COVID coverage for all dries up even as hospital costs rise
For the first time, the U.S. came close to providing health care for all during the coronavirus pandemic — but for just one condition, COVID-19. Now, things are reverting to the way they were as federal money for COVID care of the uninsured dries up, creating a potential barrier to timely access. But the virus is not contained, even if it’s better controlled. And safety-net hospitals and clinics are seeing sharply higher costs for salaries and other basic operating expenses. They fear they won’t be prepared if there’s another surge and no backstop. “We haven’t turned anybody away yet,” said Dr. Mark Loafman, chair of family and community medicine at Cook County Health in Chicago. “But I think it’s just a matter of time … People don’t get cancer treatment or blood pressure treatment every day in America because they can’t afford it.” A $20 billion government COVID program covered testing, treatment, and vaccine costs for uninsured people. But that’s been shut down. Special Medicaid COVID coverage for the uninsured in more than a dozen states also likely faces its last months. At Parkland Health, the frontline hospital system for Dallas, Dr. Fred Cerise questions the logic of dialing back federal dollars at a time when health officials have rolled out a new “test-to-treat” strategy. People with COVID-19 can now get antiviral pills to take at home, hopefully avoiding hospitalization. Vice President Kamala Harris, who recently tested positive but is back working at the White House, is an example. “Test-to-treat will be very difficult for uninsured individuals,” predicted Cerise, president and CEO of the system. “If it’s a change in strategy on the large scale, and it’s coming without funding, people are going to be reluctant to adopt that.” Officials at the federal Department of Health and Human Services say the new antiviral drugs like Paxlovid have been paid for by taxpayers, and are supposed to be free of charge to patients, even uninsured ones. But they acknowledge that some uninsured people can’t afford the medical consultation needed to get a prescription. “We hear from state and local partners that the lack of funding for the Uninsured Program is creating challenges for individuals to access medications,” said Dr. Meg Sullivan, chief medical officer for the HHS preparedness and response division. The nation has not pinched pennies on the pandemic before. “We’re well short of universal health coverage in the U.S., but for a time, we had universal coverage for COVID,” said Larry Levitt, a health policy expert with the nonpartisan Kaiser Family Foundation. “It was extraordinary.” Recently an urgent White House request for $22.5 billion for COVID priorities failed to advance in Congress. Even a pared-back version is stuck. Part of the Biden administration’s request involves $1.5 billion to replenish the Uninsured Program, which paid for testing, treatment, and vaccine-related bills for uninsured patients. The program has now stopped accepting claims due to lack of money. That program, along with a less known Medicaid option for states, allowed thousands of uninsured people to get care without worrying about costs. Bipartisan support has given way as congressional Republicans raise questions about pandemic spending. The Uninsured Program was run by the Health Resources and Services Administration, an HHS agency. Medical providers seeing uninsured people could submit their bills for reimbursement. Over the last two years, more than 50,000 hospitals, clinics, and medical practices received payments. Officials say they can turn the program back on if Congress releases more money. The Medicaid coverage option began under the Trump administration as a way to help states pay for testing uninsured people. President Joe Biden’s coronavirus relief bill expanded it to treatment and vaccine costs as well. It’s like a limited insurance policy for COVID. The coverage can’t be used for other services, like a knee replacement. The federal government pays 100% of the cost. Fifteen states, from deep blue California to bright red South Carolina, have taken advantage of the option, along with three U.S. territories. It will end once the federal coronavirus public health emergency is over, currently forecast for later this year. New Hampshire Medicaid Director Henry Lipman said the coverage option allowed his state to sign up about 9,500 people for COVID care that includes the new antiviral drugs that can be taken at home. “It’s really the safety net for people who don’t have any access to insurance,” said Lipman. “It’s a limited situation, but in the pandemic, it’s a good back-up to have. It makes a lot of sense with such a communicable disease.” With COVID cases now at relatively low levels, demand for testing, treatment, and vaccination is down. But the urgency felt by hospitals and other medical service providers is driven by their own bottom lines. In Missouri, Golden Valley Memorial Healthcare CEO Craig Thompson is worried to see federal funding evaporate just as operating costs are soaring. Staff have gotten raises, drug costs have risen by 20%, and supply costs by 12%. “We’ve now exited this pandemic … into probably the highest inflationary environment that I’ve seen in my career,” Thompson said. The health system serves a largely rural area between Kansas City and Springfield. In Kentucky, Family Health Centers of Louisville closed a testing service for uninsured people once federal funds dried up. The private company they were working with planned to charge $65 a test. Things are manageable now because there’s little demand, said spokeswoman Melissa Mather, “but if we get hit with another omicron, it’s going to be very difficult.” Floridian Debra McCoskey-Reisert is uninsured and lost her older brother to COVID-19 in the first wave two years ago. In one of their last conversations, he made her promise she wouldn’t catch the virus. McCoskey-Reisert, who lives north of Tampa, has managed to avoid getting sick so far. But she’s overshadowed by fear of what could happen if she or her husband get infected. “If either one of us get sick with COVID, we don’t have a way to pay for it,” she said. “It would
