You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Benjamin Sommers, professor of health policy and economics. This call was recorded at 11:30 am Eastern Time on Monday, April 6.
Previous press conferences are linked at the bottom of this transcript.
BEN SOMMERS: Hi, everybody. Thanks for joining today. I wanted to just to give a couple of thoughts at the outset and then kind of go wherever you’d like on the questions.
As we look to both a public health crisis and an impending economic crisis, one of the key tools to understand is how Medicaid fits in.
The states, in terms of Medicaid, see this as one of the, you know, certainly one of the most important tools available to them, both to manage the immediate medical issues related to the coronavirus epidemic, as well as the largest item in their state budget when you factor in both federal and state funds.
So, we have some new data out last week that’s shed some light on the big picture of where Medicaid financing fits in.
We looked at how the Medicaid expansion has impacted state budgets over the past eight years. And what we found is that the expansion has, as expected, lead to big increases in Medicaid spending in expansion states.
But interestingly, the source of the funds has been almost entirely federal, where we see no significant increase in state spending of their own revenues from the decision to expand Medicaid. And so, as states now consider what they’re going to do in light of a likely recession and millions more people needing health insurance because they can’t get it through work, as well as millions of people needing medical care related to the coronavirus, Medicaid is a key tool in that tool kit.
And so, I’d be very happy to talk about how states can use Medicaid flexibility to address the epidemic. This is one of the key provisions in the first COVID legislation that was passed by Congress was to boost the federal reimbursement rates to states in the Medicaid program for the next year.
And this is really, I think, a key time for the 14 states that have yet to expand Medicaid to seriously consider it given the billions of dollars that would come into their state economies support their hospitals and provide needed medical care during an epidemic to their populations.
One thing I can add while we’re waiting for to see if there any questions.
A bunch of the States have already taken action over the past several weeks. Over 40 states have applied for emergency waivers from the federal government to let them use Medicaid in flexible ways to try to deal with coronavirus.
Now, that’s not as comprehensive if you’re in a non-expansion state is actually expanding coverage to millions of low-income adults, but it is one tool.
And we saw also recently that Utah decided that it was going to suspend its work requirements in Medicaid. And I think this is a reflecting a new reality, that some of the kind of political arguments that we’ve been having for the past several years over Medicaid really take on a new shape right now, that governors are recognizing how important it is for their populations to go to get medical care and to be able to support the safety net of these health care systems and hospitals in such a public health crisis.
MODERATOR: Great. And it looks like we have our first question. Wanted to ask about Presumptive Eligibility in Florida. We have not expanded Medicaid. Could you talk a little bit about -?
BEN SOMMERS: So, let me talk a little bit about – so, presumptive eligibility is essentially a way of allowing providers to enroll people in coverage before the formal determination has been done for eligibility. As you can imagine, right now the red tape of getting the details checked on someone’s income and all the other features that go into a determination is potentially quite counterproductive, as we try to get people acute care.
And so, one of the options for the state waivers is to expand the use of Presumptive Eligibility, where essentially you know safety net hospitals, community centers can cover people and they don’t have to go through the traditional more lengthy evaluation or eligibility determination process to get covered.
So, you know, this is kind of one of the process measures that can help get people insured. Another related one that’s tied directly into the Congressional relief bill that was passed, is that states that want to get this 6.2 percentage point increase in the match rate from the federal government have to meet four criteria.
They can’t increase or can’t change any of their eligibility standards or procedures to make them more restrictive than what they had at the beginning of this year. And so that means that states can’t decide they’re going to start tightening, you know, the renewal period or other sorts of changes that could squeeze people out of the program.
They also can’t impose new premiums or higher premiums than what was in place at the beginning of the year.
They can’t remove anyone from the program as of March 18 during the course of the public health emergency unless the person has moved out of state or actually asks to be removed.
And they also have to cover without any cost sharing all testing and treatment for COVID in Medicaid.
So, what we’re seeing is this kind of, you know, there’s the big picture question of how much money we’re going to put into the program and how are we going to cover people.
But then there are also a lot of these smaller decisions in terms of red tape, including presumptive eligibility, including renewal periods where Congress is opening the door for states to be much more flexible in order to maintain people’s coverage, as you know, the crisis ramps up.
MODERATOR: Thanks. As a follow up, Florida has agreed to the terms of the up to Medicaid reimbursement rates, but not expanded Medicaid as a program. How does this method compare to other expansion states?
