Health Issues Carried Weight on the Campaign Trail. What Could Biden Do in His First 100 Days?

Joe Biden ran on an expansive health care platform during his 2020 presidential campaign, with a broad array of promises such as adding a government-sponsored health plan to the Affordable Care Act and lowering prescription drug prices. Perhaps most significantly, he pledged to get control of the covid pandemic that claimed more than 400,000 American lives by Inauguration Day.

President Biden now faces major challenges in accomplishing his health care agenda; among the biggest will be bridging partisan divides in both Congress and the nation at large.

Even with the Democrats’ newfound majority in the Senate — the result of victories by the Rev. Raphael Warnock and Jon Ossoff in Georgia’s runoff elections — differences in health policy between the party’s moderate and progressive wings will persist.

“With razor-thin Democratic majorities in both the House and the Senate and many other priorities in addition to health care, Biden is unlikely to succeed in accomplishing all of his health agenda,” said Larry Levitt, executive vice president for health policy at the KFF. (KHN is an editorially independent program of KFF.)

Still, Democratic control of the Senate will allow Biden to pursue some of his health care priorities “using a two-pronged strategy of legislation and executive actions,” Levitt said.

PolitiFact and KHN teamed up to analyze Biden’s promises during the 2020 presidential campaign and will monitor his policies over the next four years to see which ones materialize. But, for now, as Biden settles into the West Wing, what are his chances of making progress on health care?

The Covid Pandemic

In his first 100 days in office, Biden has promised to get 100 million doses of covid vaccine in the arms of Americans and — if Congress provides the funds to do so — get all kids back into schools safely. He asked people to wear face masks in public for those 100 days. He also has repeatedly promised he would get the covid pandemic under control.

Other covid promises include a pledge to double the number of drive-thru testing sites and create a national pandemic testing board. He said he wants to invest $25 billion in covid vaccine distribution and to ensure that every American has access to the vaccine at no cost. He’s also promised to use the Defense Production Act to ramp up personal protective equipment supplies and restore national stockpiles.

During his first two days in office, Biden took steps to accomplish these goals, using executive orders to put in place masking mandates regarding federal buildings and interstate travel — for example, in airports and on commercial aircraft, trains, ferries and intercity bus services — and re-engaging the United States with the World Health Organization. He also issued orders to create a covid response coordinator who will lead the federal government’s efforts for providing vaccination, testing and supplies, set up a national pandemic testing board, establish international travel protocols, use the Defense Production Act to provide necessary supplies and ensure minority communities are provided resources to combat the disease. The White House released a 200-page plan on Thursday that outlines the Biden administration’s strategy to address the covid-19 pandemic.

Some members of his covid leadership team — such as Jeff Zients, tapped to coordinate the White House’s covid response, and Dr. Rochelle Walensky, who will lead the Centers for Disease Control and Prevention — don’t require Senate confirmation, meaning they can get to work right away. But Biden’s pick for Health and Human Services secretary, Xavier Becerra, will need approval by the Senate, a step that will likely be eased because of Democrats’ Georgia victories. Still, how his nomination plays out — as well as Biden’s other selections for posts that require confirmation — could be an early sign of whether the new administration will face strong partisan resistance.

While the executive orders are strong signals of what Biden hopes to accomplish, he will need Congress to fund his plans to expand testing and vaccine distribution. Biden outlined the week before his inauguration in a $1.9 trillion proposal to address covid and the economy. However, the president could face difficulty in getting bipartisan agreement on this plan, with some Republicans criticizing it as too expensive.  It took Congress seven months to pass a second covid relief bill in December.

Other limiting factors include whether the supply of vaccine is adequate to reach 100 million doses and whether organized efforts are put in place to increase testing and ramp up production, said Dr. Georges Benjamin, executive director of the American Public Health Association.

One area in which Biden could face pushback: mask-wearing. Even though he has already issued executive orders regarding mask use in federal buildings, for instance, broader mask mandates fall under individual governors’ authority, and some Republican state executives remain resistant.

Even if Biden makes inroads on that front, Americans will have to accept this step as part of their daily lives. A December KFF survey showed that while most Americans, regardless of party, wear a mask whenever they leave their house, there is still a lag among Republicans.

“I think Biden’s biggest challenges in fulfilling his covid goals are in bringing a divided country together with the bully pulpit of the presidency,” said Levitt. “If testing and the vaccine and mask-wearing are successful in only blue America, then it will be hard to succeed overall.”

Health Insurance

As Barack Obama’s vice president, Biden was instrumental in the enactment of the Affordable Care Act, which expanded health insurance coverage to millions of people but has drawn fierce Republican opposition.

Biden’s health agenda promises to expand the ACA and undo many of the steps taken by President Donald Trump to dismantle it.

“I’ll not only restore Obamacare, I’ll build on it. You can keep your private insurance. If you like it, you can choose a Medicare-like public option,” Biden said during a campaign event in Pittsburgh on Nov. 2.

Adding a government-run public option to other ACA health care plans is one of Biden’s most ambitious pledges. It’s a controversial idea even within the Democratic caucus, where some members want instead to move to a single-payer health plan like “Medicare for All.” Remember the debates during the Democratic presidential primary?

Health policy experts we consulted said implementing a public option seems extremely unlikely in the current environment. So does lowering the Medicare eligibility age from 65 to 60, another divisive idea among Democrats. But both moderates and progressives — even lawmakers across the aisle — might be able to come together on initiatives that could shore up the ACA and make coverage more affordable, such as expanding eligibility for premium subsidies.

Biden doesn’t need Congress to restore parts of the ACA that were changed via regulations issued by the Trump administration. He can instruct agencies to issue new rules that would reverse such Trump initiatives as allowing states to implement work requirements for some adults who gained Medicaid coverage in the ACA expansion of that program. Still, regulatory changes take time. And, in some cases, altering them can be complicated.

Take, for instance, the Trump administration’s rules promoting short-term or association health plans. That metaphorical cat is already out of the bag, said Joseph Antos, a health care scholar at the American Enterprise Institute.

“There are a lot of people insured through those plans and so [changing that policy is] a very tricky thing,” said Antos. “I don’t think it would be wise for him to do anything to reverse that [rule] even though there has been a lot of noise from the left.”

In Antos’ view, the main advantage in gaining Senate control will be helping speed confirmation for key nominations, “which opens the door to new thinking on regulations.”

Drug Prices

On the campaign trail, Biden made clear his intent to bring down prescription drug prices. He promised to lower costs by 60%. Among the related policy ideas he floated: repealing the law that bars Medicare from negotiating lower drug prices and allowing the importation of prescription drugs from other countries.

But details of these proposals aren’t yet available, leaving some experts to question their feasibility.

Of course, the pharmaceutical lobby won’t be enthusiastic about any drug pricing legislation and would likely mount an aggressive campaign to defeat it. And just as with any other proposal, there will be the hurdle of getting Congress to agree on what to include in a drug pricing bill. Plus, given the rapid development of covid vaccines, Capitol Hill may be more sympathetic to the drug industry.

But Stacie Dusetzina, an associate professor of health policy at Vanderbilt University, said it’s possible Biden could succeed in lowering drug prices by limiting drug price increases to the rate of inflation and capping out-of-pocket spending for seniors covered by Medicare.

Both the House and Senate included similar proposals in past drug pricing bills, she said, and “those are both things I think could legitimately move forward, if anything moves forward.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Only a Smokescreen? Big Tobacco Stands Down as Colorado and Oregon Hike Cigarette Taxes


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Big Tobacco did something unusual in Marlboro Country last fall: It stood aside while Colorado voters approved the state’s first tobacco tax hike in 16 years.

The industry, led by Altria Group, one of the world’s largest tobacco companies, has spent exorbitantly in the past to kill similar state ballot initiatives. In 2018, Altria’s lobbying arm spent more than $17 million to help defeat Montana’s tobacco tax ballot initiative. That same year, it spent around $6 million to help defeat South Dakota’s similar measure.

And four years ago, Altria was the leading funder in a successful $16 million campaign to quash Colorado’s previous proposed tobacco tax increase.

In November, by contrast, Altria didn’t spend a penny in opposition and Colorado voters overwhelmingly approved the tax with two-thirds support. Likewise, in Oregon, Big Tobacco stayed on the sidelines while a tax hike passed there.

The tax measures are major wins for anti-smoking advocates after a string of defeats but, in an example of how politics makes strange bedfellows, Colorado’s tax might not have been possible without Altria’s help. And, advocates said, the way those measures passed could provide a blueprint for states to follow in future elections.

In Colorado, Altria, the parent company of Marlboro cigarette maker Philip Morris, insisted that a minimum price be included in the proposal, according to The Colorado Sun, citing emails between political consultants and Gov. Jared Polis’ office. So while supporters see an increased tobacco tax as more revenue for the state, a disincentive for kids to smoke and a win for public health, the measure could also allow America’s premium tobacco companies to gain market share.

The Colorado measure will increase the total state-levied tax from 84 cents to eventually $2.64 per pack by 2027. The tax rate on vaping products, not currently taxed, will be 30% of the manufacturer’s list price in 2021, gradually increasing to 62% by 2027. The proposition also set the minimum price per pack of cigarettes at $7 as of Jan. 1 and that floor rises to $7.50 in 2024. The change could effectively help premium cigarette companies corner the market, since discount cigarettes would rise to at least $7.

Discount cigarette companies Liggett Group, Vector Tobacco and Xcaliber International — which funded opposition to the tax initiative, Proposition EE — tried to sue the state over the minimum tax provision, alleging “Philip Morris will reap huge benefits from the new legislation” and the changes will “destroy their ability to compete in Colorado.” In December, a federal judge rejected the company’s request for a preliminary injunction. A spokesperson for Liggett said the company plans to appeal.

“When it came to entities like Altria and other stakeholders that we engaged in the legislative process, I think that they saw the writing on the wall,” said Jake Williams, executive director of Healthier Colorado and one of the key organizers behind Proposition EE. “And it helped us get through the legislative process, not just with Democratic votes, but Republican votes to refer the measure to the ballot.”

Altria officials said in a statement that their tobacco companies oppose excise tax increases, but they did not say whether they had worked with Colorado lawmakers.

“Altria did not advocate for or against Proposition EE, and after evaluating the content and intent of this measure, Colorado voters decided to vote in favor of it, some aspects of which were focused on tobacco harm reduction and may help transition adult smokers to a non-combustible future,” the statement said.

Polis’ office did not respond to a request for comment. The Colorado Attorney General’s Office said it would not comment on matters under active litigation. State Democratic Sen. Dominick Moreno and Rep. Julie McCluskie, both state sponsors for the legislation, declined to comment for the same reason. Fellow Democrats Rep. Yadira Caraveo and Sen. Rhonda Fields, also state sponsors for the legislation, did not respond to requests for comment.

Colorado campaign finance records show Altria and Altria’s lobbying arm in 2020 contributed to funds that support both Democratic and Republican candidates in the state — a pattern playing out nationally.

Williams said Altria’s absence of public opposition wasn’t the only factor in the initiative’s success. The tax revenue will initially fund revenue lost during the covid-19 pandemic, then fund tobacco use prevention and eventually preschool education.

The American Lung Association, which supported the Colorado measure, said it believes tobacco taxes are among the most effective ways to reduce tobacco use, especially among youths, who are more sensitive to changes in price. The organization cites studies that found every 10% increase in the price of cigarettes reduces consumption by about 4% for adults and 7% for teens.

“Without tobacco industry opposition, it’s very popular among the public,” Thomas Carr, the association’s director of national policy, said of the tax increase. “We’ve long seen it in polling on the subject.”

There was no major industry opposition to the Oregon increase, either. Its tobacco tax increase — Measure 108 — also got a resounding two-thirds of support. But Oregon didn’t negotiate with Altria lobbyists or set a minimum price provision, according to Elisabeth Shepard, campaign manager for Yes for a Healthy Future.

“I don’t know what the [Colorado] deal was,” Shepard said. “All I know is that before it even made it to the ballot, Altria indicated that they were not going to oppose the measure and stuck with their word.”

While Shepard worried until Election Day whether Big Tobacco would swoop in with opposition in Oregon, it didn’t. She believes her campaign worked because the effort had early resources and money, the tax was targeted to fund the Oregon Health Plan (the state’s Medicaid), and her campaign’s coalition had 300 endorsers, including those in health and business communities.

“We had the left, we had the right, we had the far-right, we had the far-left,” Shepard said.

Her campaign paid its advisory committee members, including representatives from affected communities such as Indigenous Oregonian tribes. At least 30% of American Indian and Alaska Native adults in the state smoke cigarettes. Oregon’s measure increases tobacco taxes $2 per pack, from $1.33 to $3.33, as well as creates a new tax for e-cigarettes. The revenues will help fund an estimated $300 million for the state’s health plan.

Altria did not respond to a request for comment about Oregon tobacco taxes, but the company has previously said it opposed Oregon’s measure.

Shepard believes her campaign model could work in other states. Other anti-smoking advocates took note of the 2020 election.

“We certainly support establishing minimum prices for all tobacco products in conjunction with tobacco tax increases, as we know increasing the price of tobacco products is one of the most effective ways to reduce tobacco use,” said Cathy Callaway, director of state and local campaigns for the American Cancer Society Cancer Action Network.

It could just come down to a state’s voters and its politics, according to Mark Mickelson, a former Republican in South Dakota’s legislature. Mickelson was behind creating his state’s failed 2018 tobacco tax ballot initiative.

“We just got beat,” Mickelson said. The opposition “got ahead of us on the message. They had a lot more money and had just played on doubts that the [tax revenue] money would go to tech ed.”

The average state cigarette tax is $1.88 per pack, but it varies across the country — as high as $4.35 in New York but only 44 cents in North Dakota, where a 2016 ballot initiative to increase that to $2.20 was defeated.

Tax increases can translate into hundreds of millions of dollars in new revenue for states, said Richard Auxier, senior policy associate at the nonpartisan Urban-Brookings Tax Policy Center.

“It’s a little easier to pass a tax on someone else, which is often how this is seen — passing this tax on smokers, rather than passing it on all working people, [compared to] if you were to increase income tax or … a sales tax.”

But not all voters get a say.

In Kentucky, which isn’t a referendum state, Republican state Rep. Jerry Miller said there’s not a lot of sympathy for tobacco companies anymore.

“The agriculture community, which used to be on the same page with cigarette companies, are now always in opposition because the cigarette companies are always trying to tweak their formula to use cheaper tobacco,” he said.

Miller’s recent vaping tax bill failed in the state legislature, but he’s working on a new one.

“We don’t have that tradition or the mechanism that somebody collects 10,000 signatures and they get a referendum on a ballot,” he said. “That’s why things like this have to go through the legislature — and so it really just depends on the state [government].”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Biden’s First Order of Business May Be to Undo Trump’s Policies, but It Won’t Be Easy

The party split in Congress is so slim that, even with Democrats technically in the majority, passing major health care legislation will be extremely difficult. So speculation about President-elect Joe Biden’s health agenda has focused on the things he can accomplish using executive authority. Although there is a long list of things he could do, even longer is the list of things he is being urged to undo — actions taken by President Donald Trump.

While Trump was not able to make good on his highest-profile health-related promises from his 2016 campaign — including repealing the Affordable Care Act and broadly lowering prescription drug prices — his administration did make substantial changes to the nation’s health care system using executive branch authority. And many of those changes are anathema to Democrats, particularly those aimed at hobbling the ACA.

For example, the Trump administration made it easier for those who buy their own insurance to purchase cheaper plans that don’t cover all the ACA benefits and may not cover preexisting conditions. It also eliminated protections from discrimination in health care to people who are transgender.

Trump’s use of tools like regulations, guidance and executive orders to modify health programs “was like an attack by a thousand paper cuts,” said Maura Calsyn, managing director of health policy at the Center for American Progress, a Democratic think tank. Approaching the November election, she said, “the administration was in the process of doing irreparable harm to the nation’s health care system.”

Reversing many of those changes will be a big part of Biden’s health agenda, in many cases coming even before trying to act on his own campaign pledges, such as creating a government-sponsored health plan for the ACA.

Chris Jennings, a health adviser to Presidents Barack Obama and Bill Clinton, said he refers to those Trump health policies as “bird droppings. As in you have to clean up the bird droppings before you have a clean slate.”

Republicans, when they take over from a Democratic administration, think of their predecessor’s policies the same way.

Though changing policies made by the executive branch seems easy, that’s not always the case.

“These are issue-by-issue determinations that must be made, and they require process evaluation, legal evaluation, resource consideration and timeliness,” said Jennings. In other words, some policies will take more time and personnel resources than others. And health policies will have to compete for White House attention with policies the new administration will want to change on anything from the environment to immigration to education.

Even within health care, issues as diverse as the operations of the ACA marketplaces, women’s reproductive health and stem cell research will vie to be high on the list.

A Guide to Executive Actions

Some types of actions are easier to reverse than others.

Executive orders issued by the president, for example, can be summarily overturned by a new executive order. Agency “guidance” can similarly be written over, although the Trump administration has worked to make that more onerous.