‘Obamacare’ survives: Supreme Court dismisses big challenge
The Supreme Court, though increasingly conservative in makeup, rejected the latest major Republican-led effort to kill the national health care law known as “Obamacare” on Thursday, preserving insurance coverage for millions of Americans. The justices, by a 7-2 vote, left the entire Affordable Care Act intact in ruling that Texas, other GOP-led states, and two individuals had no right to bring their lawsuit in federal court. The Biden administration says 31 million people have health insurance because of the law, which also survived two earlier challenges in the Supreme Court. The law’s major provisions include protections for people with existing health conditions, a range of no-cost preventive services, expansion of the Medicaid program that insures lower-income people, and access to health insurance markets offering subsidized plans. “The Affordable Care Act remains the law of the land,” President Joe Biden, said, celebrating the ruling. He called for building further on the law that was enacted in 2010 when he was vice president. Also left in place is the law’s now-toothless requirement that people have health insurance or pay a penalty. Congress rendered that provision irrelevant in 2017 when it reduced the penalty to zero. The elimination of the penalty had become the hook that Texas and other GOP-led states, as well as the Trump administration, used to attack the entire law. They argued that without the mandate, a pillar of the law when it was passed, the rest of the law should fall, too. And with a Supreme Court that includes three appointees of former President Donald Trump, opponents of “Obamacare” hoped a majority of the justices would finally kill the law they have been fighting for more than a decade. But the third major attack on the law at the Supreme Court ended the way the first two did, with a majority of the court rebuffing efforts to gut the law or get rid of it altogether. Trump’s appointees — Justices Amy Coney Barrett, Neil Gorsuch, and Brett Kavanaugh — split their votes. Kavanaugh and Barrett joined the majority. Gorsuch was in dissent, signing on to an opinion from Justice Samuel Alito. Justice Stephen Breyer wrote for the court that the states and people who filed a federal lawsuit “have failed to show that they have standing to attack as unconstitutional the Act’s minimum essential coverage provision.” In dissent, Alito wrote, “Today’s decision is the third installment in our epic Affordable Care Act trilogy, and it follows the same pattern as installments one and two. In all three episodes, with the Affordable Care Act facing a serious threat, the Court has pulled off an improbable rescue.” Alito was a dissenter in the two earlier cases in 2012 and 2015, as well. Like Alito, Justice Clarence Thomas was in dissent in the two earlier cases, but he joined Thursday’s majority, writing, “Although this Court has erred twice before in cases involving the Affordable Care Act, it does not err today.” Because it dismissed the case for the plaintiff’s lack of legal standing — the ability to sue — the court didn’t actually rule on whether the individual mandate is unconstitutional now that there is no penalty for forgoing insurance. Lower courts had struck down the mandate, in rulings that were wiped away by the Supreme Court decision. With the latest ruling, the Supreme Court reaffirmed that “the Affordable Care Act is here to stay,” former President Barack Obama said, adding his support to Biden’s call to expand the law. Texas Attorney General Ken Paxton pledged to continue the fight against “Obamacare,” which he called a “massive government takeover of health care.” But it’s not clear what Republicans can do, said Larry Levitt, an executive vice president for the nonprofit Kaiser Family Foundation, which studies health care. “Democrats are in charge and they have made reinvigorating and building on the ACA a key priority,” Levitt said. “Republicans don’t seem to have much enthusiasm for continuing to try to overturn the law.” Republicans have pressed their argument to invalidate the whole law even though congressional efforts to rip out the entire law “root and branch,” in Senate GOP leader Mitch McConnell’s words, have failed. The closest they came was in July 2017 when Arizona Sen. John McCain, who died the following year, delivered a dramatic thumbs-down vote to a repeal effort by fellow Republicans. Chief Justice John Roberts said during arguments in November that it seemed the law’s foes were asking the court to do work best left to the political branches of government. The court’s decision preserves benefits that have become part of the fabric of the nation’s health care system. Polls show that the law has grown in popularity as it has endured the heaviest assault. In December 2016, just before Obama left office and Trump swept in calling the ACA a “disaster,” 46% of Americans had an unfavorable view of the law, while 43% approved, according to the Kaiser Family Foundation tracking poll. Those ratings flipped, and by February of this year, 54% had a favorable view, while disapproval had fallen to 39% in the same ongoing poll. The health law is now undergoing an expansion under Biden, who sees it as the foundation for moving the U.S. to coverage for all. His giant COVID-19 relief bill significantly increased subsidies for private health plans offered through the ACA’s insurance markets, while also dangling higher federal payments before the dozen states that have declined the law’s Medicaid expansion. About 1.2 million people have signed up with HealthCare.gov since Biden reopened enrollment amid high levels of COVID cases earlier this year. Most of the people with insurance because of the law have it through Medicaid expansion or the health insurance markets that offer subsidized private plans. But its most popular benefit is protection for people with preexisting medical conditions. They cannot be turned down for coverage on account of health problems or charged a higher premium. While those covered under employer plans already had such protections, “Obamacare” guaranteed them for people buying
