I hope that it has become clear to the nation and its policymakers that when we don’t invest in public health, everyone is vulnerable.
The nation’s public health system needs major upgrades. We need to modernize our data systems, enhance our laboratory capacities for detection and genomic sequencing of infectious threats like viruses and better integrate public health’s information and response efforts with clinical, commercial and academic sectors. America needs a renewed and expanded public health work force that reflects advanced skills as well as the diversity of the communities we serve.
The C.D.C. and public health departments are now receiving critical financial resources on an emergency basis. But these investments and improvements must be sustained. Long-term commitments to resources and innovation are essential. The Covid-19 pandemic will not be the last major threat our nation will face.
Public service is deeply meaningful. In my first several years at the C.D.C., I conducted surveillance and epidemiologic studies of an infection, group B strep, that harms newborns. It is passed to infants from women during childbirth. Although research during the 1980s identified the benefit of providing antibiotics to high-risk women during labor, the practice was not put in place. I spearheaded the C.D.C.’s efforts, leading to the 1995 meeting where we brought together obstetric and pediatric organizations as well as parents who had lost babies to the infection. In 1996, the C.D.C., the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics issued the first consensus guidelines that made prevention of group B strep a standard of care for the nation.
Because of this new practice standard and the updated guidance requiring prenatal group B strep screening of all women during pregnancy, over 100,000 of those life-threatening infections have been prevented. A generation of babies has been born since then, and public health efforts (not a new biomedical discovery) protected most of them from this condition. I was lucky early in my career to meet several parents whose personal losses reminded me why our work matters and how urgently our progress is needed.
Public service is also joyful. Ask the people who have been administering Covid-19 vaccinations what they feel as one recipient after another experiences the relief of getting an immunization that offers high-level protection and the promise of getting their lives back. The teams carrying out data analysis and field investigations and launching communication drives or laboratory studies have experienced the joy of knowing their collective efforts can achieve something none of them could do on their own.
I have experienced that kind of joy over and over — where my limited skills were complemented by team members with the full breadth of disciplines that public health requires — and where we eventually achieved so much progress. I felt this joy when, with the College of Medical and Allied Health Sciences in Sierra Leone, our team successfully carried out a clinical trial in Sierra Leone called STRIVE to introduce a vaccine to protect against Ebola during the devastating epidemic that began in 2014.
Public health successes usually take place out of the spotlight and under the radar, which for most of us in this field is just fine; victory often means preventing something bad from happening. If no one knows about it, that is often an indication of success. I was not a student athlete, though we have some superstars at the C.D.C. who were. Being part of the public health team provided the most cherished aspect of my 33 years at the C.D.C. We did not always win, but we always showed up. We celebrated one another’s efforts and remained humble in the face of threats to the public’s health, some opponents, like SARS-CoV-2, proving more devastating than others.
The Covid-19 pandemic has been as large a disrupter as a world war, and its effect on life expectancy exceeds any threat we have faced since the last “great” pandemic of 1918. Nevertheless, I hope this is also a moment when a new generation is called to action, to experience the difficulty and meaning and joy of public service. Our world needs you.
Anne Schuchat led immunization and respiratory efforts at the Centers
for Disease Control and Prevention for a decade before becoming its top
career employee in 2015. She was a key voice for the agency during the
2009 H1N1 pandemic and retired from the U.S. Public Health Service
Commissioned Corps as rear admiral after 30 years of service.
The C.D.C.’s New Leader Follows the Science. Is That Enough?
By all accounts, Dr. Rochelle Walensky is a fierce advocate and an empathetic scientist. But C.D.C. advice must be better attuned to the real world, critics say.
On her first day as director of the Centers for Disease Control and Prevention in January, Dr. Rochelle Walensky ordered a review of all Covid-related guidance on the agency’s website. Some of its advice had been twisted by the Trump administration, and her message was clear: The C.D.C. would no longer bend to political meddling.
Four months later, Dr. Walensky announced that vaccinated people could stop wearing masks in most settings. The recommendation startled not just the White House but also state and local leaders, prompting criticism that she had failed to prepare Americans for the agency’s latest about-face during the pandemic.
The two announcements captured the challenge that will define Dr. Walensky’s tenure at the C.D.C.: restoring an agency once renowned as the world leader in public health but whose reputation has been battered by political interference, even as the country transitions out of a pandemic that has left nearly 600,000 Americans dead.
President Biden had promised that the C.D.C. director he chose would be free to make scientifically grounded decisions without interference from politicians. Dr. Walensky, a widely respected infectious disease expert known for her battles with drug companies over prohibitive prices, seemed ideally suited.
Dr. Walensky’s appointment instantly made her one of the most influential women in the nation, and was greeted with enthusiasm by public health experts and C.D.C. staff members. But that enthusiasm has been tempered by occasional missteps in communications, an aspect of the job that is more important and challenging than it has ever been.