Since the 1980s, for example, every time the presidency has changed parties, one of the incoming president’s first actions has been to issue an executive order to either reimpose or eliminate the “Mexico City Policy” that governs funding for international family planning organizations that “perform or promote” abortion. Why do new administrations address abortion so quickly? Because the anniversary of the landmark Supreme Court abortion decision Roe v. Wade is two days after Inauguration Day, so the action is always politically timely.

Harder to change are formal regulations, such as one effectively banning Planned Parenthood from the federal family planning program, Title X. They are governed by a law, the Administrative Procedure Act, that lays out a very specific — and often time-consuming — process. “You have to cross your t’s and dot your legal i’s,” said Nicholas Bagley, who teaches administrative law at the University of Michigan Law School.

And if you don’t? Then regulations can be challenged in court — as those of the Trump administration were dozens of times. That’s something Biden officials will take pains to avoid, said Calsyn. “I would expect to see very deliberate notice and comment rule-making, considering the reshaped judiciary” with so many Trump-appointed judges, she said.

What Comes First?

Undoing a previous administration’s actions is an exercise in trying to push many things through a very narrow tube in a short time. Department regulations have to go not just through the leadership in each department, but also through the Office of Management and Budget “for a technical review, cost-benefit analysis and legal authority,” said Bagley. “That can take time.”

Complicating matters, many health regulations emanate not just from the Department of Health and Human Services, but jointly from HHS and other departments, including Labor and Treasury, which likely means more time to negotiate decisions among multiple departments.

Finally, said Bagley, “for really high-profile things, you’ve got to get the president’s attention, and he’s got limited time, too.” Anything pandemic-related is likely to come first, he said.

Some items get pushed to the front of the line because of calendar considerations, as with the abortion executive orders. Others need more immediate attention because they are part of active court cases.

“You have all these court schedules and briefing schedules that will dictate the timeline where they make all these decisions,” said Katie Keith, a health policy researcher and law professor at Georgetown University.

The Trump administration’s efforts to allow states to set work requirements for many low-income adults who gained Medicaid coverage under the Affordable Care Act’s expansion of the program is the highest-profile Trump action that falls into that latter category. The Supreme Court has agreed to hear a case challenging HHS approval of work requirements for Arkansas and New Hampshire in the next few months. Some Democrats are concerned about how the high court, with its new conservative majority, might rule, and the Biden administration will have to move fast if officials decide they want to head off that case.

But court actions also might help the Biden administration short-circuit the onerous regulatory process. If a regulation the new administration wants to rewrite or repeal has already been blocked by a court, Biden officials can simply choose not to appeal that ruling. That’s what Trump did in ending insurance company subsidies for enrollees with low incomes in 2017.

Allowing a lower-court ruling to stand, however, is not a foolproof strategy. “That raises the possibility of having someone [else] intervene,” said Keith. For example, Democratic attorneys general stepped in to defend the ACA in a case now pending at the Supreme Court when the Trump administration chose not to. “So, you have to be pretty strategic about not appealing,” she said.

Adding On?

One other big decision for the incoming administration is whether it wants to use the opportunity to tweak or add to Trump policies rather than eliminate them. “Is it undoing and full stop?” asked Keith. “Or undoing and adding on?”

She said there is “a full slate of ideologically neutral” policies Trump put out, including ones on price transparency and prescription drugs. If Biden officials don’t want to keep those as they are, they can rewrite them and advance other policies at the same time, saving a round of regulatory effort.

But none of it is easy — or fast.

One big problem is just having enough bodies available to do the work. “There was so much that undermined and hollowed out the federal workforce; there’s a lot of rebuilding that needs to done,” said Calsyn of the Center for American Progress. And Trump officials ran so roughshod over the regulatory process in many cases, she said, “even putting those processes back in place is going to be hard.”

Incoming officials will also have other time-sensitive work to do. Writing regulations for the newly passed ban on “surprise” medical bills will almost certainly be a giant political fight between insurers and health care providers, who will try to re-litigate the legislation as it is implemented. Rules for insurers who sell policies under the ACA will need to be written almost immediately after Biden takes office.

Anyone waiting for a particular Trump policy to be wiped from the books will likely have to pack their patience. But law professor Bagley said he’s optimistic it will all get done.

“One of the things we’ve grown unaccustomed to is a competent administration,” he said. “When people are competent, they can do a lot of things pretty quickly.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Democrats Are Running Hard on Health Care in Georgia’s Senate Runoffs. Republicans? Not So Much.


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Vice President Mike Pence was the clear celebrity draw at a Nov. 20 campaign event for Georgia’s two incumbent U.S. senators, Kelly Loeffler and David Perdue. Both Republicans are fighting to keep their seats against two Democratic challengers in the runoff election set for Jan. 5.

People were so eager to see Pence at the rally in Canton, Georgia, that parking spots were scarce and a long line of cars snaked through the parking lot of a community college. Some drivers jumped the curb and parked in the grass.

Hundreds of people, many unmasked, were given temperature checks before boarding large coach buses for a short ride to the rally site. The venue was a large, open space outside the conference center, but few attendees maintained physical distance

The runoff in Georgia was triggered when no candidate in either Senate race won more than 50% of the vote in the general election on Nov. 3.

In the midst of the coronavirus pandemic and with the fate of the Affordable Care Act in question, Republicans hope the two incumbents will win reelection, thus preserving their party’s 50-48 control of the Senate.

But if the two challengers, Raphael Warnock and Jon Ossoff, win their runoffs, Democrats will gain narrow control of the Senate, with Vice President-elect Kamala Harris serving as the designated tie-breaker.

Yana De Moraes came to the rally from another Atlanta suburb, Buford. She is uninsured and, after a recent hospital stay, said the high cost of medical care was weighing on her mind.

“We would like our health care costs lowered, so it could be more affordable,” she said, with a rueful laugh. “So you don’t get another heart attack while you’re getting a bill!”

De Moraes added she’d also like to see better price controls on prescription drugs to stop pharmaceutical companies from “robbing American people.”

Others on their way to the rally said they were looking for any kind of change, ideally one that minimizes government involvement in health care.

Barry Brown made the 40-mile drive from his home in Atlanta for the rally. He’s retired but too young to qualify for Medicare, so he has ACA insurance, which he affords with the help of a federal subsidy.

“It sort of works. It’s better than nothing,” Brown said. “I would like to see an improved health care situation. I don’t know what that will be, so maybe they’ll mention that today. I’m hoping so.”

But at the rally, Loeffler only briefly mentioned her health care plan, which focuses on reducing drug prices and giving people access to insurance options that cost less but offer fewer benefits.

When it was his turn to speak, Perdue didn’t talk much about health care either, though he did take a shot at Obamacare, which he’s voted multiple times to overturn.

“Remember a little thing called the Affordable Care Act? You think that was done bipartisan?” Perdue asked the crowd. “No! It was done with a supermajority! Can you imagine what they’re gonna do if they get control of the Senate?”

As the two Republicans have campaigned throughout the state, they have consistently stoked fears about what Democrats will do, and health care policy has not led their messaging.

Their Democratic challengers, however, have been all over health care in their own speeches.

Warnock opened his runoff campaign to unseat Loeffler with a modestly attended Nov. 12 event devoted to health care. That’s also been a focus for Ossoff in his bid to win Perdue’s seat.

“This is why these Senate runoffs are so vital,” Ossoff explained at a small, physically distanced event in the shadow of the Georgia Capitol building in Atlanta on Nov. 10.

Ossoff and Warnock support adding a public insurance option to the Affordable Care Act. They also have emphasized the role Democrats will play in resurrecting key parts of the law if the U.S. Supreme Court decides to overturn it. The justices are set to make a ruling next year.

“If the Supreme Court strikes down the Affordable Care Act, it will be up to Congress to decide how to legislate such that preexisting conditions remain covered,” Ossoff said.

Voters like Janel Green, a Democrat, connect with that message. She’s from the nearby suburb of Decatur and is fighting breast cancer — for the second time. Green wondered whether her private health insurance might try to deny her coverage if the protections in the ACA disappear.

“I have to worry about whether or not next year in open enrollment that I won’t be discriminated against, that I won’t have limits that would then potentially end my life,” she said.

More than one-quarter of Georgians have preexisting conditions that could make it hard to get coverage if the ACA is struck down, according to an analysis by KFF. (KHN is an editorially independent program of KFF.)

That possibility also drove Atlanta resident Herschel Jones to support the runoff. On a recent weekday morning, he dropped by an Ossoff campaign office to pick up a yard sign.

Jones, who has diabetes, is insured through the Veterans Health Administration. He said everyone deserves access to health care.

“It’s a main issue, because the Affordable Care Act benefits all those individuals who might have preexisting conditions,” Jones said.

One likely reason Ossoff and Warnock are running so much harder on health care than Perdue and Loeffler is because that strategy paid off for Democrats in the general election, said Ken Thorpe, a health policy professor at Emory University.

President-elect Joe Biden can thank independent voters for his win in Georgia, Thorpe said, and they were drawn to him because of his promise to uphold Obamacare.

“The threat of potentially losing health insurance in the midst of this pandemic turned out to be probably the major defining issue in the election,” Thorpe said.

Polling in the days leading up to the Nov. 3 election showed Democrats were motivated on the issues of health care and the coronavirus pandemic.

For Democrats to win Georgia’s Senate seats, Thorpe said, they’ll need to stay focused on those issues. That emphasis could help them attract additional moderate voters, as well as entice those in the party base to cast ballots a second time.

“The health care issue is the probably main motivating factor that’s gonna get Democrats and independents to the polls,” he said.

Still, no Democrat has ever won a statewide runoff race in Georgia. That means that even with a strong health care message, it’ll be tough for Ossoff and Warnock to break that trend and unseat the Republicans, Thorpe said.

This story is from a reporting partnership that includes WABENPR and KHN.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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As Biden Gets Sworn In, White House Will Get Scrubbed Down

It was a down-in-the-mud presidential campaign, but the dirtiest part comes on Inauguration Day.

As Joe Biden lifts his right hand to take the oath of office at noon on Jan. 20 at the Capitol, a team of specially trained cleaners will be lifting their hands to disinfect the White House.

The executive mansion will get a deep clean after two COVID-19 outbreaks this fall led to President Donald Trump and members of his staff and family becoming infected.

The departure of one president and the arrival of another is always a fast but highly synchronized behind-the-scenes ballet by White House staff members and moving crews.

But this year is different. The shift means more than rearranging the Oval Office and putting new clothes in bedroom closets: It means a top-to-bottom disinfection amid a pandemic. Biden, who at 78 is taking office as the oldest president in U.S. history, is at high risk of complications from the virus.

So, the General Services Administration will oversee a thorough cleaning and disinfection of every doorknob, toilet handle, light switch, stair railing, telephone, elevator button, computer keyboard and other objects inside the 55,000-square-foot mansion at 1600 Pennsylvania Ave.

But can such a large building get fully clean in just five or six hours?

Experts say that should not be a problem with a large enough team and preparation time.

K. Mark Wiencek, lead microbiologist for South Carolina-based Contec Inc., which sells cleaning supplies to hospitals, said GSA cleaners should focus on the rooms last occupied by the Trump staff, since the virus can’t survive long on surfaces. Cleaning crews, he added, should wear masks and gloves to protect themselves and not introduce any germs.

He recommended replacing the air filters and using fogging and spraying disinfectant to kill viruses.

The GSA said it is already cleaning the White House East Wing and West Wing offices daily with disinfectant.

GSA officials said they expect no difficulties in making the transition and pledged that all furniture and surfaces would be cleaned. “GSA will thoroughly clean and disinfect the building spaces between the administrations and ensure that everything is up to standard,” a spokesperson said in a statement.

It’s vital that cleaners leave the cleaning chemicals on surfaces a full 10 minutes before wiping them down, said O.P. Almaraz, a disaster relief expert in West Covina, California, and president of Allied Restoration, which has cleaned dozens of businesses after suspected COVID cases.

“With a large enough crew, a professional disinfection company could apply disinfectants to the entire White House in six hours,” he said. It’s important, he explained, that the crew pay “special attention to points that may be touched often, like tabletops, door handles and light switches.”

As long as cleaners have an organized plan for each room, Almaraz doesn’t see them having trouble getting done before the Bidens move in at the end of the day.

Sheldon Yellen, CEO of Michigan-based Belfor Property Restoration, said cleaning crews need to be rehearsed and in fully ventilated suits to clean the White House in one afternoon.

“It’s a level 3 clean,” he said, noting the building needs the most intensive service because of confirmed COVID cases. That means disposing of anything that doesn’t have to stay for the Bidens, including pillows and bedsheets. He said books need to be wiped down, not just on the binding but all sides. He recommended cleaning the ductwork and ventilation systems as well.

Jack Shevel, co-founder of San Diego disinfection company Zappogen, said that because COVID-19 spreads by airborne transmission, it is best to disinfect using an electrostatic sprayer or fogger filled with a disinfectant designed to kill airborne pathogens. That covers a large area more easily than just wiping surfaces.

“To truly disinfect all those rooms quickly and thoroughly, they should be sprayed with a fine micron mist that can reach all crevices and surfaces evenly,” he said.

Still, the White House cleaners must be careful to remove paintings, antiques and other valuable items before spraying with disinfectant, said Ernesto Abel-Santos, professor of biochemistry at the University of Nevada-Las Vegas. Those items should be cleaned by hand.

Abel-Santos said a simple alcohol-based disinfectant should be enough to kill the COVID virus. Although the virus can be detected on some surfaces for days, it typically degrades within hours. People are much more likely to be infected by droplets expelled when someone coughs, sneezes or talks.

During the turnover, cleaners should focus on the most commonly used areas of the building, he said, such as the Oval Office and bedrooms. “The rest can get deep-cleaned as needed,” he added.

Even more important than cleaning, however, is asking the new president and his family and staff to physically distance, wear their masks and wash their hands, according to Abel-Santos.

“You don’t realize how many times in a day you touch your face with your hands,” he said. “If you touch a surface and then touch your face, it increases the probability of contagion.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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This Health Care Magnate Wants to Fix Democracy, Starting in Colorado

In the final weeks before the Nov. 3 election, supporters of a down-in-the-weeds effort to overturn a tax law in Colorado received a cascade of big checks, for a grand total of more than $2 million.

All came from Kent Thiry, the former CEO of DaVita, one of the largest kidney care companies in the country. This was not the first time he donated big to a ballot initiative aimed at tweaking the nitty-gritty details of how Colorado functions. Nor will it be the last.

Thiry has given at least $5.9 million to Colorado ballot measures since 2011 — and all of them won, according to a KHN review of Colorado campaign finance data. According to data from the National Institute on Money in Politics, Thiry’s donations to ballot measures in that state are second only to those of billionaire Pat Stryker. Campaign finance records show that before that, he gave to ballot issue committees in California, where he used to live, dating to at least 2007.

It’s the same playbook his former company has successfully used in California. As KHN has reported, in 2018 DaVita was among several companies to break an industry record in campaign spending for a ballot measure by any one side in California. This year, the industry came close to breaking that record to defeat a measure that would have further regulated dialysis clinics and that DaVita said would have limited access to care.

Ballot initiatives, which are allowed in about half the states, enable individuals and groups to circumvent legislatures and ask voters to decide on a law. And in many states, the campaigns for and against them are bankrolled by the rich: either corporations fighting to preserve their profits or multimillionaires with a political shopping list.

“Wealthy individuals have been pouring money into ballot measures, even seemingly unrelated to their industry, for over a century,” Daniel Smith, a political scientist studying direct democracy at the University of Florida, wrote in an email to KHN.

Given that health care is a $3.6 trillion industry, its top executives are among the ranks of those who can have an enormous impact in ballot measure politics. This year, Kent Thiry and Mike Fernandez, chairman and CEO of private equity firm MBF Healthcare Partners, were among the 19 individuals or couples who spent $1 million or more on ballot issue campaigns this year, according to Bloomberg. In previous elections, medical equipment company owner Loren Parks has also given big money to ballot initiatives.

Overall, those in the health industry have spent more on ballot measures in Colorado than in any other state except Missouri and California, according to data from the National Institute on Money in Politics, and that’s largely due to Thiry.

“He really has become the 800-pound gorilla of the ballot initiative process in Colorado,” said Josh Penry, a Republican campaign strategist in Denver who has worked with Thiry, including on a ballot measure campaign Thiry helped fund. “He wields more power in an informal way than virtually all the elected officials, if you look at the impact he’s had.”

Even though Thiry and his wife, Denise O’Leary, a former venture capitalist on the board of directors of medical device company Medtronic, have made hefty earnings from health care, Thiry’s ballot initiative donations as an individual have nothing to do with the industry.

“I prefer things that have systemic impact,” said Thiry. Measures he has bankrolled have eliminated the caucus system for presidential primaries, brought unaffiliated voters into the primaries and created a system intended to eliminate gerrymandering.

“Democracy is not a spectator sport,” he said.

Thiry previously donated to ballot measure committees in California, to prevent changes to term limits and to create a system for redistricting led jointly by Democrats, Republicans and citizens unaffiliated with a political party.