BEN SOMMERS: So, you know, I haven’t gone through all – I think, 41 states right now have proposed, and had approved waivers related to the coronavirus based on the guidance from CMS as of the end of last week.
So, most states are doing something. So, 41 obviously is going to include several non-expansion states, just by the numbers.
So, some states are doing both, where they’ve expanded and then they’re taking advantage of the new COVID related flexibility. The choice of whether or not to expand is a really a more fundamental question about broad access. So, you know, if you’ve gone through these waivers and you’ve now increased the availability of coverage related to COVID to uninsured people in your state, that’s great.
But that’s still the minority of care that’s being provided. Yes, in an epicenter where the epidemic is raging, there will be a period of time where the ICUs are dominated by coronavirus.
But in terms of the broad care being provided, you know, I’m practicing primary care doctor. Most of the care I’m providing right now is not coronavirus, right? It’s trying to keep people healthy in terms of their diabetes management, their blood pressure, their asthma, their COPD.
COVID adds a level of complication and risk on top of that, and we’re trying to coordinate but people’s regular health care needs continue and the health care system has to have a way of paying for that.
And, you know, there’s a double whammy here for hospitals, which is that they are having to ramp up and get all of this care ready for the epidemic when patients started arriving large numbers with serious illness. But on top of that, their whole revenue stream and business model is turned on its head right now as hospitals cancel elective procedures.
They cancel, you know, needed but non-urgent imaging tests. So, a lot of the ways that hospitals are normally kind of paying the bills, bringing money in so then they can provide care for, you know, for low income populations and those without insurance, that stream of revenue is largely gone away.
And so, you know, this is where Medicaid can really play an important role because it brings funds that are not just tied to coronavirus – it’s for all the other sorts of care that are going on.
And that’s part of why the match rate was bumped up. That’s part of why the Congressional release bill included an increased Medicare payment rate because – and you know, focus on telemedicine – so we could provide primary care services and other sorts of needed medical care that’s not coronavirus related but needs to be delivered to people in a way that safe and doesn’t have, you know, patients crowding in waiting rooms and exposing themselves to infection.
BEN SOMMERS: I see another question here. And it says, I’ve heard a lot about how Medicaid might be an option for people who have lost their jobs, especially in an expansion state. How realistic would that be for the average worker to sign up for Medicaid if they’ve never used it? And if they may be going back to work in a month or two?
BEN SOMMERS: You know, Medicaid has always been a monthly enrollment period. And what that means is that some people do come in for long periods, but others come in for shorter periods, a few months at a time.
We know that under the Affordable Care Act, one of the big differences in coverage in the country has come from the fact that when people lose insurance to work, they are able to quickly find other coverage if they’re in a Medicaid expansion state. That can be a stopgap if they have is still some income but not benefits through work, they can sign up on the marketplaces.
So, that’s what the evidence on the ACTA has shown, that people do switch into this sort of coverage temporarily when that’s what their needs are.
And it’s an absolutely, you know, reasonable and important form of a safety net. It doesn’t necessarily have to be that there’s planning to be in Medicaid for a year, but in general, I would say going – we know from the research that going a few months without coverage is high risk for people.
It can lead to worse health outcomes. It can lead to unexpected medical bills and that’s even before you’re in an epidemic. So, you know, if you’re out of work for two months, the risk that you might get seriously ill from something else or from coronavirus, you know, having the option of having Medicaid to know that you have comprehensive insurance if you do get sick is a really important safeguard.
And yes, it might be the first time that some people enroll. But the experience in expansion states has been a lot of people who’d never been in Medicaid before have enrolled and most have given it pretty high ratings. The evidence suggests that it’s been fairly popular and most people have been satisfied with the coverage.
MODERATOR: Okay, it looks like we have our next question. Mental health care seems like it will be a major need as the pandemic plays out. How prepared is the health care system for a potential influx of mental health needs among its patients?
BEN SOMMERS: This is a great question. You know, in practice, right now, when I’m seeing patients, which is mostly being done remotely, the two biggest new areas of concern are people who are worried that they have coronavirus or have confirmed infection and people who are who are struggling with the mental health implications of being in isolation, of not being able to see family or friends, not being able to go out of their houses regularly, not being able to get the in-person therapy that they’re used to getting as part of their mental health. This is a real challenge.