“Rochelle at baseline is an excellent communicator, but I think in a situation this fraught — politically, operationally and how quickly the science moves — you’re going to make mistakes,” said Dr. Celine Gounder, a former adviser to Mr. Biden’s team on Covid-19. “The question is, how does she acknowledge those and learn from those and move forward from there?”
Dr. Gounder, who has known Dr. Walensky since 2004 and considers her a friend, said Dr. Walensky was still the best person she could think of to lead the C.D.C.
The C.D.C. floundered at the beginning of the pandemic, pilloried for its botched coronavirus test and antiquated data systems. Its advice on masking, asymptomatic spread of the virus and the threat indoors was muddled. By late 2020, reports that the Trump administration had rewritten recommendations purported to be from agency experts further damaged public trust.
Dr. Anthony S. Fauci, the administration’s lead adviser on the pandemic, defended Dr. Walensky’s track record and said he had full confidence in her ability to lead the C.D.C. and the country out of the pandemic. The job, he noted, has a steep learning curve.
“Give her a little time,” he added. “By the end of one year, everybody’s going to be raving about her. I guarantee it.”
A morgue outside
When the pandemic began, Dr. Walensky, 52, was chief of the infectious diseases division at Massachusetts General Hospital. She ordered the hospital staff to wear masks before it became the national norm, and advised the mayor of her town and the governor on testing and prevention of Covid-19.
Scenes from Mass General were still fresh in her mind when she arrived at the C.D.C. “I came directly from a hospital that had a morgue sitting outside,” she said in an interview. Even apart from the fact that she is only the third woman to lead the agency, “I’m a different kind of C.D.C. director than my previous 18 predecessors, and sort of a different kind of character in public health.”
Born Rochelle Bersoff, Dr. Walensky grew up in Potomac, Md. Her father, Edward Bersoff, was a mathematician and engineer at NASA; her mother, Carol Bersoff-Bernstein, was an executive at a technology company. Her sister, Dr. Susan Bersoff-Matcha, is a deputy director at the Food and Drug Administration.
In the mid-1990s, as a medical student and resident at Johns Hopkins University, Dr. Walensky saw firsthand the impact of AIDS, which became the focus of her research.
She met her husband, Dr. Loren Walensky, now a pediatric oncologist at Brigham and Women’s Hospital in Boston, in her first year at the university. She was six feet tall, he was 5-foot-8 — and “she just caught my eye,” he recalled. They were both Jewish, and shared a deep interest in medicine and music — she played the flute and he was a classical pianist. They married in 1995 and have three sons.
Dr. Walensky joined the faculty of Harvard University in 2001, where she worked on health policy for infectious diseases, particularly H.I.V. She gained a reputation as a rigorous researcher and a generous mentor, particularly to young women.
In 2017, she became chief of infectious diseases at M.G.H., the first woman and the third person to hold the job in 70 years. She had a warm, empathetic leadership style, said Dr. Kenneth Freedberg, an H.I.V. expert at the hospital who was first her mentor, then a collaborator. Eventually, she became his boss.
For her birthday a few years ago, her team at the hospital came to work dressed like her — “wearing black, or white, or black-and-white,” Dr. Freedberg said. It wasn’t until lunchtime, when everyone took out a yogurt, a root beer and a little bag of pretzels, her standard lunch, that she noticed.
Despite a grueling workload of patient care and research, Dr. Walensky made it to her sons’ piano concerts, karate tournaments and half marathons, according to her husband. The Walenskys decided early on that they would not work evenings or weekends, would be home for dinner every day, and take laptop-free vacations whenever their children were off school.
Dr. Walensky was known as a tough-minded advocate for people with AIDS. She tussled with pharmaceutical companies to lower prices for H.I.V. treatments. She called out the drug company Gilead’s pricing of its preventive therapy for H.I.V. and the exclusion of women from its clinical trials as “unacceptable.”
In 2019, she testified before Congress about the prohibitive cost of preventive therapy and treatments for H.I.V. and made similar arguments about the pricing of Gilead’s Covid drug remdesivir.
“I literally cried the night that I found out that Rochelle was going to be C.D.C. director — in happiness, in joy,” said James Krellenstein, executive director of the advocacy group PrEP4All Collaboration. “She is absolutely fearless in doing what is the correct thing, with zero concern for the political ramifications for herself.”
These days, she spends the week in Atlanta, waking up at 5:30 a.m. and working until 11 p.m. But she still eats dinners with her family on Zoom and travels to Massachusetts every weekend. “This is a working mom who’s always been working her tail off,” her husband said.