After moving his company’s headquarters from Los Angeles to Denver in 2010, he began backing ballot measures in his new state, too, with equal success and bigger sums, jumping from the tens of thousands to the millions. He spent more than $2 million backing a pair of measures to allow unaffiliated voters to participate in primaries.

In 2018, while his company was helping break an election spending record to defeat a California measure that would have capped the industry’s profits, Thiry was putting more than $1.2 million toward redistricting efforts in Colorado very similar to the one he backed in his previous home state to help reduce gerrymandering.

His latest donations went to a measure that successfully overturned a tax law from the 1980s that may have helped Colorado homeowners, but which critics said left public services like education and fire districts underfunded in some rural areas.

Thiry doesn’t just shell out cash. As the online newspaper The Colorado Independent has pointed out, Thiry’s offices played a large role in bringing two warring groups with different ideas about redistricting to the same table. His efforts tend to revolve around raising the power of unaffiliated voters, who make up about 40% of Colorado’s active voters, according to state data.

Fernandez, the private equity billionaire, said he has similar motivations. He donated $7.3 million to a Florida initiative to change how primaries work in that state and bring unaffiliated voters like himself into the fold.

“I’ve never spent so much money [on] something that I have no business reason to be in at all,” he said.

The effort was, he said, nearly “a one-man show” in terms of financing. But it still failed, garnering 57% of votes when it needed 60% to pass. Fernandez said he’ll try again in 2022.

“I come from a country where you can see that control of a government by a single party is deadly,” said Fernandez, who was born in Cuba. “Florida has been controlled by the Republican Party for the last three decades. And when I was a Republican, that was great.”

But, he said, it quickly became clear that bringing the issue to legislators was a dead end. That’s expected, according to John Matsusaka, executive director of the Initiative and Referendum Institute at the University of Southern California. Ballot initiatives are a natural route to tweak electoral machinery, he said, because legislators have a conflict of interest on issues like gerrymandering and term limits.

In fact, Matsusaka thinks the U.S. could use national ballot initiatives, which other democracies have, as a route to restoring confidence in the federal government.

“I don’t look at ballot propositions as a way to drive a progressive agenda or conservative agenda or any sort of agenda,” he said. “I view it as a way to put the people in control. And they can go where they want to go.”

Even if that means eroding their own power a little. One of the first initiatives Thiry donated to in Colorado is something Matsusaka considers “anti-democracy” — an effort called Raise the Bar, a ballot initiative about ballot initiatives. It required petitioners to get signatures from every corner of the state to put an initiative on the ballot. Some view this as problematic.

“You have to now collect signatures in every senate district of Colorado,” said Corrine Rivera Fowler, director of policy and legal advocacy with the Ballot Initiative Strategy Center, a national organization that supports progressive ballot initiatives. “That’s a tremendous undertaking for grassroots communities.”

Thiry, meanwhile, intends to take what he’s learned in Colorado and apply it elsewhere. He said he’s getting more involved in several national democracy reform groups, including Unite America, an effort to break what’s been called the “doom loop” of partisanship. Thiry said he hopes to help create “a tidal tsunami of political momentum.”

“One of my goals is to have this democracy reform energy in places like Colorado — or elsewhere — move from being an ad hoc collection of activist projects to a true movement,” he said. “Kind of like the civil rights movement, kind of like the gay marriage movement, and like the #MeToo movement or Black Lives Matter.”

He no longer works for DaVita, after stepping down as executive chairman earlier this year.

“I have no title anymore. Just ‘citizen.’ It’s a title I wear with great pride and energy,” he said.

As for the next measure Thiry will back, he’s open to recommendations.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Dialysis Industry Spends Millions, Emerges as Power Player in California Politics

SACRAMENTO — The nation’s dialysis industry has poured $233 million into California campaigns over the past four years, establishing its leading companies as a formidable political force eager to protect their bottom line and influence state policy.


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Most of the money the industry spent from Jan. 1, 2017, through Nov. 30, 2020, funded the defeat of two union-backed ballot measures that would have regulated dialysis clinics — and eaten into their profits. But the companies and their trade association also stepped up their offense, dedicating about $16.4 million to lobbying and political contributions during the same period, a California Healthline analysis of state campaign finance records shows.

Nearly every member of the legislature, Democratic Gov. Gavin Newsom and his predecessor, former Gov. Jerry Brown, the Democratic and Republican parties, and dozens of political campaigns — including some local school board and city council races — received a contribution from a dialysis company.

“These are very large, very profitable companies,” said Mark Stephens, founder of Prima Health Analytics, a health economics research and consulting firm. “They have a lot to lose. The fear would be that if some of this stuff passed in California, the union would certainly try to get similar measures on the ballot or in the legislatures in other states. The stakes are higher than just California for them.”

Staking Ground in Sacramento

California has about 600 dialysis clinics, which are visited by an estimated 80,000 patients each month, typically three times a week. At the clinics, patients are hooked up to machines that filter toxins and remove excess fluid from their blood because their kidneys can no longer do the job.

Medicare, which covers most dialysis patients, pays a base rate of $239.33 for each dialysis treatment.

DaVita and Fresenius Medical Care North America are the largest dialysis providers in the state and country, operating roughly 80% of clinics nationwide. Last year, DaVita reported $811 million in net income, on revenue of $11.4 billion. Fresenius posted $2 billion in operating income on revenue of $13.6 billion.

DaVita was responsible for about $143 million — or more than three-fifths — of the political spending in the past four years, and Fresenius gave about $68 million.

Until four years ago, the dialysis industry’s political spending was relatively modest compared with that of the hospital, physician and other health care associations so well known in Sacramento. In those days, dialysis lobbyists focused on regulatory issues and health care reimbursement rates, and companies gave minimal campaign contributions.

The industry’s transformation into one of the biggest spenders in California politics began in 2017, the first of four years in which it faced ballot or legislative threats. In 2017, a Democratic lawmaker introduced a bill that would have set strict staff ratios at dialysis clinics. The bill, SB-349, which failed, had faced opposition from the California Hospital Association, the California Chamber of Commerce and the dialysis industry.

The SEIU-United Healthcare Workers West union (SEIU-UHW) followed the next year with Proposition 8, a ballot initiative that would have capped industry profits.

DaVita and Fresenius were forced to defend their huge profits and allegations of subpar patient care, turning the competitors into allies — at least in politics.

The industry spent $111 million to successfully defeat the measure, breaking the record for spending by one side on an initiative.

“I think it’s very natural for these private chains to spend millions to make billions of profits,” said Ryan McDevitt, associate professor of economics at Duke University. “They’re lobbying to protect their profits.”

Last year, the industry fought AB-290, a bill that aimed to stop a billing practice dialysis companies use to get higher insurance reimbursements for some low-income patients. But the legislature wasn’t swayed, and Newsom signed the bill into law, which is now tied up in federal court.

And this year, the industry spent $105 million to block Proposition 23, which would have required every clinic have a physician on site and institute other patient safety protocols.

Kent Thiry, the former chairman and CEO of DaVita, said the industry had no choice but to spend heavily to defeat the ballot measures, which he said would have increased costs and harmed patient care.

“When someone does that, you have to use some of your money to defend yourself, your patients and your teammates,” Thiry said in an interview with KHN, which publishes California Healthline. “It forces companies to allocate precious resources to do something that never should have been brought up to start with.”

In an emailed statement, DaVita said it would continue to work to “educate lawmakers and defend against policy measures that are harmful to our patients.” Fresenius also defended its advocacy, saying the company needs to protect itself against special interests intent on abusing the political system. The company will “continue to support legislation that improves access to quality care and improves patient outcomes,” said Brad Puffer, a company spokesperson.

By comparison, SEIU-UHW, which sponsored the ballot measures, spent about $25 million to advocate for the initiatives, and $7.8 million on lobbying and political contributions. The union lobbies lawmakers on a wide array of health care issues

“They’ve got tons of money. We understand that,” said Dave Regan, the union’s president. “We’ve seen them spend a quarter of a billion dollars in a very short period of time. I hope they’re prepared to spend another quarter of a billion dollars, because we’re not going to go away until there’s legitimate commonsense reforms to this industry.”

From Defense to Offense

While most of dialysis companies’ political spending in California has been used to defeat ballot measures, several of the largest companies also dedicated about $16.4 million to lobbying and political contributions over the past four years.

The companies and their trade association, the California Dialysis Council, put almost three-fourths of that — nearly $12 million — into hiring veteran lobbyists to advocate for dialysis companies when lawmakers consider legislation that could affect the industry.

For instance, when Newsom took office in 2019, both DaVita and Fresenius added Axiom Advisors to their lobbying teams, paying it $737,500 since then. One of the firm’s partners is Newsom’s longtime friend Jason Kinney, whose close relationship with the governor was highlighted by the recent French Laundry dinner fiasco. Newsom came under intense criticism for attending the early November dinner at the exclusive restaurant, held to celebrate Kinney’s birthday, because he and his administration were asking Californians not to gather.

The industry has also given at least $4.6 million in contributions to political candidates and committees, both directly and to entities on behalf of a lawmaker or candidate.

All but five state senators and Assembly members who served during the 2019-20 legislative session received a direct contribution from at least one of the companies or the California Dialysis Council.

Most of the donations to individuals went to state lawmakers, but DaVita dipped into local races, too. For instance, it contributed $10,000 to a Glendale city council candidate in February, $7,700 to an El Monte school board candidate in October and $3,500 to a Signal Hill city council candidate last year.

Dialysis companies also gave to the state Democratic and Republican parties.

“They’re spreading it out. They’re doing the full gambit,” said Bob Stern, former general counsel for the California Fair Political Practices Commission, which enforces state political campaign and lobbying laws.

Legal Loopholes

State law limits how much a company or person can give to a political candidate in an election, but there are legal loopholes that allow individuals and corporate interests to give more. The dialysis industry has taken advantage of them.

Under state campaign finance rules, lawmakers can accept only $4,700 from any one person or company per election.

But some lawmakers operate “ballot measure committees” so they can accept unlimited contributions. These committees are supposed to advocate for a ballot measure, but lawmakers often use them to pay for political consultants and marketing, and to contribute to state and local initiatives they support. Candidates can also get unlimited help from donors who independently pay for campaign costs, such as mailings and digital campaign ads.

For instance, DaVita chipped in $93,505 to help pay for a direct mail campaign on behalf of state Sen. Steve Glazer (D-Orinda) in this year’s primary election. Glazer also received $55,600 from DaVita, Fresenius and the California Dialysis Council in contributions to himself and his ballot committee, Citizens for a Better California.

In some cases, lawmakers such as Glazer who netted some of the biggest contributions from dialysis companies voted with the industry. That was the case last year when the legislature approved AB-290, the bill limiting the dialysis billing practice.

Glazer voted no, as did Assembly member Adam Gray (D-Merced), whose Valley Solutions ballot measure committee had received $112,500 from DaVita and Fresenius since 2017. Gray also received $36,900 in direct contributions from Fresenius, DaVita and U.S. Renal Care.

Gray issued a statement saying campaign contributions play “zero role” in how he represents his district. Glazer did not respond to a request for comment.

Targeting Legislative Adversaries

Assembly member Reggie Jones-Sawyer’s 84-year-old mother is on dialysis. The Los Angeles Democrat and SEIU-UHW member has called for improved staffing ratios at dialysis clinics and has voted repeatedly to regulate them.

DaVita wrote a $249,000 check in October to a political committee supporting Jones-Sawyer’s opponent, Efren Martinez, another Democrat, but one the industry considered more friendly. DaVita followed up with a $15,000 check the week before the election.

Jones-Sawyer, who won the race, said he’s frustrated dialysis companies aren’t willing to make changes to improve patient safety on their own, saying it would cost them far less than the nearly quarter-billion dollars they have spent on political contributions. So for now, he said, he will continue to push to improve conditions at dialysis clinics from the Capitol, despite the industry’s growing political clout.

“I think dialysis is saying, ‘Look, we can be the 800-pound gorilla now,’” Sawyer said. “It’s not just influence for a day; it’s longevity.”

Rae Ellen Bichell and Elizabeth Lucas of KHN contributed to this report.

Methodology

How California Healthline compiled data about dialysis companies’ political spending

Among the ways dialysis companies exert influence on the political process is by contributing money to campaigns; hiring lobbyists; and paying for advertising and marketing on behalf of candidates.

Opposition to ballot measures: Using the California secretary of state’s website, California Healthline downloaded the contributions made by DaVita, Fresenius Medical Care North America, U.S. Renal Care, Satellite Healthcare, Dialysis Clinic Inc. and American Renal Management to the campaign committees formed to defeat Propositions 8 and 23. This includes some non-monetary contributions.

Lobbying: We created a spreadsheet of expenses reported on lobbying disclosure forms, also available on the secretary of state’s website, by DaVita, Fresenius, U.S. Renal Care, Satellite Healthcare and the California Dialysis Council. We found details about how much the industry paid lobbying firms, what agencies it lobbied and which bills it tracked.

Political contributions: DaVita, Fresenius, U.S. Renal Care and the California Dialysis Council made direct contributions to more than 100 candidates, which we compiled from the secretary of state’s website. DaVita and Fresenius made other contributions, often large, to Democratic and Republican committees, and ballot measure committees led by lawmakers. The two companies also made contributions known as “independent expenditures” that benefited candidates’ campaigns and “behested payments,” which are donations to nonprofit organizations and charities in lawmakers’ names. Behested payments are disclosed on the California Fair Political Practices Commission website.

The SEIU-United Health Care West union uses two political committees for its giving. Its PAC contributes mostly to lawmakers and county and state Democratic parties while its Issues Committee gives to local hospital ballot measures. We did not tally spending for local hospital ballot measures for this story, but we did include contributions made by the Issues Committee to the California Democratic Party, which helps state lawmakers.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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As More Red States Legalize Marijuana, Some Officials Try to Nip It in the Bud

With his state reeling amid one of the worst COVID-19 outbreaks in the nation, the last thing South Dakota Speaker of the House Steven Haugaard wants to be dealing with during the upcoming legislative session is marijuana. But the state’s voters haven’t left the Republican much choice.

This fall, South Dakota became the first state in the U.S. to legalize both medical marijuana and recreational marijuana in the same election. Haugaard, who long opposed any form of marijuana legalization, now must participate in the creation of a medical marijuana program.

South Dakota voters enshrined legal marijuana in the state’s constitution. So if Haugaard had any thoughts about reversing the initiative once lawmakers reconvene on Jan. 12, they’ve been dashed.

“With a constitutional amendment, there’s really not much we can do about it. It’s written in stone until it’s repealed,” Haugaard said.

South Dakota is one of a handful of states in which voters both approved marijuana ballot questions and elected Republicans to lead state governments. Montana and Arizona, two other states in which Republicans control (or will soon control) the governor’s office and legislature, also backed recreational marijuana at the ballot box. Mississippi passed a measure legalizing medical marijuana.

New Jersey, which has a Democratic governor and Democratic-majority legislature, also passed a recreational marijuana ballot question.

Many conservative lawmakers oppose the legalization of marijuana, an illegal drug under federal law. But they are discovering obstacles to simply passing bills to reverse the initiatives when state legislatures return to work in January. Some marijuana opponents, realizing the limitations to altering a constitutional amendment, are turning to the courts or local officials to undo the measures or at least blunt the effects of legal pot.

Before the November election, 11 states and Washington, D.C., had legalized recreational marijuana, most of them left-leaning states, with exceptions like Alaska. An additional 21 states allow medical marijuana. In the wake of the election, 15 states will have legalized recreational marijuana and 35 will allow medical marijuana.

In conservative states like Montana, where passage of a bill can change or negate a ballot initiative, one thing giving lawmakers pause is that many voters who elected them also approved the legalization of marijuana use for adults 21 and up.

In Montana, 57% of voters approved the recreational marijuana initiative — the same share received by President Donald Trump. In South Dakota, 54% voted for recreational marijuana and a whopping 70% approved medical marijuana. In Arizona, the recreational pot proposition also passed easily.

Those kinds of margins are what caused state Rep. Derek Skees to reconsider a bill he was drafting to repeal the Montana ballot measure in anticipation of its passage.

Skees told the Missoulian the day after the election that after it became clear voters supported it — while also supporting Republican candidates for office up and down the ballot — he decided to shelve it.

“There’s no way I’m going to try to overturn the will of Montana,” Skees told the newspaper.

Haugaard said opposition to the South Dakota measure was derailed by the pandemic and voters never got the message from opponents about the potential negative impacts of legalization.

Proponents of legalization spent nearly $800,000 on their campaign in South Dakota — most of it coming from the New Approach Political Action Committee, a pro-legalization group that works across the country — and five times what opponents of ballot measures raised.

Colorado, the first state to allow recreational use of marijuana in 2014, is often held up as the poster child for what can happen. Proponents say the state has benefited from increased tax income and economic activity. But opponents, including Haugaard, point to studies about increased traffic deaths in Colorado since legalization to explain why they think it’s a bad idea.

“That side of the story wasn’t told and had it been told I think this vote would have gone differently,” Haugaard said.