You know, providers are taking a variety of approaches to this as with the rest of medical care. We’re seeing as much as possible a rapid shift to telemedicine when possible.
But this may be an area where that’s particularly difficult to do. Where, you know, a virtual visit or a telephone visit is not necessarily going to be the same.
But the isolation that goes with, you know, the social distancing can be really difficult for people. The anxiety around the illness itself, concern for family members, it can be quite debilitating.
So, you know, the short answer is yes, you’re exactly right. This is a big problem. The solutions are not a straightforward. Enhancing telemedicine is certainly one approach. Making sure that people can afford care again and paying providers to provide to offer those services those remote services. Those telemedicine services are important.
And then, more broadly, I think, you know, what can we all do as just regular citizens of the country, as part of our communities, is really make that extra effort to reach out to people who are isolated, right? Folks who are in nursing homes and can’t have family visit but can find other ways to reach out, people who might be living alone and lacking social support, people with substance use disorders, who are used to group support. You know, things like people who are now trying to do AA remotely.
I mean, these are really important social supports for people and there’s no replacement for in-person interaction, but given the constraints of the epidemic, we really have to do our best, both as public health providers and clinicians, as well as just friends and family. This is kind of on all of us to try to help pick up some of that slack.
MODERATOR: Okay, our next question.
Q: Okay, great. Thanks for doing the call. This question would be more about people with private insurance. Maybe people have plans through the exchange. I was wondering if you had any thoughts or could talk a little bit about the cost that they may be experiencing in the future if they do get sick? I know a lot of people insured through the exchange have high deductibles and we’ve been hearing insurers talk a lot about how they’re covering costs sharing and covering testing but I think any of us who write about insurance know that often ends up not being the case. So, I was wondering if you had any thoughts on that.
BEN SOMMERS: Yeah, so you know this for right now, what we know is the general distillation has been between testing for COVID, which is being done without cost sharing for most people in private coverage but the treatment is not. And that varies by provider.
And so, you know, for instance, some companies, you know, Aetna has said that they’re going to waive cost sharing for in-patient admissions for COVID at in-network facilities.
This raises the question of out of network and costs, you know, and surprise billing. So, a lot of the weaknesses or touch points in our healthcare system in general are going to become under even more stress now.
And so, I think that the fact that there are a fair number of people who have high deductibles and that’s both in the marketplace plans as well as employers. We know that’s just been a gradual shift over the past decade.
These are folks who, with a hospitalization, would run up a pretty big bill pretty quickly. And, you know, how sustainabl that is, if the numbers of people with serious illness is in the millions? It’s a really important question.
So, you could take extra steps here. So, Congress, for instance, could say that it’s going to put in effect, something called a reinsurance program that some of my colleagues recently proposed in an article on the Health Affairs blog, where basically they argued that the federal government ought to say it will take on any high kind of catastrophic costs for patients admitted with coronavirus and doing so they will reinsure the private sector.
So that will have two effects. One is that plans might give plans more protection against worrying that they have to charge a lot of cost sharing to people with this sort of illness, but it also will stabilize the risk pool going forward.
Because one thing we have to think about is not just right now. But what are these plans look like in a year? Do you know how many insurers are going to go out of business if they have a high burden of serious infection from coronavirus in their enrolled population?
How much our premium is going to spike? You know, if all of that is going to be paid for ultimately through premiums. There might even be a second hit a year late, you know, one year in where now people trying to stay privately insured are going to see their prices soaring. So, the federal government can play an important role there with something like reinsurance to take some of that risk off of the beneficiaries and the private payers.
But, you know, we know that people are less likely to get care when they face high cost sharing and for some sorts of conditions that may be a trade-off that is an okay in certain circumstances, if it saves money and outcomes are similar.
But for an infectious disease that’s highly contagious, you don’t want to have people putting off needed care, both because the outcomes for them will be worse if they wait too long to come in and, of course, the contagion and risk to family members and other contacts in the community.
So, this is, you know, you hit on another important area where Congress, I think is going to need to step in and do some more related to making private insurance both a stable market going forward, and also to providing more consumer protections.
MODERATOR: A follow up question she would like to know, what’s the status of reimbursing providers for telehealth? There seems to be some uncertainty about what happens when co pays are waived, for example.
BEN SOMMERS: So, on the Medicare and Medicaid side, this is now there’s been, you know, the support for shifting to tell medicine has been, I think, pretty, pretty strong and we’re seeing a lot of that happening.