Dr. Walensky was not on the Biden’s administration’s initial list of candidates for C.D.C. director. It was Dr. Fauci, who had known and admired her work on H.I.V., who recommended her. Her leadership of the C.D.C. is demonstrably different from that of her predecessor, Dr. Robert R. Redfield. Under him, the agency quietly made changes to its guidance, sometimes dictated by the Trump administration, with no public announcement.
C.D.C. scientists are now routinely involved in conversations with the White House, where previously they were sidelined and silenced. And where Dr. Redfield was reticent, Dr. Walensky has often taken a surprisingly direct approach.
During a news briefing on March 29, as infections began to rise again, she looked into the camera and, in a voice quavering with emotion, pleaded with Americans not to stop taking precautions against the coronavirus.
“I’m going to pause here, I’m going to lose the script and I’m going to reflect on the recurring feeling I have of impending doom,” she said, her eyes glistening with tears. “We have so much to look forward to, so much promise and potential of where we are and so much reason for hope. But right now I’m scared.”
Her impassioned speech startled many people, perhaps none more than her husband. “She’s not a crier — if anything, I get choked up much more easily than she does,” he said. Her openness signaled her “genuine anguish” about the state of the pandemic, he added. “She deeply felt the weight of a half a million dead.”
The day of her urgent plea, she appeared on MSNBC’s “The Rachel Maddow Show,” where she said vaccinated people “do not carry the virus” — an overly optimistic statement that the C.D.C. had to walk back. Later that week, new guidance from the agency said that vaccinated people could safely travel, but Dr. Walensky added that the agency did not actually want them to travel at all, a stance that left some Americans perplexed.
The most recent instance, when Dr. Walensky announced that vaccinated people could go mask-free indoors, was supported by the latest research, scientists said. But many felt the agency had rushed the decision to end mask use without considering parts of the country where infections were still high, and without grasping the mistrust and culture clashes the new advice would engender.
“C.D.C. got the medical and epidemiological science right, but what they did not get right was the behavioral science, the communications and working collaboratively with other stakeholders,” Dr. Gounder said. “That was a big oversight.”
Data since the announcement seem to have proved Dr. Walensky correct: Infections are still declining, even as much of the country reopens at a vigorous pace. And as promised, the agency has set about issuing more practical masking guidance regarding settings like summer camps (mostly no) and public transportation (yes).
Dr. Walensky and the C.D.C. declined to comment on how the mask recommendations were handled. But Dr. Fauci said that he believed some small missteps were inevitable, and that Dr. Walensky was a quick study.
“Retrospectively, when you look at the negative reaction of so many people, so many organizations, you have to come to the conclusion that it could have been done better,” he said. “There’ll be a lesson learned here.”
Within the C.D.C., many scientists were relieved to have a leader who put science above politics. In interviews, several said the morale had drastically improved.
But the confusing communications rattled a few, turning optimism into “uncertainty and disappointment,” one senior C.D.C. scientist, who asked not to be identified because he was not authorized to speak publicly, said in April. “The ground is not nearly as stable as we thought it would be.”
Rebuilding trust
The C.D.C. is a large and lumbering agency, bogged down by bureaucracy and hampered by what some experts describe as an overly cautious approach.
Under unrelenting pressure from the pandemic and the Trump administration, the atmosphere inside the agency devolved last year into ugly rivalries and turf wars, according to several staff scientists. Some felt betrayed by agency leaders who did not speak out publicly against the political interference.
The recent exits of two high-ranking agency officials within the C.D.C. — Dr. Anne Schuchat, the deputy director, and Dr. Nancy Messonnier, who led the agency’s infectious disease center — have led to speculation about continuing unrest within the agency.
But veterans in public health said such changes are expected after a leadership change and have occurred before. In an interview last month, Dr. Schuchat said she had come to admire and like Dr. Walensky: “This is a really tough leadership job, and I think she’s absolutely the right person for it.”
Covid has taken up nearly all of Dr. Walensky’s attention, but she has a long list of ambitious goals for the agency post-pandemic, including modernizing the nation’s public health infrastructure, addressing the health impact of climate change and managing what she called the “collateral damage” of the pandemic.
That includes 11 million delayed pediatric vaccinations; widespread mental health problems; an uptick in opioid overdoses; and lapses in control of high blood pressure, cancer and H.I.V. Dr. Walensky also has her eye trained on racial equity in health care within the ranks of C.D.C. itself. An overwhelming majority of its scientists, and particularly those in management positions, are white.
Last summer, after protests over the death of George Floyd, more than 1,200 C.D.C. employees called on then-director Dr. Redfield to address “ongoing and recurring acts of racism and discrimination” against Black staff members and outlined a seven-point plan.
Dr. Redfield did not respond, and later in the year the agency suspended diversity training programs following an executive order from the Trump administration.