Marijuana opponents aren’t waiting to see what state lawmakers do, if anything — they’re going to court. The Pennington County, South Dakota, sheriff and the superintendent of the South Dakota Highway Patrol have filed a lawsuit challenging the constitutionality of the marijuana amendment. The Rapid City Journal reported the suit had the backing of Gov. Kristi Noem, and that the state was paying for part of the suit. Noem was a vocal opponent of legalization during the campaign.

Should the legal challenge fail, the amendment is scheduled to take effect July 1 and, according to the governor’s office, it will be up to the state health department to implement it. The legislature will have more control over how the medical marijuana program will work. Haugaard said that will be a big focus of the 37-day session.

Opponents in Montana are also asking the courts to disallow recreational marijuana. Steve Zabawa, a Billings car dealer who has campaigned against legalized marijuana for years, said in his lawsuit that what the voters passed would illegally take power from state lawmakers by designating where tax revenue will go.

Zabawa blamed its passage at the ballot box on pro-marijuana advocacy groups that so outraised and outspent opponents of the measure that he compared it to David and Goliath.

“They candy-coated this deal. They lied to the entire state of Montana by saying that this would benefit veterans and fish and wildlife,” Zabawa said. “They crossed a line and we’re calling them on it.”

Zabawa said that if the courts don’t block recreational marijuana, he’s hopeful that Montana’s Republican-controlled Statehouse will stymie its implementation.

“I just don’t think there’s a lot of love for marijuana in Montana,” Zabawa said.

In Arizona, a recreational marijuana ballot measure was rejected by voters just four years ago. This year it passed by a wide margin. The state’s voters also chose Joe Biden over President Donald Trump, the first time a Democrat won the presidential election in the state since 1996.

It’s unlikely Arizona’s Republican-led legislature can do anything to stop implementation because of a 1998 law that prohibits lawmakers from changing a voter-approved initiative without a three-quarters majority.

State lawmakers’ hands may be tied, but the initiative did give municipalities some power to restrict its use. The day after the initiative passed, Oro Valley Town Council approved an emergency declaration that would limit which type of businesses could sell marijuana and prohibited its use in public places.

The declaration was based on language written by the League of Arizona Cities and Towns and given to members prior to Election Day.

One of the major backers of the state ballot measures is the Marijuana Policy Project, a Washington, D.C.-based organization that supports sweeping marijuana policy changes across the country. Deputy Director Matthew Schweich said this election showed how the public’s opinion on marijuana is rapidly evolving.

Schweich said he believes the results of the 2020 election bode well for future legalization efforts in states and even at the federal level. Because of that growing support, he dismissed any chance Montana or South Dakota could derail recreational legalization but added that his organization will do whatever it can to fight those efforts.

“This is a bipartisan issue [and] I think we’re at a tipping point. We’ve passed it in big states and small states, liberal states and conservative states,” he said. “We’re feeling pretty good. We believe that 2021 is our year.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Becerra, un candidato para el HHS con habilidad política pero sin experiencia en salud

Xavier Becerra, elegido por el presidente electo Joe Biden para dirigir el Departamento de Salud y Servicios Humanos (HHS), será un secretario de la era pandémica, sin experiencia en salud pública. Si eso importa o no, depende de quién conteste.

Becerra construyó su carrera en la Cámara de Representantes de los Estados Unidos antes de convertirse en fiscal general de California. Algunos se preguntan si sus habilidades políticas y legales serían las adecuadas para conducir al HHS a través de una catástrofe de salud que está matando a miles de estadounidenses cada día.

Aunque aportará al cargo años de trabajo en legislacones y políticas de salud, nada de esto proviene de la experiencia de primera línea como ejecutivo o administrador dirigiendo programas de salud pública, gerenciando la atención de pacientes o controlando la propagación de enfermedades.

Sin embargo, más allá de la crisis inmediata de COVID-19, muchos demócratas ven a Becerra como un aliado importante para deshacer el daño que causaron los esfuerzos de la administración Trump para socavar la Ley de Cuidado de Salud a Bajo Precio (ACA); el Medicaid, que brinda cobertura a más de 70 millones de estadounidenses; la salud reproductiva; y más.

Como fiscal general de California desde 2017, Becerra ha sido una molestia para la administración Trump, presentando 107 demandas para revocar la acción federal sobre ACA, la anticoncepción, inmigración, derechos de los trabajadores, derechos LGBT, educación, protección del consumidor,  violencia con armas de fuego, y medio ambiente.

“COVID es el mayor problema sobre la mesa, pero no es el único”, dijo el doctor Georges Benjamin, director ejecutivo de la Asociación Estadounidense de Salud Pública. “Si miras su trabajo, no es tu abogado tradicional. Su trabajo en el área de la salud es sustancial. Y creo que eso cuenta”.

El martes 8 de diciembre, Biden está presentando formalmente a Becerra junto con otros candidatos para los principales puestos de salud, muchos con una profunda experiencia en salud pública.

Entre ellos se encuentra la doctora Rochelle Walensky, experta en enfermedades infecciosas de la Escuela de Medicina de Harvard, quien ejerce en el Hospital General de Massachusetts, en Boston, como próxima directora de los Centros para el Control y Prevención de Enfermedades (CDC).

Como “zar” de COVID, la elección de Biden es Jeffrey Zients, un ejecutivo de inversiones y ex funcionario de la administración Obama que dirigirá la respuesta a la pandemia desde la Casa Blanca. El doctor Vivek Murthy es el nominado a cirujano general de los Estados Unidos, cargo que ocupó en los últimos años de Obama.

Biden ha dicho que permitirá que los científicos veteranos del gobierno federal guíen su respuesta a la pandemia, en particular los de los CDC, a los que supervisa el HHS. El presidente Donald Trump marginó a la agencia, dañando su reputación como la institución de salud pública más confiable del mundo.

El hecho de que la experiencia más profunda de Becerra sea política hace que algunos observadores desconfíen.

“Creo que siempre existe el peligro de dejar que eso enturbie el juicio científico y médico sobre la mejor manera de hacer las cosas. Espero que puedan manejar eso bien”, dijo Jeffrey Morris, profesor de bioestadística en la Universidad de Pennsylvania, quien ha trabajado en temas de COVID.

Morris agregó que tuvo sentimientos encontrados sobre la elección de Becerra. “¿Cuál es el estilo de liderazgo? ¿Habrá una microgestión? Para mí, ese es el aspecto clave”.

Garry South, estratega demócrata con sede en Los Ángeles, calificó el nombramiento de Becerra de “curioso”.

“Mucha gente está levantando las cejas, incluso aquellos que están complacidos y orgullosos de que Biden eligiera a otro californiano para unirse a su administración”, dijo South. “Si los republicanos buscan apuntar a algunos de los nombrados, para rechazarlos, pueden plantear que no existe un nexo lógico entre un fiscal general estatal y el cargo de secretario de Salud y Servicios Humanos”.

Aún así, Becerra, quien como miembro del Congreso trabajó con el liderazgo demócrata de la Cámara y fue miembro del poderoso Comité de Medios y Arbitrajes, tiene más experiencia en políticas de salud y más conocimiento de los sistemas financieros y de prestación de servicios de salud del país que sus predecesores en el HHS, que tiene más de 80,000 empleados y un presupuesto de $1.3 mil millones.

Durante tres años, Becerra ha administrado el Departamento de Justicia de California, con un presupuesto de $1.1 mil millones y 4,800 empleados. Como fiscal general, ha estado profundamente involucrado en la elaboración de políticas de salud. Su oficina ha perseguido el comportamiento anticompetitivo de los hospitales. Y ha patrocinado una legislación para enfrentar a los fabricantes de medicamentos y los esquemas de pago por demora.

“Ha perseguido a intereses poderosos en la atención de salud”, dijo Anthony Wright, director ejecutivo de Health Access California, una organización sin fines de lucro.

El Departamento de Juticia de los Estados Unidos y la Comisión Federal de Comercio son las entidades que vigilan la aplicación de las leyes antimonopolio. Pero Becerra lo convirtió en una prioridad como principal fiscal de California. En mayo de 2018, presentó un caso antimonopolio contra el gigante de la atención médica sin fines de lucro Sutter Health, acusando al sistema de prácticas monopólicas que elevaban el costo de la atención médica en el norte de California.

“Este es un gran acuerdo”, dijo Becerra en una conferencia de prensa. El caso, que llevó años de trabajo del departamento y sus predecesores y millones de páginas de documentos, alegó que Sutter había comprado agresivamente hospitales y consultorios médicos en toda la región y había explotado ilegalmente ese poder de mercado con fines de lucro.

Los costos de la atención médica en el norte de California, donde Sutter domina con sus 24 hospitales, son entre un 20% y un 30% más altos que en el sur de California, incluso después de ajustar por el mayor costo de vida del norte del estado, según un estudio de 2018 del Nicholas C. Petris Center de la Universidad de California-Berkeley, que se citó en la demanda.

En diciembre de 2019, Sutter acordó pagar $575 millones para resolver el caso y prometió poner fin a una serie de prácticas que, Becerra alegó, sofocaban a la competencia.

Becerra canalizó las lecciones aprendidas del caso Sutter en un proyecto de ley antimonopolio en la Legislatura de California. En última instancia, la legislación fracasó, pero le habría dado al fiscal general el poder de revisar las fusiones o adquisiciones de un sistema de atención médica o un hospital lideradas por fondos de inversión o fondos de cobertura.

“El caso Sutter es un modelo para una política nacional que podría comenzar a restaurar la competencia por el sistema de atención médica y ahorrar a los consumidores miles de millones de dólares de inmediato”, dijo Glenn Melnick, economista de salud de la Universidad del Sur de California.

Melnick ve a Becerra como “un verdadero experto en algunos de los problemas más importantes que enfrenta nuestro sistema de atención médica, no solo en California sino a nivel nacional”.

Si el Senado lo confirma, los partidarios de Becerra dicen que aportará al trabajo una perspicacia política de sus más de dos décadas en el Capitolio, que probablemente será una ventaja para la administración Biden, mientras negocia proyectos de ley de ayuda para enfrentar la pandemia, y otras leyes de salud con un Congreso políticamente dividido.

Henry Waxman, ex miembro demócrata del Congreso de California, trabajó con casi una docena de secretarios del HHS durante su tiempo en el Comité de Energía y Comercio de la Cámara de Representantes. Dijo que no le preocupa que Becerra no tenga experiencia en el liderazgo de una vasta burocracia sanitaria. Para ser secretario del HHS, “se necesitan habilidades políticas para ver hasta dónde se puede llegar con otras personas en un contexto político”. Es por eso que la mayoría de los secretarios del HHS, republicanos y demócratas, han tenido antecedentes políticos.

Becerra “comprende las políticas y tiene un profundo compromiso con ellas”, dijo. “Creo que le irá bien”.

Los funcionarios de salud pública dicen que el trabajo que enfrenta Becerra es gigantesco.

El doctor Gary Pace, oficial de salud en la zona rural del condado de Lake, en California, dijo que Becerra tendría la tarea de reconstruir un sistema de salud pública que no funciona.

“Queremos un aliado federal que pueda brindarnos una buena orientación; algo que no hemos tenido”, dijo Pace. “Lo primero que necesitamos es que los CDC vuelvan a desempeñar un papel emblemático en la salud pública, con una guía confiable y oportuna basada en evidencia”.

Nacido en Sacramento de padres inmigrantes mexicanos, Becerra sería el primer secretario latino del HHS. Fue elegido para el Congreso a los 30 años y ha estado involucrado en la legislación nacional de salud durante las últimas dos décadas, aunque es más conocido por su participación en temas de inmigración e impuestos.

Se unió al poderoso Comité de Medios y Arbitrajes de la Cámara, que supervisa la legislación fiscal y sanitaria, en la década de 1990. El comité jugó un papel central en la redacción de lo que se convertiría en la Ley de Cuidado de Salud a Bajo Precio, en 2010.

Si bien el HHS supervisa las principales agencias de salud federales, incluidos los CDC, los Centros de Servicios de Medicare y Medicaid, la Administración de Alimentos y Medicamentos y los Institutos Nacionales de Salud, también tiene una amplia cartera de servicios sociales, incluida la supervisión del cuidado y el bienestar infantil, programas de beneficiencia, Head Start, programas para personas mayores y reasentamiento de refugiados.

Dan Mendelson, ex funcionario de salud de la administración Clinton, dijo que Becerra era una “elección inspiradora”. “Creo que el punto más importante es que este es el líder de un equipo”.

Las redactoras de California Healthline, Rachel Bluth y Samantha Young, colaboraron con esta historia.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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In Becerra, an HHS Nominee With Political Skill But No Front-Line Health Experience

Xavier Becerra, President-elect Joe Biden’s choice to head the Department of Health and Human Services, is set to be a pandemic-era secretary with no public health experience. Whether that matters depends on whom you ask.

Becerra built his career in the U.S. House of Representatives before becoming California’s attorney general, and some wonder whether his political and legal skills would be the right fit to steer HHS through a health catastrophe that’s killing thousands of Americans every day.

Although he would bring years of health politics and policy work to the role, none of it comes from front-line experience as an executive or administrator running public health programs, managing patient care or controlling the spread of disease.

Yet beyond the immediate COVID-19 crisis, many Democrats see Becerra as an important ally to undo what they view as years of damage from the Trump administration’s efforts to undermine the Affordable Care Act; the Medicaid program, which provides coverage for more than 70 million Americans; reproductive health; and more.

As California’s attorney general since 2017, Becerra has been a thorn in the side of the Trump administration, filing 107 lawsuits to overturn federal action on the Affordable Care Act, contraception, immigration, workers’ rights, LGBT rights, education, consumer protection, gun violence and the environment.

“COVID is the biggest issue on the table, but it is not the only issue on the table,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “If you look at his body of work, he is not your traditional attorney. His body of work in the health area is substantial. And I think that counts.”

On Tuesday, Biden will formally introduce Becerra along with other candidates for top health jobs, many with deep public health experience.

They include Dr. Rochelle Walensky, an infectious disease expert at Harvard Medical School who practices at Massachusetts General Hospital in Boston, as the next director of the Centers for Disease Control and Prevention. Biden’s choice for COVID “czar” is Jeffrey Zients, a private equity executive and former Obama administration official who will steer the pandemic response from the White House. Dr. Vivek Murthy is the nominee for U.S. surgeon general, a position he held in the final Obama years.

Biden has said he will let the federal government’s longtime scientists guide his pandemic response, in particular those at the CDC, which is overseen by HHS. President Donald Trump sidelined the agency, damaging its reputation as the world’s most trusted public health institution.

That Becerra’s deepest experience is political makes some observers wary.

“I think there’s always a danger of letting that sort of cloud the scientific and medical judgment of how best to do things. I hope they can manage that well,” said Jeffrey Morris, a biostatistics professor at the University of Pennsylvania who has worked on COVID issues. He said he had mixed feelings about the Becerra selection. “What is the leadership style, and is there going to be micromanaging from the top down into these organizations? To me, that’s the key aspect.”

Garry South, a Los Angeles-based Democratic strategist, called Becerra’s appointment “curious.”

“A lot of people are raising eyebrows — even those who are pleased and proud that Biden picked another Californian to join his administration,” South said. “If Republicans are looking to target a few Biden appointees for rejection, you can expect them to make the case that there is no logical nexus between a state attorney general and serving as secretary of Health and Human Services.”

Still, Becerra, who as a member of Congress worked in the House Democratic leadership and was a member of the powerful Ways and Means Committee, has more health policy background and knowledge of U.S. health care finance and delivery systems than many previous heads of the sprawling HHS, which employs more than 80,000 people and has a $1.3 trillion budget.

For three years, Becerra has managed California’s Justice Department, with a $1.1 billion budget and 4,800 employees. As attorney general, he’s been deeply involved in crafting health policy. His office has gone after anti-competitive behavior from hospitals. And he’s sponsored legislation to take on drugmakers and pay-for-delay schemes.

“He’s gone after powerful health care interests,” said Anthony Wright, executive director of the nonprofit Health Access California.

Antitrust enforcement is more commonly handled by the U.S. Department of Justice and the Federal Trade Commission. But Becerra made it a priority as California’s top cop. In May 2018, he brought an antitrust case against nonprofit health care giant Sutter Health, accusing the system of monopolistic practices that drove up the cost of medical care in Northern California.

“This is a big ‘F’ deal,” Becerra said at a news conference unveiling the lawsuit. The case — which encompassed years of work by the department and his predecessors and millions of pages of documents — alleged that Sutter had aggressively bought up hospitals and physician practices across the region and illegally exploited that market power for profit. Health care costs in Northern California, where Sutter dominates with its 24 hospitals, are 20% to 30% higher than in Southern California, even after adjusting for Northern California’s higher cost of living, according to a 2018 study from the Nicholas C. Petris Center at the University of California-Berkeley that was cited in the complaint.

In December 2019, Sutter agreed to pay $575 million to settle the case and promised to end a host of practices that Becerra alleged stifled competition.

Becerra channeled lessons learned from the Sutter case into an antitrust bill in the California legislature. The legislation ultimately failed, but it would have given the attorney general power to review private equity- or hedge fund-led mergers or acquisitions of a health care system or hospital.

“The Sutter case is a blueprint for a national policy that could start to restore competition for the health care system and save American health care consumers billions of dollars right away,” said Glenn Melnick, a health care economist at the University of Southern California. He views Becerra as “a real expert in some of the most important issues facing our health care system, not just in California but nationally.”