On the private side it is, you know, essentially plan by plan. For instance, in Massachusetts, most of the big state-based insurers have announced that they are going to wave patient cost sharing for telemedicine during the epidemic.
But that’s a choice that they’ve made and not all of the national insurers are following suit. So, this gets into some, you know, some pretty nitty gritty details but that actually have important financial implications for patients.
Which is that, you know, a normal telephone call. If your doctor or nurse practitioner calls you up and just checks into see how things are going and makes a couple quick changes over the phone, typically that doesn’t get reimbursed.
And providers do some of that, just as part of the job. But when that’s become one of the defining features of what we do, since we’re trying to keep people out of the office, that, you know, to keep small practices open and to keep these, you know, these health care providers solvent, you have to be able to reimburse for that sort of thing.
But now if patients are unaware, they may get a bill for a copay because it wasn’t just a phone call. It was actually a build telemedicine visit.
So, providers really need to be clear with patients. What is a visit and when they’re going to be charged.
And I do think we ought to be as much as possible, trying to reduce the burden on patients, again, where if the implication of copay is that a patient’s not going to be evaluated, not even going to talk to their doctor, we are going to be at risk of making the epidemic worse through these financial barriers. But that has not been fully fleshed out and right now is largely a private insure decision plan by plan.
MODERATOR: Okay, it looks like the next question.
Q: Hi. I just had a quick follow up question to my earlier question. You mentioned steps that Congress could take. And I was just – you know, the conversation we’ve been having on our health team is that we read that a lot of the issues that patients are encountering now: costs, access to testing, more testing being done in wealthier areas as opposed to low income areas are things that we see repeated time and again in healthcare just in general.
I was curious if you had any thoughts on whether the fact that we’re experiencing all of these issues that are common to healthcare in a pandemic-type situation could kind of be the push that Congress needs to take bigger action on health care, maybe universal health care or some of the other debates that we’ve had for years and years about how to improve access?
BEN SOMMERS: Yeah, you know, an epidemic can be a catalyst for change in a lot of ways. I think we’re already seeing some of that on the delivery side with this rapid shift to as much telemedicine as we can do, and just, you know, crisis management on the fly in a lot of our biggest or, you know, our major healthcare providers.
You know, on the financing side and on the policy side, it really remains to be seen. You know, in the article that Jon Gruber and I wrote, we essentially say looking at the evidence is now in, right? We have a decade, or almost a decade, of evidence on the Affordable Care Act, Medicaid expansion, and what it does for patients and what it does for hospitals, which is pretty unequivocal.
It boosts hospital safety and safety net financial performances improved. Hospitals do better. We see fewer hospital closures, in particular rural areas and Medicaid expansion states. We see that patients are much better off financially, and Medicaid expansion also improves the types of care they get and their health outcomes.
And then finally, this last piece of data from our study now is that the state budgets don’t suffer, that the states actually take this really generous 90% federal subsidy through the Medicaid expansion and they figure out ways to offset things they were already doing.
So, there’s no negative impact on state spending from expansion things like education or transportation. It’s really a win-win: the state covers more people, their hospitals get more financing, patients are improving, circumstances are improving, the budgets are stable.
So, given that story, why in an epidemic do we still have fourteen states that haven’t expanded, you know, I find that, you know, pretty galling from the public health perspective.
And it’s largely a political argument, because the main economic argument was state. The state says we can’t afford it. Well, that’s not what we’re seeing in the data, that states can’t afford this. And we’re not seeing those budget harms that were predicted.
So, you know how much we can see a catalyst for change in the epidemic and broad policy question really depends on what policymakers see as their incentives, what the political tradeoffs are and whether there’s a groundswell for change.
I do think probably some states as we’re already seeing are revisiting policies and Medicaid, whether it’s Utah stopping its work requirements or other states applying for these waivers. Whether this gets more states to actually expand, we’ll see.
I don’t have much confidence that this would lead to, you know, say, a push for universal coverage at Congress, that gets in Congress, that gets a lot of traction. Again, given how much we’re seeing, given that the state level opposition to Medicaid expansion, which is a much more incremental change, still is there, the likelihood that you’re going to get through Congress something like, you know, Medicare for All, or a major expansion of the Affordable Care Act with the current composition seems unlikely.