At her first all-hands meeting, Dr. Walensky startled the staff when she spoke emphatically about measures to increase diversity and inclusion in the agency’s work and in its ranks. She reinstated diversity training, and has promoted two Black scientists into management positions.
Covid remains her focus for now, and the flawed communications in recent weeks suggest that she is still finding her way. But in a recent interview, she was unapologetic about the rapid shifts in C.D.C. guidance or in her tone: The virus’s hold on the country is loosening, but large parts of the population remain unvaccinated and the pandemic is not yet over.
“There are two things happening at the same time,” she said. “It’s my responsibility to tell both of those stories.”
https://www.nytimes.com/2021/06/10/health/walensky-cdc-covid.html?referringSource=articleShare
Government Warns Doctors and Insurers: Don’t Bill for Covid Vaccines
Such billing has been rare, but public concern about it may be contributing to hesitancy about getting the shot.
by Sarah Kliff - NYT - June 9, 2021
The New York Times is investigating the costs associated with coronavirus testing, treatment and vaccination. You can read more about the project and submit your medical bills here.
The Biden administration is reminding doctors, hospitals, pharmacies and insurers that it is illegal to bill patients for coronavirus vaccines, a letter obtained by The Times shows.
The new warning responds to concerns among unvaccinated Americans that they could receive a bill with their shot. A recent Kaiser Family Foundation poll found that about a third of unvaccinated adults were unsure whether insurance covered the new vaccine.
“We recognize that there are costs associated with administering vaccines — from staff trainings to vaccine storage,” Xavier Becerra, the Health and Human Services secretary, wrote in a letter to vaccinators and insurers. “For these expenses, providers may not bill patients but can seek reimbursement through Medicare, Medicaid, private insurance or other applicable coverage.”
The letter warns that billing patients could lead to state or federal “enforcement actions,” but does not specify what the penalty would be.
The federal government wrote strong consumer protections to ensure that patients do not have to pay for coronavirus vaccines.
In stimulus legislation last spring, it barred insurers from charging patients co-payments or deductibles for the vaccines. The same law also created a fund that would cover the costs of vaccinating uninsured Americans.
Layered on top of those legislative protections are the contracts that doctors and hospitals signed to receive vaccines. Those documents specify that vaccinators cannot bill patients for the service.
The stronger protections appear to have worked. While many patients have encountered coronavirus bills for testing, there have been only a handful involving vaccines.
Still, the rules are not foolproof, and some patients have faced illegal charges. In April, the Health and Human Services office of the inspector general published a letter saying it was “aware of complaints by patients about charges by providers when getting their Covid-19 vaccines.”
A few patients have submitted bills showing surprise charges to a Times project collecting patient bills for testing, treatment and vaccination. The fees range from $20 to $850. If you received a bill for your coronavirus vaccine, you can submit it here.
Patients who receive bills for coronavirus vaccines can challenge the charge. Those with health insurance can reach out to their plan to ask why they received a bill when two federal laws — the Families First Coronavirus Response Act and the CARES Act — outlaw it.
A small subset of health plans is exempt from the laws. These “grandfathered” plans existed before the Affordable Care Act, and are not subject to requirements to fully cover the coronavirus vaccine or any other preventive service.
But even those patients are still protected by the contract that doctors signed barring any billing. The doctors can send the outstanding charges to a new Coverage Assistance Fund created by the Biden administration last month specifically to address patient coverage gaps.
Uninsured patients can direct their providers to bill the Covid-19 Uninsured Program, which was set up to cover those without coverage.
If an insurer or doctor is unwilling to reverse a bill, patients can seek help from state regulators. State departments of insurance typically deal with complaints about whether health plans are not appropriately covering medical care, while state attorneys general tend to field complaints about possible inappropriate bills from doctors and hospitals.
Outcry Forces UnitedHealthcare to Delay Plan to Deny Coverage for Some E.R. Visits
Within days of announcing a policy shift aimed at cutting back on reimbursements for emergency room care, the major insurer retreated — for now.
by Reed Abelson - NYT - J une 10, 2021
In the face of growing opposition from hospital and doctors groups, UnitedHealthcare said on Thursday it would delay a plan to stop paying for emergency room visits that it deemed nonurgent, at least until the pandemic has ended.
The policy, which would affect millions of United’s customers, was greeted with longstanding worry over the unintended consequences of the coronavirus crisis on Americans’ health as people put off care for serious illnesses. The change had also sparked outrage in light of the steep declines in E.R. visits that ironically resulted in healthy profits and savings for insurers.
Critics of United’s policy shift said it would exacerbate what experts said was a disconcerting pattern of people shunning emergency rooms in the last year or so, potentially contributing to heart attacks and other illnesses among those who not only feared contagion but also medical bills due to the economic fallout of layoffs and unemployment.