If confirmed by the Senate, Becerra supporters say, he will bring to the job a political acumen from his two decades-plus on Capitol Hill that’s likely to be an asset for the Biden administration as it negotiates pandemic relief bills and other health legislation with a politically divided Congress.

Former California Democratic member of Congress Henry Waxman worked with nearly a dozen HHS secretaries during his time on the House Energy and Commerce Committee. He said he’s not worried that Becerra lacks experience leading a vast health care bureaucracy. The HHS secretary job, he said, is one “where you need political skills to see how far you can get with other people in a political context.” That’s why most HHS secretaries, Republicans and Democrats, have had political backgrounds.

Becerra “understands the policies and has a deep commitment to them,” he said. “I think he’ll do well.”

Public health officials say the job before Becerra is gigantic.

Dr. Gary Pace, the health officer in rural Lake County, California, said Becerra would be tasked with rebuilding a broken public health system.

“We want a federal partner who can give us good guidance — we haven’t had that,” Pace said. “For him, I’d say what we need first is starting to get the CDC back into a flagship public health role, with trusted and timely evidence-based guidance.”

Born in Sacramento to Mexican immigrant parents, Becerra would be the first Latino HHS secretary. He was elected to Congress in his 30s and has been involved in national health legislation during the past two decades, even though he is more widely known for his involvement in immigration and tax issues. He joined the powerful House Ways and Means Committee, which oversees tax and health legislation, in the 1990s. The committee played a central role in the drafting of what would become the Affordable Care Act in 2010.

While HHS oversees major federal health agencies, including the CDC, the Centers for Medicare & Medicaid Services, the Food and Drug Administration and the National Institutes of Health, it also has a wide-ranging human services portfolio, including oversight of child care and welfare programs, Head Start, programs for seniors and refugee resettlement.

“It’s not like any one person is going to have everything,” said Dan Mendelson, a former Clinton administration health official, who called Becerra an “inspired choice.” “I think that the most important point is that this is a leader of a team and not the be-all and end-all.”

KHN staff writers Rachel Bluth and Samantha Young contributed to this story.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Senate Republicans Throw the Brakes on Timing for Becerra Hearings

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Senate Republicans are signaling they will delay considering President-elect Joe Biden’s nominee to run the Department of Health and Human Services, threatening to slow the Biden administration’s response to the pandemic that has killed more than 283,000 Americans.

On Monday, Republican spokespeople for the committees responsible for vetting HHS nominations said the Senate may not hold hearings on California Attorney General Xavier Becerra, Biden’s pick to lead the department, until the Senate approves committee assignments and other organizational details for the new Congress.

Republicans, who will hold at least 50 seats next year, remain in control of the Senate until Jan. 20. But Georgia has two Senate runoff elections scheduled for Jan. 5, and those results will determine which party controls the chamber in the new, 117th Congress.

Political observers say the results could take days or even weeks.

“Every day is a wasted day,” said Kathleen Sebelius, who served as President Barack Obama’s first HHS secretary. (Sebelius is on the board of KFF, and KHN is an editorially independent program of KFF.)

On Monday, Biden announced he has asked Becerra to serve as HHS secretary. Becerra mounted a vigorous defense of Democratic health laws against the Trump administration and other Republicans. He led the effort by 20 states and the District of Columbia to fight a suit brought by Republican state officials and supported by President Donald Trump to overturn the Affordable Care Act. That case was argued before the Supreme Court last month.

The early reaction from Republicans signaled Becerra could face strong political opposition to his nomination, with critics like Arkansas Sen. Tom Cotton citing Becerra’s opposition to abortion restrictions and calling him “unqualified” to lead HHS.

“I’ll be voting no, and Becerra should be rejected by the Senate,” he wrote on Twitter. Becerra also supported single-payer health care reform.

In addition, Biden intends to name Dr. Rochelle Walensky, chief of infectious diseases at Massachusetts General Hospital, as the head of the Centers for Disease Control and Prevention, and private equity executive Jeffrey Zients to be his COVID “czar” heading up a task force in the White House. Those jobs do not require Senate confirmation. Biden is nominating Dr. Vivek Murthy as surgeon general, who must face hearings before the Senate.

Becerra would be the first Latino to lead HHS. Before becoming attorney general, he served in the House of Representatives, representing Los Angeles for 24 years. There, he was a member of Democratic leadership and served on the Ways and Means Committee, the House committee charged with writing health-related tax policy.

Becerra returned to California in 2017, replacing the outgoing attorney general who had just been elected to the Senate — now Vice President-elect Kamala Harris.

The HHS secretary is responsible for one of the federal government’s largest departments, coordinating not only the Centers for Medicare & Medicaid Services but also the Food and Drug Administration and the CDC — agencies critical to the nation’s pandemic response.

Although Biden has created his own task force to address the pandemic, the White House lacks many of the powers of the HHS secretary — including the authority to implement its own recommendations, said Donna Shalala, who served as HHS secretary under President Bill Clinton for eight years.

“Any delay [in confirmation] delays COVID, despite a strong White House coordination,” Shalala said, “because you’ve got to get the agencies in sync and you can’t do that from the White House.”

In 2009, as H1N1 flu began to spread and Obama’s first HHS pick withdrew from consideration, the administration was forced to improvise. With no confirmed health secretary, Obama turned to Janet Napolitano, the Homeland Security secretary, to coordinate a plan to distribute vaccines with the CDC.

Sebelius was sworn in as HHS secretary in late April, two days after the Obama administration declared H1N1 a public health emergency.

It would be hard to mount a pandemic response without a secretary, she said. “That pressure falls on Congress,” Sebelius said. “There’s just a sense we can’t screw around with this.”

She also added that the Obama administration did not pursue any lower-level health appointments before confirming the secretary, a protocol that left many offices vacant. She expects Biden will follow the same process.

The Senate can, and often does, begin considering nominees before a new president is sworn in, in particular by arranging one-on-one meetings for senators and examining a nominee’s qualifications and background. Presidents Donald Trump and George W. Bush’s nominees for HHS secretary both received confirmation hearings before Inauguration Day, though Democrats later fought Trump’s nominee, then-Rep. Tom Price (R-Ga.), by boycotting his committee vote.

Republicans say that until the Senate approves what is known as an organizing resolution, which formalizes details like which senators sit on which committees, they cannot move forward with confirmation hearings.

A further complication is that while Republicans already control the two committees tasked with vetting an HHS secretary, neither chairman is staying in that job next year. Sen. Lamar Alexander of Tennessee, who runs the Health, Education, Labor and Pensions Committee, is retiring from Congress. And due to term limits, Iowa Sen. Chuck Grassley, who runs the Finance Committee, will move to a different committee.

Senate Democrats, who would take control of the confirmation process next month should they win both of Georgia’s Senate seats, praised the selection of Becerra and promised to push for a speedy process.

Becerra “has been a staunch defender of affordable health care and preexisting condition protections in the face of Trump’s attacks in court and federal regulation,” said Oregon Sen. Ron Wyden, the Finance Committee’s top Democrat. “I look forward to Attorney General Becerra’s hearing in the Finance Committee as soon as possible next year, so he is on the job quickly.”

“Xavier Becerra is a highly qualified nominee, and I will be pushing for a swift, fair confirmation so we can get to work on the serious health issues our nation faces,” said Sen. Patty Murray of Washington, the HELP Committee’s top Democrat.

If Democrats win both of the Georgia elections next month, the Senate would be evenly split 50-50, likely leading to debates about how to divide control and distracting senators from nomination hearings.

When that happened in 2001, Senate Democrats held the majority for a couple of weeks until Bush was sworn in, making Vice President Dick Cheney the tie-breaking vote and giving Republicans the majority on Jan. 20. Bush’s first HHS secretary, Tommy Thompson, was confirmed four days later.

Bill Dauster, who advised Democrats on the Senate’s procedural rules for decades, said that the split took a long time to negotiate in 2001 but that it left behind a model that senators can use today.

Senate Republicans could follow the precedent of holding hearings before the inauguration, especially due to the urgency of responding to the pandemic, Dauster said.

“If they don’t, it will clearly be foot-dragging,” he said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What the Health?’: Transition Interrupted

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Five days after the election was called for President-elect Joe Biden, President Donald Trump has not conceded — and instead ordered his administration not to begin the transition of power. That could have serious ramifications for health care, particularly as nearly every state is experiencing a spike in COVID-19 cases.

One piece of good news is that early results for a coronavirus vaccine made by Pfizer look promising. But that vaccine, even if it is approved soon, won’t likely be ready for wide distribution for several months.

And for the third time in eight years, the Supreme Court heard a case that could invalidate the Affordable Care Act. Judging from the oral arguments, though, it appears the justices are likely to leave most or even all of the law intact.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Stephanie Armour of The Wall Street Journal and Shefali Luthra of the 19th News.

Among the takeaways from this week’s podcast:

  • The transition teams advising Biden cannot officially contact current government officials. But many team members have long-standing relationships with people in the government and were talking to those officials before the election, so they have a good sense of what is happening in the administration.
  • The pandemic further complicates the handoff. The new administration will need to hit the ground running to distribute any coronavirus vaccine, so communication with Trump administration officials would be beneficial for the Biden team.
  • Two members of Biden’s COVID task force, Drs. Vivek Murthy, former surgeon general, and David Kessler, former commissioner of the Food and Drug Administration, have been briefing the former vice president since March on the threats of the coronavirus.
  • Since Democrats may not control the Senate — and if they do have control, it will be by the slimmest majority — Biden may be forced to make changes to health policy through executive actions and regulations. That will limit his ambitions.
  • Still, even these smaller moves can have major results, such as allowing Planned Parenthood to again participate in federal health programs to expand the number of providers from which low-income women can seek care.
  • The Pfizer vaccine requires extremely cold temperatures for storage, complicating the logistics for distribution. It is an obstacle but not an insurmountable one for most areas in this country.
  • Supreme Court justices signaled this week they might not strike the Affordable Care Act in its entirety. Several of the conservatives, including Justice Brett Kavanaugh, who was appointed by President Donald Trump, suggested that any ruling that the mandate to have insurance is unconstitutional does not have to doom the rest of the law.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: KHN and The Washington Post’s “In Medical Schools, Students Seek Robust and Mandatory Anti-Racist Training,” by Elizabeth Lawrence

Joanne Kenen: KHN’s “Trump’s Anti-Abortion Zeal Shook Fragile Health Systems Around the World,” by Sarah Varney

Stephanie Armour: KHN’s “Biden Plan to Lower Medicare Eligibility Age to 60 Faces Hostility From Hospitals,” by Phil Galewitz

Shefali Luthra: Stat News’ “With a Meteoric Rise in Deaths, Talk of Waves Is Misguided, Say Covid-19 Modelers,” by Elizabeth Cooney

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Biden Plan to Lower Medicare Eligibility Age to 60 Faces Hostility From Hospitals

Of his many plans to expand insurance coverage, President-elect Joe Biden’s simplest strategy is lowering the eligibility age for Medicare from 65 to 60.

But the plan is sure to face long odds, even if the Democrats can snag control of the Senate in January by winning two runoff elections in Georgia.

Republicans, who fought the creation of Medicare in the 1960s and typically oppose expanding government entitlement programs, are not the biggest obstacle. Instead, the nation’s hospitals, a powerful political force, are poised to derail any effort. Hospitals fear adding millions of people to Medicare will cost them billions of dollars in revenue.

“Hospitals certainly are not going to be happy with it,” said Jonathan Oberlander, professor of health policy and management at the University of North Carolina-Chapel Hill.

Medicare reimbursement rates for patients admitted to hospitals average half what commercial or employer-sponsored insurance plans pay.

“It will be a huge lift [in Congress] as the realities of lower Medicare reimbursement rates will activate some powerful interests against this,” said Josh Archambault, a senior fellow with the conservative Foundation for Government Accountability.

Biden, who turns 78 this month, said his plan will help Americans who retire early and those who are unemployed or can’t find jobs with health benefits.

“It reflects the reality that, even after the current crisis ends, older Americans are likely to find it difficult to secure jobs,” Biden wrote in April.

Lowering the Medicare eligibility age is popular. About 85% of Democrats and 69% of Republicans favor allowing those as young as 50 to buy into Medicare, according to a KFF tracking poll from January 2019. (KHN is an editorially independent program of KFF.)

Although opposition from the hospital industry is expected to be fierce, that is not the only obstacle to Biden’s plan.

Critics, especially Republicans on Capitol Hill, will point to the nation’s $3 trillion budget deficit as well as the dim outlook for the Medicare Hospital Insurance Trust Fund. That fund is on track to reach insolvency in 2024. That means there won’t be enough money to fully pay hospitals and nursing homes for inpatient care for Medicare beneficiaries.

Moreover, it’s unclear whether expanding Medicare will fit on the Democrats’ crowded health agenda, which also includes dealing with the COVID-19 pandemic, possibly rescuing the Affordable Care Act if the Supreme Court strikes down part or all of the law in a current case, expanding Obamacare subsidies and lowering drug costs.

Biden’s proposal is a nod to the liberal wing of the Democratic Party, which has advocated for Sen. Bernie Sanders’ (I-Vt.) government-run “Medicare for All” health system that would provide universal coverage. Biden opposed that effort, saying the nation could not afford it. He wanted to retain the private health insurance system, which covers 180 million people.

To expand coverage, Biden has proposed two major initiatives. In addition to the Medicare eligibility change, he wants Congress to approve a government-run health plan that people could buy into instead of purchasing coverage from insurance companies on their own or through the Obamacare marketplaces. Insurers helped beat back this “public option” initiative in 2009 during the congressional debate over the ACA.

The appeal of lowering Medicare eligibility to help those without insurance lies with leveraging a popular government program that has low administrative costs.

“It is hard to find a reform idea that is more popular than opening up Medicare” to people as young as 60, Oberlander said. He said early retirees would like the concept, as would employers, who could save on their health costs as workers gravitate to Medicare.

The eligibility age has been set at 65 since Medicare was created in 1965 as part of President Lyndon Johnson’s Great Society reform package. It was designed to coincide with the age when people at that time qualified for Social Security. Today, people generally qualify for early, reduced Social Security benefits at age 62, though they have to wait until age 66 for full benefits.

While people can qualify on the basis of other criteria, such as having a disability or end-stage renal disease, 85% of the 57 million Medicare enrollees are in the program simply because they’re old enough.

Lowering the age to 60 could add as many as 23 million people to Medicare, according to an analysis by the consulting firm Avalere Health. It’s unclear, however, if everyone who would be eligible would sign up or if Biden would limit the expansion to the 1.7 million people in that age range who are uninsured and the 3.2 million who buy coverage on their own.

Avalere says 3.2 million people in that age group buy coverage on the individual market.

While the 60-to-65 group has the lowest uninsured rate (8%) among adults, it has the highest health costs and pays the highest rates for individual coverage, said Cristina Boccuti, director of health policy at West Health, a nonpartisan research group.

About 13 million of those between 60 and 65 have coverage through their employer, according to Avalere. While they would not have to drop coverage to join Medicare, they could possibly opt to also pay to join the federal program and use it as a wraparound for their existing coverage. Medicare might then pick up costs for some services that the consumers would have to shoulder out-of-pocket.

Some 4 million people between 60 and 65 are enrolled in Medicaid, the state-federal health insurance program for low-income people. Shifting them to Medicare would make that their primary health insurer, a move that would save states money since they split Medicaid costs with the federal government.

Chris Pope, a senior fellow with the conservative Manhattan Institute, said getting health industry support, particularly from hospitals, will be vital for any health coverage expansion. “Hospitals are very aware about generous commercial rates being replaced by lower Medicare rates,” he said.

“Members of Congress, a lot of them are close to their hospitals and do not want to see them with a revenue hole,” he said.

President Barack Obama made a deal with the industry on the way to passing the ACA. In exchange for gaining millions of paying customers and lowering their uncompensated care by billions of dollars, the hospital industry agreed to give up future Medicare funds designed to help them cope with the uninsured. Showing the industry’s prowess on Capitol Hill, Congress has delayed those funding cuts for more than six years.

Jacob Hacker, a Yale University political scientist, noted that expanding Medicare would reduce the number of Americans who rely on employer-sponsored coverage. The pitfalls of the employer system were highlighted in 2020 as millions lost their jobs and workplace health coverage.

Even if they can win the two Georgia seats and take control of the Senate with the vice president breaking any ties, Democrats would be unlikely to pass major legislation without GOP support — unless they are willing to jettison the long-standing filibuster rule so they can pass most legislation with a simple 51-vote majority instead of 60 votes.

Hacker said that slim margin would make it difficult for Democrats to deal with many health issues all at once.

“Congress is not good at parallel processing,” Hacker said, referring to handling multiple priorities at the same time. “And the window is relatively short.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Biden Wins, but His Health Agenda Dims With GOP Likely to Hold Senate

Former Vice President Joe Biden secured the 270 electoral votes needed to capture the White House on Saturday, major news organizations projected,  after election officials in a handful of swing states spent days in round-the-clock counting of millions of mail-in ballots and early votes.