Justice Department move on health law has risks for GOP
The Trump administration’s decision to stop defending in court the Obama health law’s popular protections for consumers with pre-existing conditions could prove risky for Republicans in the midterm elections — and nudge premiums even higher. The Justice Department said in a court filing late Thursday that it will no longer defend key parts of the Affordable Care Act, beginning with the unpopular requirement that people carry health insurance, but also including widely-supported provisions that guarantee access for people with medical problems and limit what insurers can charge older, sicker adults. Friday, the insurance industry warned in stark terms of “harm that would come to millions of Americans” if such protections are struck down, causing premiums “to go even higher for older Americans and sicker patients.” Weighing in on a Texas challenge to the health law, the Justice Department argued that legally and practically the popular consumer protections cannot be separated from the unpopular insurance mandate, which Congress has repealed, effective next year. That argument is likely to be lost on consumers, said Robert Blendon, a polling expert at the Harvard T.H. Chan School of Public Health — particularly in the heat of an election that will determine control of Congress. “The pre-existing condition thing is what the ads will be run on,” said Blendon. “Pre-existing conditions have gotten to be an issue that people walking on the streets understand … it’s very emotional.” Some Democratic politicians didn’t waste much time. “Democrats will not allow Republicans to get away with quietly trying to strip away pre-existing conditions protections for millions of Americans through a legal backdoor,” said Rep. Frank Pallone, D-N.J., a spokesman for his party on health care. Senate Democratic Leader Chuck Schumer of New York urged President Donald Trump to reverse the decision. Administration officials at the departments of Health and Human Services and Treasury would not comment, instead pointing to the Justice Department filing, which said other parts of the health law would continue to stand, including its Medicaid expansion covering about 12 million low-income people. HHS and Treasury administer the health law’s coverage and subsidies. Loosening the health law’s rules on pre-existing conditions and on charging more to older adults is a key goal for the Trump administration. Partly that’s because those consumer protections also raise premiums across the board, as the cost of covering the sick is spread among all customers, including healthier people who previously benefited from lower rates. Indeed, people who pay the full cost of their individual health plans and aren’t eligible for subsidies under the health law have been clamoring for relief from several years of double-digit premium increases. Economist Gail Wilensky, who’s advised Republicans, said she’s not sure about the timing of the administration’s action. “You can definitely assume Democrats will use it to whip up their side,” said Wilensky, administrator of Medicare under former President George H.W. Bush. “For the people not affected by the ACA, or not particularly supportive, I don’t know that it will matter much.” The issues in the court case are unlikely to be resolved quickly, but some experts said the added uncertainty could prompt insurers to seek higher premiums in 2019 for health plans sold to individuals. “Insurance companies hate uncertainty, and when they face uncertainty they tend to increase premiums and hedge their bets,” said Larry Levitt of the nonpartisan Kaiser Family Foundation. America’s Health Insurance Plans, the main industry trade group, bemoaned the Justice Department’s stance, saying it could upset a market that is becoming “more steady” for most consumers. “Zeroing out the individual mandate penalty should not result in striking important consumer protections,” the group said. It will lead to “renewed uncertainty in the individual market” and a “patchwork of requirements in the states” and make it more challenging to offer coverage next year. The lawsuit, filed in February by Texas and other GOP-led states, is in many ways a replay of the politically divided litigation that ended with the Supreme Court upholding the health care overhaul in 2012. In this case, California is leading a group of Democrat-led states in defending the law. The Trump administration’s stance is a rare departure from the Justice Department’s practice of defending federal laws in court. Attorney General Jeff Sessions said in a letter to Congress that Trump, who campaigned on repealing the law and nearly did so his first year in office, approved the legal strategy. Donald Verrilli Jr., President Barack Obama’s top Supreme Court lawyer who defended the law, called the decision “a sad moment.” “I find it impossible to believe that the many talented lawyers at the department could not come up with any arguments to defend the ACA’s insurance market reforms, which have made such a difference to millions of Americans,” Verrilli said. Shortly before the government’s court filing Thursday, three career lawyers at the Justice Department withdrew from the case and were replaced by two political appointees, according to court filings. Republished with the permission of the Associated Press.