Under the new policy, which was to go into effect next month, UnitedHealthcare, the giant insurer, had planned to scrutinize the medical records of its customers’ visits to emergency departments to determine if it should cover those hospital bills. But in the last week, several major hospital and doctors groups demanded that United abandon the policy.
The decision to hold off “offers a temporary reprieve for patients, and we urge its full and permanent reversal,” Rick Pollack, the chief executive of the American Hospital Association, a trade group, said in a statement. Mr. Pollack had described the policy earlier as “very misguided,” particularly during the pandemic.
In a letter to UnitedHealthcare’s chief executive, Mr. Pollack had sought a policy reversal and emphasized the risks of people not seeking care. “Deferred and delayed care during the pandemic has already contributed to adverse health conditions and increased acuity,” he wrote.
On Thursday, United acknowledged the concerns raised by many groups, in announcing its decision to delay the new policy: “Based on feedback from our provider partners and discussions with medical societies, we have decided to delay the implementation of our emergency department policy until at least the end of the national public health emergency period,” it said in a statement.
Top U.S. health officials have not said what would lead them to declare an end to the crisis.
Hospitals and doctors had raised concerns that the new policy signaled a return to a contentious tactic used by health insurers to clamp down on care they argue should be delivered in a less costly setting.
Anthem, another large insurer that operates for-profit Blue Cross plans, announced a similar policy several years ago that led to a political backlash and a federal lawsuit from emergency room physicians claiming it violated federal protections for patients seeking emergency care. Anthem said it could not comment because of the continuing litigation.
In addition to its questionable timing, the policy shift seemed puzzling since there had already been significant declines in emergency room visits throughout the pandemic into this year. Emergency room visits across the country fell by 27 percent in 2020, compared with the previous year, according to Gist Healthcare, a consultant. which also predicted that people with less serious conditions would continue to stay away.
United’s decision seemed aimed at making sure people did not go back to using the emergency room for nonurgent care, even as hospitals might try to encourage more people to return, said Chas Roades, a co-founder of Gist. Given the potential blowback, he did not believe United was likely to generate significant savings from the program. “I can’t quite believe the juice is really worth the squeeze on this policy right now,” he said.
Physician groups were also critical of the decision to deny coverage for emergency visits that United considered nonurgent. “We object to UnitedHealthcare’s pending policy that asks patients to second guess their instincts that emergency care is needed,” Dr. Susan R. Bailey, the president of the American Medical Association, said in a statement. “Patients should not be expected to self-diagnose to determine whether, for example, chest pain is a heart attack or indigestion.”
Others noted that such a policy could thwart federal efforts to enlist emergency rooms in reaching more people for immunization against the coronavirus.
“This new policy will leave millions fearful of seeking medical care, just as we’re getting hold of the Covid-19 pandemic and trying to get as many people vaccinated as possible,” Dr. Mark Rosenberg, the president of the American College of Emergency Physicians, said in a statement earlier this week.
If United still goes ahead with the change later on, the policy would apply to millions of people in United’s fully insured plans in 35 states, including New York, Ohio, Texas and Washington. People covered through an employer that is self-insured or enrolled in a Medicare Advantage plan or Medicaid would not be affected. The policy would exempt care for children under 2 years old.
United had insisted that its policy was not aimed at preventing customers from going to the emergency room to rule out a heart attack if they had chest pain or to address a medical crisis. The insurer said it would take into account the original reason for the visit, any laboratory work or imaging performed and whether there were existing medical conditions or other factors that could have warranted a visit. A hospital could still attest to the emergency needs, and patients could ultimately appeal.
“Unnecessary use of the emergency room costs nearly $32 billion annually, driving up health care costs for everyone,” the company said in a statement on Monday. “We are taking steps to make care more affordable, encouraging people who do not have a health care emergency to seek treatment in a more appropriate setting, such as an urgent care center. If one of our members does receive care in an emergency room for a t issue, like pink eye, we will reimburse the emergency facility according to the member’s benefit plan.”
During the pandemic and for months of lockdown, non-Covid care, ranging from knee surgeries to mammograms to emergency room visits, fell. While some experts worried that the lack of care would cause patients’ conditions to worsen, others argued the drop off might provide evidence that some care, like screenings, was unnecessary.
United’s initial decision was viewed by some critics as a message directed at hospitals.
“They see this as a way to get the upper hand in their perpetual battle with providers,” said Jonathan Kolstad, a health economist at the University of California, Berkeley.
It was the latest example of the insurer clashing with doctors and hospitals, said Michael R. Turpin, a former United executive who is now an executive vice president at USI, an insurance brokerage that helps businesses find coverage. Most recently, United’s sparring with anesthesiologists resulted in lawsuits from a sizable physician-owned practice backed by private-equity investors, and the hospitals complain that United has adopted other policies that make it difficult for patients to get their care covered.