The Democrat’s victory came after the latest tallies showed him taking an insurmountable lead in Pennsylvania, a state both Biden and President Donald Trump had long identified as vital to their election efforts.  Trump has signaled he will fight the election results in several states, filing a number of lawsuits and seeking recounts.

“America, I’m honored that you have chosen me to lead our great country,” Biden tweeted shortly after the news organizations called the race. “The work ahead of us will be hard, but I promise you this: I will be a President for all Americans — whether you voted for me or not.”

The Democratic celebration was tempered because it appeared the party would have a hard time taking back the Senate majority it lost in 2014. If that bears out, it will likely keep Biden and Democratic lawmakers from enacting many of the plans they campaigned on, including major changes in health care.

Party control of the Senate may not be determined until January — thanks to what preliminary returns suggest will be runoffs for both Senate seats in Georgia. No candidate for either seat reached the required 50% threshold.

Without a Democratic majority in the Senate, Biden will likely face strong Republican opposition to many of his top health agenda items — including lowering the eligibility age for Medicare to 60, expanding financial assistance for health insurance under the Affordable Care Act, and creating a “public option” government health plan.

However, his administration would be a bulwark to defend the ACA against Republican attacks, although the Supreme Court case challenging the health law — which will be heard next week — presents a major wild card for its future.

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Health care was a key element of Biden’s campaign, especially improving the federal response to the coronavirus pandemic. He championed the use of face masks and blasted the Trump administration for shifting to states much of the responsibility for fighting the virus and helping hospitals. He was regularly mocked by the president for wearing a mask, working and campaigning from home, and not having an in-person Democratic convention.

Even before the latest vote tallies were released late Saturday morning, Biden had begun moving toward setting up his administration. On Thursday his transition team unveiled a website, BuildBackBetter.com, although it was only one page. And the former vice president held a meeting Thursday with health and economic advisers on the pandemic.

In a brief television statement Friday night, Biden reiterated his commitment to fight the pandemic, which he said “is getting more worrisome across the country.”

“We want everyone to know on day one we are going to put our plan to control this virus into action. We can’t save any of the lives that have been lost, but we can save a lot of lives in the months ahead,” Biden said.

The electoral outcome is not the one Democrats were hoping for — or, to some extent, expecting, based on preelection polling. Andy Slavitt, who ran the Centers for Medicare & Medicaid Services during the Obama administration, noted that frustration in a tweet Wednesday. “A large disappointment is that many hoped for a significant repudiation of Trump & his indifference to human life, human suffering, his corruption, and goal of getting rid of the ACA. No matter the final total it will be hard to make that claim,” Slavitt said.

Still up in the air is how willing a Republican-led Senate will be to provide further relief to individuals, businesses and states hit hard by the pandemic, and whether they will participate in previously bipartisan efforts to curtail “surprise” out-of-network medical bills and get a handle on prescription drug prices.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What The Health?’: Change Is in the Air

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Assuming former Vice President Joe Biden becomes President-elect Joe Biden and Republicans retain control of the Senate, the health agenda could be very different from what Democrats campaigned on. A GOP Senate is unlikely to want to pursue many of Biden’s agenda items, including expanding eligibility for Medicare, boosting financial assistance for people who buy insurance under the Affordable Care Act, and creating a federal “public option” insurance plan.

Meanwhile, no matter who is elected, the ACA is on the line next week as the more conservative Supreme Court hears oral arguments in a case that could potentially result in its total overturn. A decision in that case is not expected until sometime next year.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Kimberly Leonard of Business Insider and Mary Ellen McIntire of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • Republicans and Democrats on Capitol Hill might find common ground on some smaller — but important — issues, such as restricting surprise medical bills, which consumers get after they receive care from doctors outside their insurance network. But changes in the GOP committee chairs could dim current efforts to reduce prescription drug prices.
  • One issue that might have bipartisan support next year is enhancement of the public health system. The coronavirus pandemic has shown that parts of the system have deteriorated in recent years.
  • Democrats’ dreams of major gains in both the House and Senate failed to materialize Tuesday. That suggests that their arguments that Democrats would protect the ACA did not carry as much weight this year as they did in 2018, when the party saw success in midterm elections.
  • Although the campaign is over, there’s no clear indication that the debate on how to attack COVID-19 will become less politicized. The fear of another economic shutdown and the consequences of that for millions of Americans is driving strong — and very divided — public sentiment on the issue.
  • The Trump administration appeared to be seeking to enhance the president’s campaign in Georgia when it announced Sunday that it would allow the state to starkly revamp its offerings of ACA marketplace plans in a couple of years.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The New York Times’ “A New Item on Your Medical Bill: The ‘Covid’ Fee,” by Sarah Kliff and Jessica Silver-Greenberg

Joanne Kenen: PBS NewsHour’s “Amid COVID-19 Pandemic, Wisconsin Voters Choose Biden Over Trump,” by Laura Santhanam

Kimberly Leonard: The Wall Street Journal’s “States Hire Consultants for Covid-19 Help, With Mixed – and Expensive – Results,” by Jean Eaglesham and Kirsten Grind

Mary Ellen McIntire: The AP’s “Counties With Worst Virus Surges Overwhelmingly Voted Trump,” by Carla K. Johnson, Hanna Fingerhut and Pia Deshpande

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And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Longtime Health Advocate Donna Shalala Loses House Reelection Race

Rep. Donna E. Shalala of Florida, the first-term Democratic member of Congress and former Health and Human Services secretary in the Clinton administration, lost her campaign for reelection Tuesday.

Shalala’s loss to Maria Elvira Salazar — a Republican and former television journalist who compared Democratic policy proposals to leftist oppression in countries like Cuba while campaigning in the Miami district — was a notable upset for House Democrats. While Democrats held onto control of the House, so far they have fallen short of expectations that they would secure an even stronger majority there.

Political forecasters like The Cook Political Report had projected it was “likely” Shalala would win. She lost 48.6% to 51.3%.

In the final weeks of the campaign, Shalala, 79, and Salazar, 58, traded attack ads that touched on the election’s significance for health care.

“Salazar supports Trump, who wants to eliminate the Affordable Care Act and remove coverage of preexisting health conditions,” a Shalala ad warned.

Salazar pointed to Shalala’s failure to disclose stock trades in violation of federal law. She also accused the representative, who was appointed to the federal commission overseeing the distribution of coronavirus relief to small businesses, of not doing enough for her constituents during the pandemic.

Shalala came to Congress in 2018, helping Democrats reclaim the House of Representatives on promises to defend the Affordable Care Act and popular consumer protections for those with preexisting conditions.

But 2020 is proving a much different election year. A political rematch after Shalala defeated Salazar two years ago, this election appeared to hinge on issues beyond health care coverage and affordability.

Early reports signal Shalala was not the only casualty of a strong showing by Republicans in the Miami-Dade area of South Florida. Another first-term Democratic member of Congress representing part of Miami-Dade County, Rep. Debbie Mucarsel-Powell, also lost. Former Vice President Joe Biden trailed Hillary Clinton’s showing there in 2016, when she won the district by almost 20 points.

Shalala first won the seat after it was vacated by Ileana Ros-Lehtinen, a retiring Republican who had held it for 30 years, including when her district went for Clinton in 2016.

At the time, it was seen as a vulnerability that Shalala did not speak Spanish while seeking to represent a heavily Latino district. Salazar, who worked for the Spanish-language news channel Univision, often campaigned in Spanish.

During her two years in Congress, Shalala served on the House Committee on Education and Labor and its subcommittee that addressed health issues, as well as the House Rules Committee — a sign of her favor with Democratic leaders.

After the Rules Committee held a hearing on a “Medicare for All” proposal in 2019, Shalala referred to it as “the first step in exchanging ideas on how we move toward universal health coverage.” But she also expressed concerns that Medicare is “not as good” as many private insurance plans and that some constituents would prefer to keep their plans.

“Why should we spend money when people have good private health insurance?” she told C-SPAN. “We need to cover those that don’t have coverage now.”

When President Bill Clinton appointed Shalala as the nation’s top health and human services official in 1993, she was seen as a controversial pick, too liberal for some. As chancellor of the University of Wisconsin in Madison, she had encouraged the school to adopt a speech code intended to restrict hate speech, a move later ruled unconstitutional in federal court.

Shalala served as health secretary until 2001, becoming president of the University of Miami until 2015 and then head of the Clinton Foundation until 2017.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Sin presidente todavía, el futuro de la salud también sigue siendo incierto

Sin un ganador y sin saber todavía qué partido controlará el Senado, el futuro del sistema de salud de la nación también sigue siendo incierto.

Lo que está en juego es si el gobierno federal desempeñará un papel más importante en el financiamiento y el establecimiento de las reglas básicas para la cobertura de atención médica o cederá más autoridad a los estados y al sector privado.

Si el presidente Donald Trump gana y los republicanos retienen el control del Senado, es posible que Trump aún no pueda hacer cambios radicales mientras la Cámara siga bajo control demócrata.

Pero, gracias a las reglas establecidas por los republicanos del Senado, se podrían seguir apilando demandas en los tribunales federales con juristas conservadores que probablemente defiendan el uso expansivo del poder ejecutivo por parte de Trump para tomar decisiones de salud.

El presidente también se ha comprometido a continuar sus esfuerzos para deshacerse de la Ley de Cuidado de Salud a Bajo Precio (ACA). Si la Corte Suprema anula la ley general como parte de un desafío que escuchará la próxima semana, se pondrá a prueba la promesa de los republicanos de proteger a las personas con condiciones médicas preexistentes.

En un segundo mandato, la administración probablemente también continuará sus esfuerzos para modificar Medicaid instituyendo requisitos laborales para los adultos inscritos y brindando más flexibilidad a los estados para cambiar el diseño del programa.

Si Joe Biden gana y los demócratas obtienen la mayoría en el Senado, sería la primera vez que el partido controla la Casa Blanca y ambas cámaras del Congreso desde 2010, el año en que se aprobó ACA.

Una de las principales prioridades será lidiar con la pandemia de COVID-19 y sus consecuencias económicas. Biden hizo de este tema una piedra angular de su campaña, prometiendo implementar políticas basadas en el asesoramiento médico y científico, y proporcionar más directrices y ayuda a los estados.

Pero también ocupa un lugar destacado en su agenda abordar partes de ACA que no han funcionado tan bien como esperaban sus autores. Se comprometió a agregar una “opción pública” administrada por el gobierno, que sería una alternativa a los planes de seguros privados en los mercados, y a reducir la edad de elegibilidad para Medicare a 60 años.

Si bien los demócratas continuarán controlando la Cámara, aún no se ha determinado la composición final del Senado. E incluso si los demócratas ganan el Senado, no se espera que obtengan una mayoría que les permita aprobar leyes sin el apoyo de algunos senadores republicanos, a menos que cambien las reglas del Senado.

Pero quién controle Washington es solo una parte del impacto de las elecciones en las políticas de salud. Varios problemas de salud clave están en manos de los estados. Algunos de ellos:

Aborto

En Colorado, una medida que habría prohibido los abortos después de las 22 semanas de embarazo, excepto para salvar la vida de la embarazada, fracasó, según The Associated Press. Colorado es uno de los siete estados que no prohíben los abortos en algún momento del embarazo.

También alberga una de las pocas clínicas del país que realizan abortos en el tercer trimestre del embarazo, a menudo por complicaciones médicas graves. La clínica atrae pacientes de todo el país, por lo que los residentes de otros estados se habrían visto afectados si se aprobara la enmienda de Colorado.

En Louisiana, sin embargo, los votantes aprobaron fácilmente una enmienda a la constitución estatal para indicar que nada en el documento proteja el derecho al aborto o a financiarlo. Esto facilitaría que el estado prohíba el aborto si la Corte Suprema anula Roe v. Wade, que hace que las prohibiciones estatales del aborto sean inconstitucionales.

Medicaid

El destino del programa de salud para las personas de bajos ingresos no está en la boleta electoral directamente en ninguna parte de esta elección. (Los votantes aprobaron expansiones del programa en Missouri y Oklahoma a principios de este año).

Pero el programa se verá afectado no solo por quién controle la presidencia y el Congreso, sino también por quién controle las legislaturas en los estados que no han expandido Medicaid en el marco de ACA. Carolina del Norte es un estado clave donde un cambio en la mayoría de la legislatura podría modificar el rumbo de la expansión.

Marihuana y alucinógenos

En seis estados, los votantes están decidiendo la legalidad de la marihuana de una forma u otra. Montana, Arizona y Nueva Jersey estaban decidiendo si unirse a los 11 estados que permiten su uso recreativo.

Los votantes de Mississippi y Nebraska estaban eligiendo si legalizarían la marihuana medicinal, y Dakota del Sur se convirtió en el primer estado en votar sobre la legalización de la marihuana medicinal y recreativa en la misma elección.

Las setas alucinógenas (hongos) están en dos papeletas. Se aprobó una medida en Oregon para permitir el uso de hongos productores de psilocibina con fines medicinales, y una propuesta del Distrito de Columbia para despenalizar los hongos alucinógenos estaba ganando adeptos.

También se aprobó una pregunta en la boleta electoral en Oregon para despenalizar la posesión de pequeñas cantidades de drogas duras, incluida la heroína, cocaína y metanfetamina, y ordenar el establecimiento de centros de recuperación de adicciones, utilizando parte de los ingresos fiscales de las ventas de marihuana para establecer esos centros.

California

Como de costumbre, los votantes de California se enfrentaron a una larga lista de medidas electorales relacionadas con la salud.

Por segunda vez en dos años, la rentable industria de diálisis renal del estado fue cuestionada en las urnas. Una iniciativa patrocinada por un sindicato habría requerido que las empresas de diálisis contrataran a un médico en cada clínica y presentaran informes sobre casos de infecciones al estado. Pero la industria gastó $105 millones en contra de la medida. La medida falló, según AP.

También se les pidió a los votantes que decidieran, nuevamente, si financiarían la investigación con células madre del Instituto de Medicina Regenerativa de California a través de la Proposición 14. Los votantes aprobaron por primera vez el financiamiento para la agencia en 2004 y, desde entonces, se han gastado miles de millones con pocos resultados que derivaran en curas. La medida estaba ganando en los primeros resultados.

California ha estado a la vanguardia de la lucha por la llamada economía de los gig, y la votación de este año incluyó una propuesta impulsada por empresas de transporte como Uber y Lyft que les permitiría seguir tratando a los conductores como contratistas independientes en lugar de empleados.

Según la Proposición 22, las empresas no tendrían que proporcionar beneficios de salud directos a los conductores, pero tendrían que darles a los que califiquen un estipendio que podrían utilizar para pagar las primas de seguro médico comprado en el mercado del estado, Covered California. La medida fue aprobada.

Finalmente, se preguntó a los votantes si imponer impuestos a la propiedad más altos a los dueños de propiedades comerciales con terrenos y tenencias de propiedades valoradas en $3 millones o más, lo que podría ayudar a proporcionar nuevos ingresos destinados a ciudades y condados con problemas económicos afectados por el COVID-19, así como escuelas K-12 y colegios comunitarios.

Las clínicas comunitarias, las enfermeras de California y Planned Parenthood se lanzaron a la espinosa batalla política por la Propuesta 15, enfrentándose a poderosos grupos empresariales, con la mira puesta en los ingresos para ayudar a reconstruir el empobrecido sistema de salud pública de California.

Los demócratas en California, que controlan todos los cargos electos en todo el estado y tienen una supermayoría en la legislatura, se han estado posicionando para una victoria de Biden, y algunos ya estaban redactando una ambiciosa legislación de atención médica para el próximo año.

Si gana Biden, dijeron que planean tomar medidas enérgicas contra la consolidación de hospitales y terminar con las facturas sorpresa de las salas de emergencias, y algunos estaban discutiendo en silencio iniciativas liberales como buscar un sistema de atención médica de pagador único y expandir Medicaid para cubrir a más inmigrantes sin papeles.

JoNel Aleccia, Rachel Bluth, Angela Hart, Matt Volz y Samantha Young colaboraron con esta historia.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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No Winner for President Yet and Health Care Hangs in the Balance

With the winner of the presidency and party control of the Senate still unclear the morning after Election Day, the future of the nation’s health system remains uncertain. At stake is whether the federal government will play a stronger role in financing and setting the ground rules for health care coverage or cede more authority to states and the private sector.

Should President Donald Trump win and Republicans retain control of the Senate, Trump still may not be able to make sweeping changes through legislation as long as the House is still controlled by Democrats. But — thanks to rules set up by the Senate GOP — the ability to continue to stack the federal courts with conservative jurists who are likely to uphold Trump’s expansive use of executive power could effectively remake the government’s relationship with the health care system even without signed legislation.

The president has also pledged to continue his efforts to get rid of the Affordable Care Act, and if the Supreme Court overturns the sweeping law as part of a challenge it will hear next week, the Republicans’ promise to protect people with preexisting medical conditions will be put to the test. In a second term, the administration would also likely push to continue to revamp Medicaid with its efforts to institute work requirements for adult enrollees and provide more flexibility for states to change the contours of the program.

