As the number of coronavirus cases rapidly increases, quick, impactful action from both state and federal governments to ensure that people have health coverage and care that is affordable becomes more critical than ever. Taking such action will supplement other urgently needed public health measures—such as paid sick leave, social distancing, and emergency federal support for state and local health departments (building on the $950 million emergency funding laws passed in early March)—by encouraging people to seek testing and care. And while other urgent and expansive efforts to bolster our medical supplies, testing capabilities, and hospitals and clinics’ capacity to serve patients are increasingly necessary, actions making coverage and care affordable to individuals will not only improve individual health outcomes but also can contribute to a slowing of the spread of the virus (“flattening the curve”), mitigating the stress on our health care system at any given time—which, in turn, will save lives.
Making both coverage and care affordable will also help prevent financial disaster for people who seek and need them, particularly at a time when the economy is likely to experience a severe decline as a result of the pandemic.
Below are a number of actions that states and the federal government could take immediately, as well as actions that may take the next three to four months, to change coverage laws and help mitigate the pandemic. The good news is that some states have already started down this path, and the House of Representatives has proposed a bill that will take steps in that direction as well.
1. Eliminate costs for coronavirus testing and treatment.
Several states (including Washington, New York, New Jersey, Massachusetts, and California) have taken swift action to eliminate out-of-pocket costs for testing for coronavirus. New York State’s executive action, for example, requires insurers to waive deductibles and co-pays for screening and testing of coronavirus whether it is done at in-network providers, urgent care facilities, or at emergency rooms. Importantly, the Washington State directive included short-term, limited duration plans, which are more likely to be low-value and include significant out-of-pocket costs.
Massachusetts’ directive goes further, and includes not just testing, but also requires the coverage of co-pays for treatment and, in the future, a vaccine.
Unfortunately, states are unable to impose these requirements on self-insured plans regulated under the ERISA, a federal law that courts have found to preempt state oversight. But states can still include student health insurance and self-funded (meaning the risk is borne by the college) student health insurance in these directives (plans that often sit between legal frameworks at the state level).
2. Expand options to enroll in and retain ACA exchange plans immediately.
Typically, individuals who want to enroll in individual health insurance have to wait for an open enrollment period, or enroll when they qualify for what’s called a “special enrollment period” after qualifying life events such as losing a job, moving, or giving birth. Washington State became the first state to create a special enrollment period for those affected by coronavirus. All states who run their own insurance exchanges could take similar action, and Massachusetts followed suit. Further state action could include requiring that insurance take effect immediately, rather than the start of the next month.
States that do not run their own exchange do not have the same level of flexibility as those that do. States that use HealthCare.gov must wait for the federal government to allow a special enrollment period.
Finally, states could expand grace periods allowed for premium nonpayment. While consumers who qualify for marketplace subsidies have a ninety-day grace period to pay their premiums before coverage is terminated, grace periods for unsubsidized consumers are governed by state law and are often limited to thirty days. Coverage is critical right now, and the very individuals most likely to rely on individual coverage—gig workers, self-employed contractors, and so on—may be the ones hit hardest by the immediate economic impact of the pandemic and thus unable to pay their premiums right away. Given this crisis, short-term economic instability should not result in coverage losses, which could exacerbate this public health crisis.
3. Disaster relief funds, emergency powers, and coordination.
A number of states have proposed or already appropriated funds to handle increased staffing and to establish task forces to coordinate across agencies, and states have a broad range of authorities to allocate existing funding to address coronavirus-related costs under their emergency powers; states can add to those efforts by supplementing federal funds (see below) to support safety net providers and others that will likely see an influx of uninsured patients to whom they must provide free or low-cost services. These measures should ensure that, at a minimum, those providers can administer free tests at scale.
4. Request Medicaid waivers to quickly expand coverage and eliminate costs.
States have significant authority to request waivers from the federal government in their Medicaid programs to expand who gets covered and what gets covered, and to enroll people through presumptive eligibility (essentially, enrolling people on the spot). New York used this flexibility in the aftermath of 9/11; Louisiana utilized it in the aftermath of Katrina; and Michigan relied on it in the aftermath of lead contamination of drinking water in Flint. Medicaid waivers should be approved on a fast track in order to accomodate the immediate health care needs of low-income people during this public health crisis.