A few consumers are already battling insurers and some providers over billing for Covid vaccines, prompting the federal government to remind the participants that it is illegal to bill patients for those costs.
There is also increasing evidence that some of the people who didn’t go to emergency rooms during the pandemic would have been better off seeking care. Experts pointed to the increase in death rates from heart disease, diabetes and other illnesses that could indicate people were putting off necessary care. A recent study in Health Affairs by researchers from the M.I.T. Sloan School of Management, working with Boston Emergency Medical Services, found evidence of an increase in heart attacks that had occurred out of the hospital, particularly in low-income neighborhoods.
Mr. Pollack noted that even post-pandemic, such a policy would be problematic: “There is no justification for these restrictions now or after the public health emergency,” he said.
The people delaying care may be among those populations that are already the most vulnerable, according to a study by researchers from the Centers for Disease Control and Prevention, which looked at individuals who said they had put off care. “Avoidance of urgent or emergency care was more prevalent among unpaid caregivers for adults, persons with underlying medical conditions, Black adults, Hispanic adults, young adults, and persons with disabilities,” the researchers wrote.
Dr. Damian Caraballo, an emergency room doctor in Tampa, Fla., points out that patients are simply unable to tell the difference between an ovarian cyst, which is usually not life-threatening, and appendicitis, which is. The penalty for being mistaken could amount to hundreds, if not thousands, of dollars. “The last thing I want is for patients to get hosed,” he said.
On Medicare and Need Dental Work? Beware a Big Bill.
The traditional version doesn’t cover dental, vision or hearing care. Advocates hope for change under a Biden proposal.
by Mark Miller - NYT - June 9, 2021
Ellen Phillips hasn’t eaten much solid food over the past year and a half. She has lost all of her upper teeth — badly infected, they had to be extracted in 2019. Her tongue is constantly swollen.
“I do well with Cheerios, applesauce and chocolate pudding, but I literally choke if I try to eat solid food, and that’s not how I should be eating,” said Ms. Phillips, 76, who is diabetic.
The extractions were a necessary prelude to needed heart surgery — dental infection or gum disease can allow bacteria to get into the bloodstream, causing surgical complications. The solution Ms. Phillips needs now includes extraction of her lower teeth and a set of implants that she said would cost at least $32,000.
But Ms. Phillips, of West Hartford, Conn., is enrolled in traditional Medicare — which pays for dentistry only in very limited circumstances. Her extractions were not covered, and she doesn’t expect Medicare will pay for her implants. Many Medicare Advantage plans, the managed-care alternative to traditional Medicare offered by private insurance companies, do include a limited amount of dental coverage. But none would come close to covering her needs.
Because of the anatomy of Ms. Phillips’s mouth, dentures are not an option, and as much as she would like to get the implants, the cost is prohibitive — especially since she is providing support to two adult sons whose livelihoods have been hurt by the pandemic. She retired nine years ago as the executive director of a nonprofit community health and home care agency.
“I’m sitting here not sure what to do next,” she said.
Coverage for dental, visual and hearing care has moved to the front burner this year as part of a broader discussion about Medicare expansion in Washington. President Biden proposed adding coverage for all three as part of the federal budget he unveiled last month. But adding coverage has been on the to-do list of Medicare advocates and progressive lawmakers for many years.
A study published in the journal Health Affairs last year noted that poor oral health was associated with higher rates of diabetes, cardiovascular disease and pulmonary infections. Vision loss and hearing loss are associated with a higher risk of falls, depression and cognitive impairment, and hearing loss with higher rates of hospitalization.
“These areas of health are really fundamental parts of our everyday living,” said Amber Willink, lead author of the study and an associate professor at the University of Sydney in Australia. “Good oral health, hearing and vision are things that we often just take for granted, but they are so fundamental to our daily needs, especially when it comes to improving and maintaining our health as we get older.”
The unmet need for such care in the Medicare population is high. Federal data shows that 19 percent of older adults have untreated tooth decay and another 19 percent have complete tooth loss. In 2016, 39 percent of Medicare beneficiaries reported having trouble seeing even with their glasses, and only 58 percent of those beneficiaries reported having had an eye exam in the previous 12 months. Two-thirds of Americans 70 and older have hearing loss.
Two-thirds of all people on Medicare don’t have dental coverage, according to the Kaiser Family Foundation. Among Medicare beneficiaries who used dental services, average out-of-pocket spending on dental care was $874 in 2018, and one-fifth spent more than $1,000 out of pocket, according to Kaiser.