If former Vice President Joe Biden wins and Democrats gain a Senate majority, it would represent the first time the party has controlled the White House and both houses of Congress since 2010 — the year the ACA was passed. A top priority will be dealing with the COVID-19 pandemic and the economic fallout. Biden made that a keystone of his campaign, promising to implement policies based on advice from medical and scientific advisers and provide more directives and aid to the states.

But also high on his agenda will be addressing parts of the ACA that haven’t worked as well as its authors hoped. He pledged to add a government-run “public option,” which would be an alternative to private insurance plans on the marketplaces, and to lower the eligibility age for Medicare to 60.

While Democrats will continue to control the House, the final makeup of the Senate is still to be determined. And even if the Democrats win the Senate, they are not expected to come away with a majority that would allow them to pass legislation without support from at least some GOP senators, unless they change the Senate’s rules. That could lower expectations of what the Democrats can accomplish — and may lead to some tensions among members.

But who controls Washington, D.C., is only part of the election’s impact on health policy. Several key health issues are on the ballot both directly and indirectly in many states. Here are a few:

Abortion

In Colorado, a measure that would have banned abortions after 22 weeks of pregnancy — except to save the life of the pregnant person — failed, according to The Associated Press. Colorado is one of seven states that don’t prohibit abortions at some point in pregnancy. It is also home to one of the few clinics in the nation that perform abortions in the third trimester, often for severe medical complications. The clinic draws patients from around the nation, so residents of other states would have been affected if the Colorado amendment passed.

In Louisiana, however, voters easily approved an amendment to the state constitution to say that nothing in the document protects the right to, or requires the funding of, abortion. That would make it easier for the state to outlaw abortion if the Supreme Court overturns Roe v. Wade, which makes state abortion bans unconstitutional.

Medicaid

The fate of the Medicaid program for people with low incomes is not on the ballot directly anywhere this election. (Voters approved expansions of the program in Missouri and Oklahoma earlier this year.) But the program will be affected not only by who controls the presidency and Congress, but also by who controls the legislatures in states that have not expanded the program under the Affordable Care Act. North Carolina is a key swing state where a change in majority in the legislature could turn the expansion tide.

Drug Policy

In six states, voters are deciding the legality of marijuana in one form or another. Montana, Arizona and New Jersey were deciding whether to join the 11 states that allow recreational use of the drug. Mississippi and Nebraska voters were choosing whether to legalize medical marijuana, and South Dakota became the first state to vote on legalizing both recreational and medical pot in the same election.

Magic mushrooms are on two ballots. A measure in Oregon to allow the use of psilocybin-producing mushrooms for medicinal purposes was leading, as was a District of Columbia proposal to decriminalize the hallucinogenic fungi.

Also apparently heading for approval was a separate ballot question in Oregon to decriminalize possession of small amounts of hard drugs, including heroin, cocaine and methamphetamine, and mandate establishing addiction recovery centers, using some tax proceeds from marijuana sales to establish those centers.

California

As usual, voters in California faced a lengthy list of health-related ballot measures.

For the second time in two years, the state’s profitable kidney dialysis industry was challenged at the ballot box. A union-sponsored initiative would have required dialysis companies to employ a doctor at every clinic and submit infection reports to the state. But the industry spent $105 million against the measure. The measure failed, according to AP.

Voters were also asked to decide, again, whether to fund stem cell research through the California Institute for Regenerative Medicine via Proposition 14. Voters first approved funding for the agency in 2004, and since then, billions have been spent with few cures to show for it. The measure was winning in early returns.

California has been at the forefront of the fight over the so-called gig economy, and this year’s ballot included a proposal pushed by ride-hailing companies like Uber and Lyft that would let them continue to treat drivers as independent contractors instead of employees. Under Proposition 22, the companies would not have to provide direct health benefits to drivers but would have to give those who qualify a stipend they could use toward a premium for health insurance purchased through the state’s individual marketplace, Covered California. The measure also appeared to be headed for approval.

Finally, voters in the Golden State were asked whether to impose higher property taxes on commercial property owners with land and property holdings valued at $3 million or more, which could help provide new revenue earmarked for economically struggling cities and counties hit hard by COVID-19, as well as K-12 schools and community colleges. Community clinics, California nurses and Planned Parenthood jumped into the thorny political battle over Proposition 15 — taking on powerful business groups — eyeing revenue to help rebuild California’s underfunded public health system. The measure was too close to call in early returns.

Democrats in California, who control all statewide elected offices and hold a supermajority in the legislature, have been positioning for a Biden win, and some were already penning ambitious health care legislation for next year. Should Biden win, they said they plan to crack down on hospital consolidation and end surprise emergency room bills, and some were quietly discussing liberal initiatives such as pursuing a single-payer health care system and expanding Medicaid to cover more unauthorized immigrants.

JoNel Aleccia, Rachel Bluth, Angela Hart, Matt Volz and Samantha Young contributed to this story.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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How COVID Death Counts Become the Stuff of Conspiracy Theories

In the waning days of the campaign, President Donald Trump complained repeatedly about how the United States tracks the number of people who have died from COVID-19, claiming, “This country and its reporting systems are just not doing it right.”

He went on to blame those reporting systems for inflating the number of deaths, pointing a finger at medical professionals, who he said benefit financially.

All that feeds into the swirling political doubts that surround the pandemic, and raises questions about how deaths are reported and tallied.

We asked experts to explain how it’s done and to discuss whether the current figure — an estimated 231,000 deaths since the pandemic began — is in the ballpark.

Dismissing Conspiracy Theories, Profit Motives

Trump’s recent assertions have fueled conspiracy theories on Facebook and elsewhere that doctors and hospitals are fudging numbers to get paid more. They’ve also triggered anger from the medical community.

“The suggestion that doctors — in the midst of a public health crisis — are overcounting COVID-19 patients or lying to line their pockets is a malicious, outrageous, and completely misguided charge,” Dr. Susan R. Bailey, American Medical Association president, said in a press release.

Hospitals are paid for COVID treatment the same as for any other care, though generally, the more serious the problem, the more hospitals are paid. So, treating a ventilator patient — with COVID-19 or any other illness — would mean higher payment to a hospital than treating one who didn’t require a ventilator, reflecting the extra cost.

There is one financial difference. Medicare, the government health program for the elderly and disabled, pays 20% on top of its ordinary reimbursement for COVID patients — a result of the CARES Act, the federal stimulus bill that passed in the spring.

That additional payment applies only to Medicare patients.

Experts say there is simply no evidence that physicians or hospitals are labeling patients as having COVID-19 simply to collect that additional payment. Rick Pollack, president and CEO of the American Hospital Association, wrote an opinion piece in September addressing what he called the “myths” surrounding the add-on payments. While many hospitals are struggling financially, he wrote, they are not inflating the number of cases — and there are serious disincentives to do so.

“The COVID-19 code for Medicare claims is reserved for confirmed cases,” he wrote, and using it inappropriately can result in criminal penalties or a hospital being kicked out of the Medicare program.

Public health officials and others also pushed back.

Said Jeff Engel, senior adviser for COVID-19 at the Council of State and Territorial Epidemiologists: “Public health is charged with the duty to collect accurate, timely and complete data. We’re not incentivized to overcount or undercount for any political or funding reason.”

And what about medical examiners? Are they part of a concerted effort to overcount deaths to reap financial rewards?

“Medical examiners and coroners in the U.S. are not organized enough to have a conspiracy. There are 2,300 jurisdictions,” said Dr. Sally Aiken, president of the National Association of Medical Examiners. “That’s not happening.”

Still, there’s an ongoing debate about which mortalities should be considered COVID deaths.

Behind the Numbers

The Centers for Disease Control and Prevention, as well as nongovernmental organizations like the COVID Tracking Project and Johns Hopkins University, compile daily data on COVID deaths. Their statistics rely on state-generated data, which begins at the local level.

States have leeway to decide how to gather and report data. Many rely on death certificates, which list the cause of death, along with contributing factors. They are considered very accurate but can take one to two weeks to be finalized because of the processes involved in filling them out, reviewing and filing them. These reports generally lag behind testing and hospitalization data.

The other way deaths get reported is through what’s known as the case classification method, which reports deaths of people with previously identified cases of COVID, whether listed as confirmed or probable. Confirmed COVID deaths are affirmed by a positive test result. Probable COVID deaths are classified by using medical record evidence, suspected exposure or serology tests for COVID antibodies. The case classification method is faster than using death certificates and makes the data available in a more real-time fashion. Epidemiologists say this information can be helpful in gaining an understanding in the midst of an outbreak of how many people are dying and where.

Some experts point out that, while both methods have their virtues, each shows a different mortality count at a different time, so the best practice is to gather both sets of information.

The federal government, though, has offered conflicting guidance. The National Center for Health Statistics, an arm of the CDC, recommends primarily using death certificate data to count COVID deaths. But in April, the CDC asked jurisdictions to start tracking mortality based on probable and confirmed case classifications. Most states now gather data only one of the two ways, though a couple use both.

This patchwork approach does lead to conflicting data on total deaths.

Why Is the Count So Hard?

For the most part, public health researchers and medical examiners agree that COVID deaths are likely being undercounted.

“It’s very hard in a situation moving as rapidly as this one, and at such a large scale, to be able to count accurately,” said Sabrina McCormick, an associate professor in environmental and occupational health at George Washington University.

For one thing, the processes for certifying deaths vary widely, as does who fills out the death certificates. While physicians certify most death certificates, coroners, medical examiners and other local law enforcement officials can also do so.

Aiken, the medical examiner of Spokane County, Washington, said any time someone in her area dies at home and may have had COVID symptoms, the deceased person will automatically be tested for the disease.

But that doesn’t happen everywhere, she added, which means some who die at home could be omitted from the count.

It’s also unknown how accurate post-mortem COVID testing is, because there haven’t yet been any research studies on the practice — which could lead to missed cases.

Another wrinkle: Doctors in hospitals might not always be trained in the best practices for filling out death certificates, Aiken said.

“These folks are dealing with ERs and ICUs that are crowded. Death certificates are not their priority,” she said.

Emergency room doctors acknowledged the challenges, noting they don’t always have the resources that coroners and medical examiners do to perform autopsies.

“Much of the time, we don’t have an answer as to the final reason that a person died, so we are often stuck with the old cardiopulmonary arrest, which coroners and certifiers hate,” said Dr. Ryan Stanton, a Lexington, Kentucky, ER doctor and board member of the American College of Emergency Physicians.

That gets to how complex it is to determine what, exactly, caused a death — and what some say is a confusion between who died “with” COVID-19 (but may have had other underlying conditions that caused their death) and who died directly “of” COVID-19.

John Fudenberg, the former coroner for Clark County, Nevada, which surrounds Las Vegas, said including some of those who died with COVID-19 could result in an overcount.

“As a general rule, if someone dies with COVID, it’s going to be on the death certificate, but it doesn’t mean they died from COVID,” said Fudenberg, now executive director of the International Association of Coroners and Medical Examiners. For example, “if somebody has end-stage pancreatic cancer and COVID, did they die with COVID or from COVID?”

That question has proven controversial, and Trump has claimed that counting those who died “with COVID” has led to an inflation of the numbers. But most public health experts agree that if COVID-19 caused someone to die earlier than they normally would have, then it certainly contributed to their death. Additionally, those who certify death certificates say they list only contributing factors that are certain.

“Doctors don’t put things on death certificates that have nothing to do with the death,” said Dr. Amesh Adalja, senior scholar at the Johns Hopkins Center for Health Security.

COVID-19 can directly lead to death in someone with cancer or heart problems, even if those conditions were also serious or even expected to be fatal, he said.

And the claim that some states are counting people who die in car accidents, but also test positive for COVID-19, as COVID deaths is just plain unfounded, experts said.

“I can’t imagine a scenario where a medical examiner would test someone for COVID who died in a motor vehicle accident or a homicide,” said Engel, at the epidemiologists council. “I think that’s been greatly exaggerated on the internet.”

Excess Deaths

An additional approach to determining the pandemic’s scope has emerged, and many experts increasingly point to this measure as a useful indicator.

It relies on a concept known as “excess deaths,” which involves comparing the total number of deaths from all causes in a given period with the same period in previous years.

A CDC study estimated that almost 300,000 more people died in the U.S. this year from late January through Oct. 3 than in previous years. Some of those excess deaths were no doubt COVID cases, while others may have been people who avoided medical care because of the pandemic and then died from another cause.

These excess deaths are “the best evidence” that undercounting is ongoing, said Dr. Jeremy Faust, an ER doctor at Brigham and Women’s Hospital in Boston. “The timing of the excess deaths exactly parallels the COVID deaths, so when COVID deaths spike, all causes of deaths spike. They are hugging each other like parallel train tracks on a graph.”

Faust believes the majority of the excess deaths should be attributed in some way to COVID-19.

Even so, it’s unclear if we’ll ever get an accurate count.

Aiken said it is possible but could take years. “I think eventually, when this is said and done, we’ll have a pretty good count,” she said.

McCormick, of George Washington University, isn’t as sure, mostly because the number has become a flashpoint.

“It will always be a controversy, especially because it’s going to be so politically charged,” she said. “I don’t think we’ll come to a final number.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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¿Estás internado? Todavía puedes votar en gran parte del país

Johnathon Talamantes se rompió la cadera en un accidente de auto el 22 de octubre y se sometió a una cirugía cinco días después en un hospital público cerca del centro de Los Angeles.

Talamantes tendrá que estar en el hospital del condado de LA USC Medical Center hasta pasadas las elecciones, algo que le preocupaba antes de la cirugía.

“Una de las primeras cosas que le pregunté a mi enfermera esa mañana fue: ‘Oh, ¿cómo voy a votar?’”, contó Talamantes, de 30 años, el día antes de la operación.

Primero le pidió a su mamá que buscara la boleta electoral que había recibido tiempo antes, como todos los votantes registrados de California para esta elección.

Pero el personal de LAC + USC le dio otra opción: podían ayudarlo a obtener una boleta de emergencia y emitir su voto sin tener que levantarse de la cama. Entonces Talamantes le dijo a su mamá que no se molestara.

“No quiero que ella venga aquí, por las restricciones de COVID”, dijo.

La ley de California protege los derechos de los votantes que se encuentran en el hospital u otras instalaciones de atención, o confinados en sus hogares. Les permite obtener ayuda de cualquier persona que elijan, que no sea un empleador o un representante sindical, y emitir un voto de emergencia.

Al menos otros 37 estados permiten la votación de emergencia por razones médicas, según la Conferencia Nacional de Legislaturas Estatales. Pero las prácticas varían.

En algunos, solo los miembros de la familia pueden ayudar a los pacientes hospitalizados a votar desde el hospital.

En California, Nueva York y varios otros estados, los empleados y voluntarios del hospital pueden ayudar a un paciente a completar una solicitud de boleta de emergencia. Pueden recoger la boleta del paciente y enviarla a la oficina electoral o depositarla en un buzón oficial.

Por el contrario, en Carolina del Norte, que un trabajador de salud ayude a un paciente a votar es un delito.

En 18 estados, la ley permite que las juntas electorales locales envíen representantes directamente a las cabeceras de los pacientes, aunque seis de esos estados cancelaron ese servicio este otoño debido a la pandemia de COVID-19, dijo el doctor Kelly Wong, fundadora de Patient Voting, un organización no partidista dedicada a aumentar la participación entre los votantes registrados hospitalizados inesperadamente durante la época de las elecciones.

El sitio web del grupo tiene un mapa interactivo de los Estados Unidos con información estado por estado sobre la votación en el hospital. También permite a los pacientes verificar si están registrados para votar.

Wong, residente de la sala de emergencias del Hospital de Rhode Island en Providence, recordó que cuando era estudiante de medicina y trabajaba en una sala de emergencias, los pacientes que estaban a punto de ser ingresados ​​en el hospital le decían: “No puedo estar internado, tengo que cuidar a mi perro o atender a mi abuela”. Luego, durante las elecciones de 2016, escuchó: “No puedo quedarme. Tengo que ir a votar”.

“Eso realmente me llamó la atención”, dijo Wong. Investigó y descubrió que los pacientes podían votar en el hospital mediante una boleta de emergencia, algo que ninguno de sus compañeros de trabajo sabía. “Nuestros pacientes no saben esto. Debería ser nuestro trabajo decírselo”, dijo.

Algunos hospitales han estado ayudando a los pacientes a votar en las elecciones principales durante dos décadas o más, como parte de una tendencia en la industria de la atención médica hacia el compromiso cívico.

Las clínicas comunitarias registran a los votantes en sus salas de espera o en campañas de registro público. En un número cada vez mayor de salas de emergencia, los pacientes y sus familias tienen la oportunidad de registrarse. Muchos hospitales, incluido LAC + USC, tendrán unidades de votación móviles este año, abiertas a los miembros del personal, a los pacientes que están lo suficientemente bien para caminar y a sus familias.

Estos esfuerzos tienen como telón de fondo el papel protagónico de la atención médica en el acalorado drama político de la nación: COVID-19 se ha convertido en un tema principal de la campaña presidencial, mientras que la Corte Suprema de los Estados Unidos, más conservadora desde esta semana, se prepara para escuchar un caso, una semana después de las elecciones, que podría ser la sentencia de muerte para la Ley del Cuidado de Salud a Bajo Precio (ACA).