Obviously, come November, you know, healthcare is going to be a big part, you know, coronavirus and otherwise will be a big part of the debate around the election. And if there’s a change in the House and the Senate and the White House with, you know, uniform democratic control, I don’t know. It would be interesting to see what they would be able to push through.
In the absence of that, we have not seen a lot of reflection or revisiting of priorities from the Trump administration on this broad question. Health care, for instance, they continue to support the lawsuit that would overturn the entire affordable care act. There has been no change on that and there’s been no encouragement from the administration for other states to expand Medicaid. So, the big picture federally, I think, is less encouraging that the epidemic’s prompting a broad revisit revisiting of the flaws in our system.
We are seeing kind of step by step, well, what can we do to try to fix this particular problem right now. I think more dramatic action will be needed. But, you know, the politics of this are still quite unclear and we’ll have to see where the public ends up settling out in terms of what it demands from officials in response to the to the epidemic.
MODERATOR: Next question.
Q: Hi, thank you. I was curious about your thoughts on the push to create a special enrollment period for the federally-run exchanges. I’m trying to see the need for it, since a lot of people who have lost jobs already qualify for a special enrollment period. And those who passed on insurance last fall probably still can’t afford it. Do you think states will see a big enrollment jump, if we do get a special enrollment period? Is there a lot of pent up demand now?
BEN SOMMERS: It’s a good question. You know, we know that, based on the most recent numbers on the uninsured population, that about 7 to 8 million are uninsured and likely would qualify for tax credits to get coverage on the marketplaces, but aren’t currently enrolled. And that’s before the recession, or at least the sharp downturn we’re seeing in the economy now.
How many of those folks would sign up now with an open enrollment possibility? You know, it’s – there are a lot of reasons that those 7 or 8 million folks aren’t enrolled. Some were in the plans before, but found the cost sharing to be too high and didn’t find that worth the coverage.
Some may have simply lost track of the open enrollment period There was a shorter period the last two years, there was less enrollment outreach being done by the administration. So, people simply may have forgotten to do so until it was too late.
So, you know, for some of those groups, coronavirus may prompt of revisiting of the tradeoffs here and they may say, ‘actually, you know what? This is not the time for me to go uninsured and this is a high priority and I’m thinking about my health every day – I’m going to sign up if they let me’. So, I think it would lead to, you know, an increase.
Now what share of that population would sign up, I don’t know. You’re right that most people who are losing jobs right now with the downturn, if they had employer coverage before and now they’re losing it, that is a qualifying event and they can enroll.
But, you know, there is also just the red tape that goes with this whole sort of enrollment process that people may not know those details and so you’re worried that some folks who might be eligible for a special enrollment period won’t know that. And that might just be an argument for, across the board, let’s get as many people covered as possible.
And we know that we’re going to have to protect insurers against this surge in cost, which is going to occur, whether or not they have a new open enrollment period, so why don’t we make an open enrollment period and couple that with federal reinsurance so that the insurers aren’t going to take a huge hit financially but we get as many people covered? We keep resources coming into hospitals and other health care providers.
I think that would be a sensible compromise where you don’t just open the doors but you also provide some additional financial protection to the insurers themselves.
Q: Thank you.
MODERATOR: Dr. Sommers, do you have any final words you would to end with before we close the call?
BEN SOMMERS: No, but again, I think these are such important questions and the reality in every state differs quite a bit. And I know we have a lot of state and local reporters on.
You know, there are all sorts of considerations that each state’s going to have to deal with but just because you’re not in an area that might be getting the brunt of the epidemic right now, doesn’t mean you won’t be shortly. And there’s no reason to wait for that to happen for state policymakers to get the financing in place and to figure out how to help people afford their care.
And then the other part to just think about is in all of the discussion about how to do it, how to respond to a recession that’s on its way.
You know, federal stimulus dollars have to be spent. They have to work their way into the system. And so right now we’re hearing a lot about how, you know, when will these rebate checks get sent out and who’s going to get them. And what’s the process.
It’s really important for the government to take actions that take advantage of existing pathways to pump money into the economy.
Medicaid is one of those, you know, food stamps, the SNAP program is another. These are programs that already exists. If you get more people and more benefits that that money flows starting today. And so that’s really a key tool.
This is not just a health argument again. This is an economic argument of how do you prop up states during this, you know, this impending economic downturn.
This concludes the April 6 press conference.
Michael Mina, assistant professor of epidemiology (April 3, 2020)