For traditional Medicare to pay for dental care, it must be deemed necessary as part of a covered procedure — for example, a tooth extraction needed in preparation for radiation treatment. Likewise, the program does not cover hearing aids (which are notoriously expensive, often running into four figures) or exams, or most vision care.
Most Medicare Advantage plans offer some level of dental, vision and hearing care. Some plans charge additional premiums for these services, but often they come with no additional charge to beneficiaries. Instead, they are funded through Medicare’s complex Advantage payment system, which includes bonuses the government pays to plans based on quality ratings, and rebates, which are given in certain circumstances.
“Some of the savings must be spent directly on care for beneficiaries, and they go into these extra benefits,” said Allyson Y. Schwartz, president and chief executive officer of the Better Medicare Alliance, a Medicare Advantage research and advocacy group.
But the limits on what those plans cover vary widely. Among people in plans that offered both preventive and more extensive dental benefits, 43 percent faced annual dollar caps, typically around $1,000, Kaiser research shows.
“Some provide preventive and diagnostic services but don’t cover more expensive treatments,” said Tricia Neuman, executive director of the Medicare policy program at the Kaiser Family Foundation. “Others also cover pricier services, like implants, but have high coinsurance requirements or annual dollar limits. It’s better than nothing, but people with relatively skimpy dental coverage may be caught off guard when they see their bill.”
Some seniors buy a commercial, individual policy just for dental care, but these plans also leave them exposed to high out-of-pocket costs for the most expensive procedures. For example, a 66-year-old resident of New York City could choose between a basic ($24 per month) or premium ($48 per month) Delta Dental P.P.O. plan, both with a $50 annual deductible. The basic plan pays a maximum of $1,000 per year in care and the premium plan $1,500.
Low-income seniors are most likely to go without care. Medicaid covers dental, vision and hearing care for some low-income seniors, but states are not required to cover these services, and access to care is inconsistent across the country.
The median annual income for Medicare beneficiaries in 2019 was $29,650, according to Kaiser. The Health Affairs study found that 27 percent of low-income Medicare beneficiaries had visited a dentist in the previous 12 months, compared with 73 percent of high-income beneficiaries. And Kaiser reports that in 2016, 71 percent of Black Medicare beneficiaries did not visit a dentist in the previous year; nor did 65 percent of Latinos.
“Lower- and middle-income people, who may have comparable or greater needs, are going without needed dental care,” Dr. Neuman said. “The costs of some of these dental services are absolutely unaffordable for people living on a fixed income.”
The most serious financial risk comes with restorative procedures like the ones Ms. Phillips needs, said Wey-Wey Kwok, senior attorney at the Center for Medicare Advocacy, which has long urged more robust Medicare coverage of dental, vision and hearing care.
“It doesn’t cost private dental insurance plans a lot to cover preventive care like routine cleanings, exams and X-rays, which is why most cover that fully,” Ms. Kwok said. “The expense lies in restorative care, which is why plans minimize that risk by requiring greater cost-sharing, or imposing an annual dollar cap on coverage.”
For example, the median cost across the United States last year for a root canal and crown, extraction of four teeth and a partial upper denture was $4,800, according to a survey by the American Dental Association’s Health Policy Institute. The median cost for a patient needing periodontal treatment, three fillings and two crowns was $4,360.
What Can Be Done?
The Center for Medicare Advocacy has long lobbied for Medicare to expand the definition of “medically necessary” dental care, arguing that it has the legal authority to do so. A wider definition might be helpful to patients like Ms. Phillips.
More comprehensive solutions would require legislation. A standard set of benefits for dental, vision and hearing could be added under Medicare Part B — with services covered under the same terms applied to other outpatient services. If this was done, Medicare Advantage plans would be required to mirror the benefits in traditional Medicare.
The Congressional Budget Office estimated that an earlier proposal to add these benefits would have increased Medicare spending by $358 billion from 2020-29. Some proposals call for offsetting those higher costs by permitting Medicare to negotiate prescription prices with pharmaceutical companies.
Another option is a voluntary stand-alone program similar to Part D, which covers prescription drugs.
“There’s a great deal of interest in helping people who are struggling with the cost of their dental care,” Dr. Neuman said. “But there is a real issue about what it would mean for Medicare spending and potentially for Medicare premiums.”
Still, it’s not clear how a stand-alone plan could address all three needs — dental, vision and hearing. And adding a standard benefit would be the most straightforward solution, Dr. Willink said.