5. Ensure that nonprofit hospitals direct community benefit dollars to testing and care.
As a condition of their nonprofit status, nonprofit hospitals are required to provide charitable community benefits and invest in activities that benefit the health of the communities they serve. These hospitals benefited from at least $24.6 billion in tax exemptions in 2011. Although these hospitals typically devote their community benefits resources to clinical care, such as making up for Medicaid shortfalls and providing charity care, few states have set standards to govern community benefit requirements and hospital spending.
States could ensure that hospitals are maximizing their community benefits spending in the midst of this crisis by requiring hospitals to direct these funds to care for the uninsured affected by coronavirus or to reduce or waive cost-sharing for those affected by coronavirus. States could make community benefit dollars go further by instructing nonprofit hospitals to base rates for the uninsured on the rates paid by public payers, rather than rates from the hospital’s chargemaster.
6.Protect consumers from low-value short-term health plans.
Short-term, limited duration plans are low-value plans that do not have to offer the protections or services otherwise available through ACA-compliant plans (and the Trump administration made these plans more easily available by allowing twelve-month renewable plans instead of limiting them to just three months). An individual enrolled in such a plan who suspected they were infected with coronavirus and sought medical care ended up with thousands of dollars of bills and a requirement that he submit medical records for the prior three years, as these plans can discriminate based on pre-existing conditions. Five states regulate these plans such that they are not offered in the state; more states should take swift action to protect consumers who need access to quality coverage.
7. Protect people from balance or “surprise” billing and limit or suspend facility fees.
Many patients are exposed to surprise medical bills and facility fees, particularly when seeking emergency care. To date, twenty-eight states have at least some protections against balance billing; of those, thirteen states have adopted comprehensive protections. Far fewer states have explicitly addressed facility fees, which are additional fees charged by hospitals (and increasingly for outpatient services at hospital-owned facilities) to offset overhead costs.
States should quickly pass comprehensive balance billing legislation, or, at a minimum, pass balance billing legislation to address emergency services. Doing so helps remove the most severe cost implications of ending up in a hospital or care situation that imposes major charges for services out of network on consumers. States should also limit hospitals from charging facility fees in all emergency care settings and when care is related to coronavirus screening, testing, and treatment. Governors should consider whether they have the authority to take some of these actions through an emergency declaration that protects consumers from price gouging.
8. Pass the Medicaid expansion.
If there ever was a time for the fourteen states who have refused to expand Medicaid to swiftly expand their program, it is now. The coronavirus pandemic will increase both the need for covered preventive care, and comprehensive care more broadly. Furthermore, the increasing likelihood of the pandemic inducing a significant economic downturn, and possibly a recession, the number of unemployed and thus uninsured people is likely only to increase, even further exacerbating the level of uncompensated care that health care providers will need to provide. States should prioritize Medicaid expansion this spring; Kansas, for example, has a bipartisan plan to pass Medicaid expansion that is currently being held hostage by anti-abortion rights legislators.
The federal government can encourage states to apply for, and quickly approve, changes (discussed earlier) to state waivers to allow for the coverage of expanded populations and quick sign-ups. It can also enable states to ensure that coronavirus testing and diagnostic services are available through Medicaid with no cost-sharing, a proposal included in the House emergency funding bill proposed on March 11, the Families First Coronavirus Response Act.
The federal government can also increase the federal match (the FMAP) for existing Medicaid programs to help them handle increased sign-ups likely to result from expanded need or an economic downturn that may otherwise lead to states restricting access; increasing the match will also allow states to afford to pay for a broad range of urgent public health needs. The House bill proposed an FMAP increase of 8 percent, which is a strong start with support from across the aisle.
10. Provide free testing and care for people (or services) not covered by insurance through the National Medical Disaster System or other new funding.
The federal government has the authority to utilize government health systems or pay private ones to provide care in an emergency situations through the National Medical Disaster System. The federal government should use that authority, or create new ones, to provide free testing and care to coronavirus patients, and to otherwise provide financial support for people quarantined (the same authority will allow the federal government to expand supplies, build temporary facilities to serve patients, and deploy response teams). It can also expand upon the initial emergency funding bill passed by Congress in early March, which includes $100 million directly to community health centers to prevent and respond to coronavirus.
The Trump administration could move more quickly on all of this and release new funds by declaring a national emergency. Doing so is also necessary to enable the executive branch to take additional measures, such as waiving certain federal requirements under Section 1135 of the Social Security Act in response to emergencies, as was done during the H1N1 flu pandemic.
