The outbreak of the COVID-19 pandemic has transformed the face of healthcare globally, bringing into focus the need for significant healthcare reforms that will eventually promote universal access to affordable care.
The U.S. healthcare industry has faced incredible challenges in the wake of this pandemic and is expected to come across even more. The way in which U.S. providers are delivering care and the way in which the patients are paying for the same is particularly unravelling in this crucial time. This in turn leaves millions of people vulnerable, calling for strict and swift coordinated political action to ensure access to affordable care.
Pre-pandemic, approximately half of the Americans enjoyed employer-sponsored health coverage. However, with the record numbers filing for unemployment insurance, millions of Americans are left without health insurance amidst the severe crisis. And even those who are lucky enough to maintain insurance coverage are struggling to find affordable care.
Research suggests that more than half of Americans with employer-sponsored health insurance used to delay or postpone their recommended treatment prior to the pandemic, primarily because of the associated costs[1]. With the outbreak of the pandemic, the entire situation is expected to exacerbate further, owing to the loss of jobs and health insurance. In a recent poll it was found that 68% of adults identified that the out-of-pocket costs that they might have to pay would perhaps be the most important factor affecting their decision to seek care if they had COVID-19 symptoms[2]. All in all, failure to receive testing and treatment because of cost concerns will only aggravate the already adverse impact of the pandemic.
Congress has passed two important legislations to address the myriad issues raised by the COVID-19 pandemic. And there are more expected to follow. For instance, The Families First Coronavirus Response Act (FFCRA) necessitates all private insurers, Medicare, Medicare Advantage, and Medicaid to cover COVID-19 testing, as well as to eliminate all cost-sharing associated with the testing services including co-payments, deductibles, and co-insurance payments. $1billion has also been appointed for the Public Health and Social Services Emergency Fund to cover testing for the uninsured Americans under Medicaid plans. Even though FFCRA facilitates with testing costs, patients still remain vulnerable to cost-sharing expenses associated with the treatment. Hospitalization costs is their major concern, especially until they receive their annual out-of-pocket maximum, which ranges between $8000 for an individual to $16000 for a family.
A $2.2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act, is another important legislation that requires all private plans to cover COVID-19 testing and future vaccines. However, it fails to eliminate the cost-sharing for COVID-19 treatment. Nevertheless, many private insurers have agreed to waive cost-sharing payments for plan members. These include Humana, Cigna, UnitedHealth Group and Blue Cross Shield. The CARES Act has apportioned $100 billion for healthcare providers and hospitals, conditioned on provider’s agreement not to bill insured patients more than their cost-sharing amounts. Also, they are liable to not bill uninsured patients for COVID-19 treatment. The federal government will reimburse providers at Medicare rates for treating uninsured patients. Moreover, the CARES Act also offered substantial tax credits, loans and emergency grants to help the businesses so they can sustain employees on the payroll, while also increasing the unemployment benefits to those who lost their jobs to COVID-19.
Although these legislations offer crucial assistance, additional well-thought policies are required to ensure that Americans continue to access affordable and quality care amid the public health emergency. In my opinion, firstly the policymakers must freeze people’s insurance status as of April 1, 2020 to sustain as many people as possible in their existing plans. People who were previously on employer-sponsored plans should be able to continue their plans during the crisis even if they lose their jobs or are unable to pay their premiums. The first step in due regard has been the introduction of grace periods in several states on insurance-premium payments for all policies[3]. For instance, the Ohio Department of Insurance has extended a 60-days grace period for premium payments to help insurers retain employees and their health benefits[4].
Secondly, secured coverage must be a priority of policymakers, especially for people who have already lost their jobs in the wake of the pandemic. Eleven states and the District of Columbia have introduced new enrollment periods for their state ACA marketplaces to encourage enrollment[5]. People who have lost jobs within the past 60 days or who might lose their jobs in the next 60 days can enroll in an ACA marketplace, despite President Trump’s announcement of not opening enrollment in the 38 states with ACA plans.
Nearly all states have received 1135 Medicaid waivers in response to the pandemic in order to meet the medical needs of their most vulnerable residents[6]. Majority of the states sought such waivers to reduce COVID-19-related cost-sharing and to facilitate healthcare providers while encouraging patient enrollment. Moreover, many states who had already applied for and received a Medicaid waiver will halt disenrollment to receive a higher federal matching rate as determined by FFCRA. Finally, no state is currently enforcing work requirements for maintaining Medicaid eligibility.
State or federal governments can also implement plans similar to Disaster Relief Medicaid program (DRM) implemented in New York after the 9/11 incident. Such temporary public health insurance programs can be tailored to the size and scope of the pandemic in different states. The DRM allowed almost 350000 people in New York to easily and quickly access Medicaid benefits by increasing eligibility thresholds and by using short-form applications. 4 months of emergency Medicaid coverage was provided to the local residents under this program and they were then gradually transitioned to other coverage plans. A similar emergency program in other vulnerable states can plausibly raise eligibility thresholds beyond Medicaid expansion levels to facilitate the people during the crisis period.
The third intervention strategy could be devised around the state and federal officials continuing to address the out-of-pocket expenses including surprise medical bills and cost-sharing. Hospital and provider reimbursement shortages can be easily covered by the CARES Act appropriations.
The COVID-19 pandemic has also created unique challenges pertaining to the affordability factor associated with surprise medical billing, which can occur when a patient receives treatment from an out-of-network physician at an in-network facility. Such situations arise in the wake of other challenges such as staffing shortage and triage protocols. Furthermore, provider shortages may compel providers to fill in care gaps for many medical conditions others than COVID-19, which eventually expands the potential for out-of-network care and surprise billing during crisis periods such as these. Policymakers must necessarily eliminate bills from out-of-network providers that are in excess of in-network cost-sharing limits, for all medical treatments received during the public health emergency.
Comprehensive protection planning requires federal level intervention while the states endeavor to lead the way on COVID-19 policies. The Employee Retirement Income Security Act of 1974 (ERISA) prohibits state laws governing health insurance from applying to self-insured employer plans. As a result, nearly 60% of Americans with employer-sponsored health insurance will be deprived of the current state surprise billing protections, cost-sharing prohibitions and coverage mandates. ERISA, therefore, leaves millions of Americans unprotected by state healthcare reforms. However, states can avoid some of the ERISA challenges by directly prohibiting healthcare providers from charging cost-sharing rates for COVID-19 treatment as well as from surprise billing.
One thing that has become much evident in the course of this global pandemic is the fact that health, finances and social fabric are all closely-knit and interdependent. It has never been more apparent than today that healthcare reforms are the need of the hour in order to be able to ensure universal access to affordable care for all Americans. This is essentially why our healthcare policies must necessarily reflect this reality, both during and post-pandemic.
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