“A standard set of benefits in Part B for all beneficiaries would be really important,” she said. “As we’re seeing in Medicare Advantage, people may be getting plans that include these types of care, but they don’t quite understand what’s really included. A standard benefit would remove some of the confusion from a program that is already challenging to navigate.”
https://www.nytimes.com/2021/06/09/business/medicare-dental-work-bill.html?action=click&module=by In%20Other%20News&pgtype=HomepageOpinion: The debate over the FDA-approved Alzheimer’s drug showcases our system’s skewed priorities
by Helaine Olen - Washington Post - June 11, 2021
The Food and Drug Administration’s first approval of a drug to treat Alzheimer’s since 2003 should be a cause for celebration. Alzheimer’s is a scourge of aging societies that already affects more than 6 million Americans. The disease strips patients of their memory and ability to manage even basic tasks of independent living, while burdening caretakers emotionally, financially and physically. Progress against this horror ought to be cheered.
But more than any potential gains against Alzheimer’s, this FDA approval — and the controversy it has sparked — underscores shortcomings in the U.S. health-care system, which too often prioritizes corporate financial interests over the needs of patients and taxpayers.
Let’s start with the conflict. Three members of an FDA advisory committee have resigned in the wake of the drug’s approval, to which outside advisers had previously objected. Supporters say the medication, called aducanumab, can slow cognitive deterioration in the early stages of Alzheimer’s. Critics say there is little evidence the drug is effective. (The treatment does not cure or reverse the disease.) Clinical studies are nebulous; the FDA, which green-lighted the medication under its program for accelerated approval, is requiring follow-up study.
The drug’s maker, the biotech giant Biogen, announced that it would charge $56,000 a year per patient for the treatment. An industry watchdog panel had forecast an $8,300 annual cost; not surprisingly, the news was a boon for Biogen shareholders, with the stock gaining 38 percent the day of the announcement.
Because of the need for diagnostic tests and ongoing monitoring — potential side effects include brain swelling — costs are likely to run even higher.
Now, guess who will ultimately foot many of these immense bills. Most Americans living with Alzheimer’s are 65 or older. This means that Medicare is on tap to pick up the largest share of the drug’s expense, which could be as much as $50 billion annually, according to Bloomberg. Rachel Sachs, a Washington University associate law professor who studies regulatory efforts, warned that this could single-handedly triple annual expenditures on Medicare Part B, which pays for drugs administered intravenously in doctor’s offices as aducanumab would be. Such cost increases could threaten the program’s solvency. Private-insurance costs, too, could be affected if a wide array of people — such as seniors who suspect mild memory issues — seek the medication, not just the early-stage Alzheimer’s patients to whom it is targeted.
So what’s standing in the way of Biogen’s pricing plan becoming a taxpayer heist? Not much. The federal government has long been banned from negotiating Medicare drug prices. Whereas other countries don’t simply pick up whatever tab Big Pharma sends over, Americans pay multitudes more for prescription drugs — 256 percent more, according to a recent Rand Corporation study.
These excessive bills have simmered as a political issue. Despite the occasional high-profile, high-outrage congressional hearing, politicians haven’t mustered the will to effectively push back against pharmaceutical lobbying and address skyrocketing prescription-drug costs. Democrats, led by Sen. Ron Wyden (Ore.) — who called the cost of the new treatment “unconscionable” — are reportedly mounting a legislative effort, though other attempts have ended in failure. President Donald Trump promised much but delivered little. Legislation that House Speaker Nancy Pelosi (D-Calif.) pushed in this Congress and the last session appears moribund, done in by opposition from both Republicans and centrist Democrats. A series of bills by Sen. Bernie Sanders (I-Vt.) and Rep. Ro Khanna (D-Calif.) to allow Medicare to negotiate the cost of prescription drugs, as well as peg U.S. drug prices to the cost in other countries, are effectively aspirational.
Alzheimer’s is a terrible disease. If this treatment ultimately works as proponents hope, this outlay of funds would be understandable and valuable. Supporters of the new treatment hope that a big investment will spur other research that could yield benefits and, one day, a cure. But such outcomes are far from certain. Indeed, positive findings for early-stage patients emerged only after initial trials were halted due to poor results, and a division of the FDA worked with Biogen to reanalyze the data. (Do-gooder outfit Public Citizen complained about this relationship, which it termed “regulatory capture.”)
As important as it is to question the taxpayer bonanza that might be heading toward Biogen, there are other Alzheimer’s costs to consider. Patients and their families — including many unpaid caretakers — struggle here and now. Wait lists for home-based care are often long. Professional caregivers receive low wages, and turnover is high. President Biden’s infrastructure package contains $400 billion for home care of seniors and disabled Americans, but the proposal is stalling as Republicans reject the concept of human infrastructure.
Yet even this situation festers, our elected leaders are willing to pick up the multibillion-dollar tab for a drug that’s quite possibly ineffective for many who will take it. In the U.S. health-care system, patients’ interests chronically come behind the interests of big business.
Players can play the Infinity Wars mashup for a limited time in Battle Royale mode. Like the previous update, a meteor will land on the map in the safe zone, dropping the infinity gauntlet.
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