11. Immediately require all private and public insurance plans to provide free coronavirus testing, including ERISA and grandfathered plans.
Congress could require all private health insurance plans to cover testing for coronavirus immediately (rather than using the year-long process required through the Affordable Care Act to include the test as free preventive care). Moreover, even under the slower ACA process, grandfathered plans would still not be required to provide free preventive care. The Families First Coronavirus Response Act includes such a requirement immediately, and does include grandfathered plans.
While some employers and insurers are announcing that they will cover the coronavirus test voluntarily, federal action is critical to ensure immediate and uniform coverage of coronavirus testing. This is because states do not have the authority to require federally regulated self-insured plans to do so. About 61 percent of workers are in these plans, making federal action critical.
12. Expand flexibility in signing up and paying for insurance on healthcare.gov and other government coverage.
Either administratively or through congressional action, the federal government can enable the uninsured to enroll in coverage and help people who are struggling to pay for care. As some state exchanges have already done, the Department of Health and Human Services (HHS) could adopt a new special enrollment period option to allow people to newly enroll in coverage. HHS has regularly extended new special enrollment period opportunities across its programs in response to other crises; for example, HealthCare.gov and Medicare have regularly allowed for a special enrollment period in response to hurricanes.
13. Make the future coronavirus vaccine free (and add to the list of preventive services).
The $8.3 billion emergency funding package to combat coronavirus passed by Congress in early March includes about $3 billion to research and develop vaccines and another $300 million to purchase vaccines, therapeutics, and diagnostics to help ensure that the vaccine is affordable. Congress also has a number of long-term options to keep down the price of antivirals and avoid future price gouging.
The Affordable Care Act relies on the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention to identify immunizations that group and individual health plans must provide for free (that is, without cost-sharing), but requires the update to plans not take effect for a year. ACIP recently, for instance, recommended a pre-exposure vaccination against Ebola for high-risk health care workers and responders. Congress could eliminate the delay in the effective date of coverage and require no-cost coverage of a coronavirus vaccine immediately as it becomes available and recommended by ACIP.
14. Immediately stop implementation of the public charge rule.
The Trump administration recently promulgated a rule that penalizes immigrants who access public benefits and deters immigrants and their families from accessing benefits that they are legally entitled to. The Department of Homeland Security has already conceded that the new rule could lead to an increase in communicable diseases. While this rule has been challenged in court and is working its way through the system, it was recently allowed to go into effect. In light of the coronavirus, state attorneys general arguing against the rule have asked the Trump administration to immediately halt its implementation, noting that the public charge rule “directly undermines and frustrates our public health professionals’ efforts, putting our communities and residents at unnecessary risk.” The Trump administration should immediately halt implementation of the public charge rule.
15. Drop the anti-ACA lawsuit.
The ACA already provides a number of protections to enrollees: It protects people from pre-existing condition discrimination, caps out-of-pocket health care expenses, provides expanded Medicaid coverage for states who accept expansion dollars, subsidizes individual insurance coverage to those who qualify, and requires that individual and small group plans cover a set of “essential health benefits”—that generally include laboratory and diagnostic services, hospitalization, and prescription drugs—all services that will be needed to treat coronavirus.
Yet, the Trump administration has joined with state attorneys general to once again try and repeal the entire law, and the U.S. Supreme Court has agreed to hear the case (California v. Texas) in the coming months—recklessly putting the coverage of millions of Americans at risk as the country faces a pandemic.
The coronavirus health crisis—which may be exacerbated by our fragmented system of providing health care and coverage—underscores the need for bold efforts that move toward universal coverage. The parameters of what that should look like have been the subject of intensive debate during the Democratic primaries, and members of Congress have proposed at least nine different plans to do so. Several states have also begun to roll out a state-level public option, utilizing existing public insurance infrastructure to expand coverage.
In the meantime, in the coming days, weeks, and months, state and federal governments will need to explore expansive measures to promote public health, ease financial burdens felt by people who cannot work, provide care for individuals who get sick, and take broader action to reverse the economic turmoil and job loss that may result through a comprehensive stimulus package. But policymakers must also pursue a range of changes to our health care coverage policy to create the right incentives for people to seek care and to minimize the financial harm that results, and both state and federal governments have a role in that.
There’s a lot of work to do, and, quite literally, no time to waste.