La pandemia ha hecho que la votación para los pacientes internados sea un desafío debido a las estrictas restricciones en los hospitales y a los muchos empleados que han sido despedidos, cesanteados o que trabajan desde la casa. Y un aumento significativo en la votación adelatanda y el uso de boletas por correo en muchos estados puede reducir la cantidad de pacientes que necesitan ayuda.

“La mayoría de nuestros pacientes, espero, ya habrán votado, porque eso aliviará el estrés; para ellos, es una cosa menos de qué preocuparse”, dijo Camille Camello, directora asociada de servicios de voluntariado en las casi 900 camas del Cedars-Sinai Medical Center en Los Angeles, que tiene un programa para ayudar a los pacientes hospitalizados a votar. Dijo que, en elecciones pasadas, más de 200 pacientes solicitaron boletas.

En LAC + USC, los administradores han intentado asegurarse de que los pacientes sepan que pueden obtener ayuda para votar. Hay carteles en los espacios comunes y el personal está repartiendo volantes con información sobre las votaciones a cada paciente que ingresa, dijo Gabriela Hernández, directora de servicios voluntarios del hospital.

Hernández dijo que ella y unos 25 voluntarios han estado visitando las distintas unidades durante el último mes, preguntando a los pacientes si quieren ayuda para votar.

Los pacientes que dicen que sí reciben solicitudes de boleta de emergencia, que el hospital ha estado enviando al área de registro de votos condado del condado de Los Ángeles para verificación. Las solicitudes de boleta seguirán estando disponibles para los pacientes hasta la mañana del día de las elecciones.

Hernández y su equipo recogerán las boletas y las distribuirán a los pacientes, luego las devolverán al registro antes de las 8 pm, fecha límite el día de las elecciones.

Otros hospitales tienen una agenda más apretada.

En St. Jude Medical Center en Fullerton, California, el personal del hospital está preguntando a los pacientes el lunes 2 de noviembre si quieren asistencia para votar y les traerán boletas el día de las elecciones, dijo Gian Santos, gerente de servicios voluntarios en el hospital. En las elecciones de 2016, solo unos siete u ocho pacientes votaron de esa manera, agregó Santos.

El Hospital St. Joseph en Orange, California, planea hacer todo -solicitudes y boletas- el mismo día de las elecciones.

Para los grandes hospitales, la votación de pacientes hospitalizados puede ser una tarea enorme. Las personas a menudo necesitan asistencia en varios idiomas y los hospitales suelen contratar servicios de traducción.

Muchos hospitales reciben pacientes de numerosos condados y de otros estados.

El Hospital Lenox Hill en Manhattan planea ayudar hasta a 200 pacientes de nueve condados en el estado de Nueva York y tres en Nueva Jersey, dijo Erin Smith, enfermera especializada en obstetricia que, junto con su colega Lisa Schavrien, está liderando el esfuerzo.

El hospital asignará uno o dos “corredores” a cada una de las 12 juntas electorales del condado, dijo Smith. Para ella, hacer que los pacientes vulnerables puedan ejercer su derecho al voto merece el esfuerzo.

“Si no los ayudamos, ¿cuántas miles de personas no van a votar en las elecciones porque sufrieron un accidente automovilístico, tuvieron apendicitis, o una cirugía cerebral inesperada?”, se preguntó Smith.

“Si no lo hacemos en el hospital, es como negarles el voto a los votantes”.

Esta historia de KHN fue publicada primero en California Healthline, un servicio de la California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘His Lies are Killing my Neighbors’: Swing-state Health Workers Try to Defeat Trump

Dr. Chris Kapsner intubated his first COVID-19 patient — a 47-year-old man who arrived short of breath at an emergency room in Minnesota’s Twin Cities — back in April.

Now, seven months later, Kapsner, who lives across the border in Wisconsin, is weary and exhausted from the steady stream of patients arriving with a virus that is spreading across this part of the Midwest. Hospital beds and personal protective equipment are in short supply, and his colleagues are getting sick. “Even if we put up all the field tents in the world, we don’t have the staff for this,” he said.

Kapsner believes political disfunction at the state level and a “disastrous” federal response are responsible for Wisconsin’s spike in cases. It’s part of the reason he’s running for office.

Kapsner is one of at least four health care workers running for Democratic seats in the Wisconsin state assembly, and one of many in his field speaking out against President Donald Trump and the GOP’s response to COVID-19.

Wisconsin is in the throes of one of the country’s worst COVID outbreaks. On Oct. 27, the state reported more than 5,000 new cases and a test positivity rate of over 27%. Nearly 2,000 people have died, and only the Dakotas are currently reporting more cases per capita.

Despite this, Trump has been holding large rallies across the state where crowds gather by the thousands, often without masks. Another Trump rally was planned for Monday evening in Kenosha, the site of unrest last summer after Jacob Blake was shot in the back by police. Wisconsin is a crucial swing state in Tuesday’s election; Trump carried the state by just 27,000 votes in 2016 and is currently trailing Joe Biden in the polls.

Last month, a group of 20 doctors sent an open letter to Trump asking him to stop holding rallies in the state. Thursday, the night before Trump was scheduled to appear in Green Bay, hospitals released a joint statement urging locals to avoid large crowds. Earlier in October, the Trump campaign scuttled plans for a rally in La Crosse, in western Wisconsin, after the city’s mayor asked him not to come amid a spike in cases there.

Dr. Kristin Lyerly, an OB-GYN in Appleton, in eastern Wisconsin, said she struggles to find the right words to describe her anger over the rallies, which have been linked to subsequent coronavirus outbreaks. On Oct. 24, at a rally in Waukesha, about 100 miles south of Appleton, Trump falsely accused health care workers of inflating the number of COVID cases for financial gain.

“His lies are killing my neighbors,” she said.

Lyerly, who is also running for state assembly, said she spends her days trying to reassure terrified pregnant patients, while fearing she might contract the virus herself. She and her colleagues are overwhelmed. She keeps her PPE in her car to ensure she never goes without it. “We’ve completely forgotten about the human impact on our health care workers. Our health care workers are exhausted, they’re burned out and they feel entirely disrespected,” she said.

Lyerly said she decided to run for office in April, after the Republican-controlled assembly refused to postpone a statewide election, in which the Democratic presidential primary and a key state Supreme Court seat were on the ballot. The state GOP also stymied efforts to make it easier for Wisconsinites to vote by mail.

“As a physician, I think many of us were shocked that our legislature would put us in danger, and make us decide between our vote and our health,” she said. She’s running in a district that typically leans conservative but said her campaign’s latest polls put her within the margin of error of her opponent, an incumbent.

Dr. Robert Freedland, an ophthalmologist in southwestern Wisconsin and state lead for the Committee to Protect Medicare, signed the letter asking Trump to stop holding rallies in Wisconsin. He wanted to go on the record as having spoken out in the name of public health.

Freedland, who is 65 and has Type 2 diabetes, said he fears for his health when he goes to work.

Dr. Jeff Kushner, a cardiologist who also signed the letter, said he hasn’t been able to work since March because of the pandemic. Kushner, 65, has non-Hodgkins lymphoma and is on immunosuppressants. “If I got COVID, I wouldn’t survive,” he said.

Though he follows politics closely, Kushner said that he’s not “politically involved” and that he tends to keep his politics to himself and a close inner circle. But he said he doesn’t consider signing the letter to Trump a political act. “It’s a statement of what I believe about our society’s health and not a political statement,” he said. “It wasn’t an anti-Trump letter. We were just saying, ‘Please don’t have these superspreader events in our state.’”

Kapsner, the emergency room doctor, said he still speaks with patients and voters who doubt the severity of COVID-19. “My job isn’t to shame them,” he said. “There are many people out here who have had the good fortune of not being personally affected by COVID. Their friends or families haven’t had it yet. I fear their luck is going to run out.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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California’s Progressive — and Expensive — Health Care Ambitions Rely on Biden Win

SACRAMENTO — For deep blue California, where first-in-the-nation health care proposals regularly flood the Democratic agenda, there could not be more at stake in the presidential race.

If Republican President Donald Trump prevails, Democratic state lawmakers worry, they’ll be forced to scale back their ambitious plans and play defense the next four years, battling Republican attempts to curtail federal Medicaid spending and further unravel the Affordable Care Act.

Should Democratic presidential nominee Joe Biden win, California Democrats — who control all statewide elected offices and hold a supermajority in the legislature — are poised to go big on health care, pushing aggressively for a health care system that covers all Californians, regardless of their immigration status or ability to pay.

“This election will determine whether California has a willing federal partner who can move us forward in the ways we want to see health care expanded,” said Assembly member David Chiu (D-San Francisco).

“It is incredibly unlikely that another four years of Trump will allow us to make significant strides toward universal health care, whereas a Biden-Harris administration would allow us to make real progress toward not just health care for all, but so much more.”

California Dems Counting on Biden Win

Behind the scenes, Democrats in California are positioning for a White House led by Biden and vice presidential nominee Kamala Harris — which they presume would be more supportive of California’s agenda — and some are already planning legislation for next year. Not only are they plotting ways to crack down on hospital consolidation and end surprise emergency room bills, but they are also quietly discussing a trio of liberal initiatives that could again push California to the forefront of health care policy. They include:

  • A new single-payer health care bill that would nix private insurance and create a taxpayer-funded health care system for all Californians. “Just expanding the Affordable Care Act is not nearly enough. We need to be willing to stand up to the drivers of health care costs rather than give Americans an insurance card that they can’t afford to use,” said Assembly member Ash Kalra (D-San Jose), who is considering introducing the measure. A legislative analysis in 2017 estimated that single-payer could cost California $400 billion a year.
  • A wealth tax that could generate $7.5 billion a year to help finance potential coverage expansions. Assembly member Rob Bonta (D-Alameda) said wealthier people should pay more to help finance health care, education and other services, especially for Californians hit hard by the pandemic. “Some people have been offended and think that punishes the doers and innovators, but our intent is to help the most vulnerable,” he said.
  • Expanding its Medicaid program for low-income residents, called Medi-Cal, to more unauthorized immigrants. California currently offers full Medi-Cal benefits to all qualified residents, regardless of immigration status, up to age 26. “To see Latinos in this state testing positive at disproportionate rates of COVID-19, it makes it clear that people are dying and suffering from lack of health coverage,” said state Sen. Maria Elena Durazo (D-Los Angeles), who plans to spearhead the proposal.

Democratic Gov. Gavin Newsom has argued that the future of health care, and California’s ability to combat COVID-19, is at stake this election.

Although Newsom has sought to play nice with Trump — partly because California relies on federal cooperation and federal money to respond to COVID-19 — the first-term governor strongly backs Biden.

“We can quite literally go backward with an administration that actively wants to get rid of health care for tens of millions of people with preexisting conditions,” Newsom said in September. But Biden, he said, will allow California to “accelerate our health care reforms and have a real partner that can advance those reforms to lower costs and improve quality, as well as expand access.”

The governor’s health care agenda includes far-reaching measures to expand access to care and set government-imposed limits on health care spending, possibly penalizing hospitals and doctors for failing to meet cost reduction targets. Though Newsom withdrew his biggest proposals earlier this year, citing a projected $54 billion state budget deficit, Health and Human Services Secretary Dr. Mark Ghaly said the administration is considering reintroducing proposals that died this year, including a new Office of Health Care Affordability.

But these plans could be jettisoned no matter who wins the election, warned Rose Kapolczynski, a California-based Democratic strategist. The state’s pandemic-crippled economy is likely to lead to more budget cuts, making it difficult to adopt new, expensive programs, she said.

“Everyone is going to be fighting for money, and it’s going to be hard to pass big-ticket expensive items like single-payer if California faces massive layoffs of state workers and cuts to health care programs that already exist,” she said.

A Trump Win Could Spur Health Care Innovation

While Democrats fear a rollback of health care funding and benefits should Trump win, his reelection could offer greater opportunity for Medicaid innovation in states, said Lanhee Chen, former adviser to 2012 Republican presidential nominee Mitt Romney and research fellow at Stanford University’s right-leaning Hoover Institution.

“States can be laboratories of innovation,” Chen said at an October presidential election forum at the UCLA Fielding School of Public Health.

In what is known as the waiver process, states can ask the federal government for permission to use federal dollars to offer services or pursue new approaches to health care that go beyond what Medicaid and Obamacare traditionally allow.

If reelected, Trump could help both red and blue states by giving them greater “freedom and flexibility” to undertake new programs, Chen said. The Trump administration has begun to embrace such experiments, including in Minnesota, where it approved a bipartisan effort to establish a reinsurance program that compensates insurers for taking on certain high-cost patients.

In Georgia, Republican Gov. Brian Kemp received permission from the administration to impose work requirements for Medicaid enrollees and require some to pay monthly premiums.

This process “is a way of both satisfying a conservative desire to enhance private marketplaces as well as a progressive desire to expand coverage,” Chen said.

Mark Peterson, a professor of public policy, political science and law at UCLA, is skeptical, saying the process has favored Republicans under Trump.

“The Trump administration has been trying to use Medicaid waivers to go in a more conservative direction, doing things such as allowing Medicaid work requirements,” he said.

The Newsom administration is seeking permission from the Trump administration to dramatically transform Medi-Cal to focus more on preventing enrollees from getting sick, and to invest in getting homeless people into housing and treatment. A COVID-spurred budget crisis forced Newsom to pause the $3.5 billion Medi-Cal overhaul earlier this year.

Newsom is also relying on federal cooperation to respond to COVID-19. The federal government, for example, allows California hospitals in hard-hit communities to relax minimum nursing staff levels.

To go as far as California wants on health care, “we do need the support and cooperation of the federal government — there’s no doubt,” Ghaly said in an interview with California Healthline.

But state Sen. Richard Pan (D-Sacramento) dismissed the idea that the Trump administration’s idea of innovation would help California Democrats, who are pursuing health policies Trump has attacked. “We’ve been hamstrung,” said Pan, who chairs the Senate Health Committee. “Trump has been president for four years and we haven’t seen it.”

The Affordable Care Act

One major issue doesn’t hinge on the presidential election but could nonetheless cast major doubt on Democrats’ big health care plans: the fate of the Affordable Care Act.

The U.S. Supreme Court will hear a case on Nov. 10 brought by Republican states, and backed by the Trump administration, that could invalidate Obamacare. California is leading the defense, and the state “stands to lose much of the historic gains it made,” said Melanie Fontes Rainer, a health care adviser to Attorney General Xavier Becerra.

Should the law be struck down, nearly 5 million Californians could lose health coverage, health insurance premiums could rise, and the state would likely have to make dramatic cuts to health and social safety net programs. Last year alone, the state received $25 billion to help fund its Affordable Care Act programs, according to Ben Johnson, a health care analyst at the nonpartisan Legislative Analyst’s Office.

California has also gone well beyond the requirements of Obamacare. It has expanded Medi-Cal to more people; imposed its own requirement to have insurance or pay a tax penalty after Congress eliminated the federal tax penalty; and offers state-financed premium subsidies for low- and middle-income Californians.

Yet state leaders have not identified a backup plan if Obamacare is struck down, and as they plot a far more aggressive agenda, they fear they would be forced to backtrack and struggle to protect what California has already done.

“We’ll be crippled and our gains would collapse,” Pan said. “We’d have to retrench entirely.”



This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Hospitalized? You Can Still Vote in Most Parts of the Country

Johnathon Talamantes, of South-Central Los Angeles, broke his hip in a car accident on Oct. 22 and underwent surgery five days later at a public hospital near downtown.

His post-op recovery will keep him in the hospital, L.A. County+USC Medical Center, beyond Election Day, and as he prepared himself for the surgery, he wondered what that would mean.

“One of the first things I asked my nurse this morning was, ‘Oh, how am I going to vote?’” Talamantes, 30, said from his hospital bed the day before the operation.

He initially thought of asking his mom to rummage through a pile of papers at the home he shares with her and bring him the mail-in ballot that he, like all registered California voters, received for this election.

But then staffers at LAC+USC told him about another option: They could help him get an emergency ballot and cast his vote without having to get out of bed. So Talamantes told his mom not to bother.

“I don’t want her coming down here, because of the COVID restrictions,” he said.

California law protects the rights of voters who are in the hospital or other care facilities, or confined at home. It allows them to get help from anyone they choose — other than an employer or a union representative — and to cast an emergency ballot.

At least 37 other states allow emergency voting for medical reasons, according to the National Conference of State Legislatures. But practices vary.

In some states, only family members can assist hospitalized patients with voting from the hospital.

In California, New York and several other states, hospital employees and volunteers can help a patient complete an emergency ballot application. They can pick up the ballot for the patient and deliver the finished ballot back to the election office or deposit it in an official drop box.

In North Carolina, by contrast, it is a felony for a health care worker to assist a patient with voting.

In 18 states, the law allows local election boards to send representatives directly to patients’ bedsides, though six of those states have canceled that service this fall because of the COVID-19 pandemic, said Dr. Kelly Wong, founder of Patient Voting, a nonpartisan organization dedicated to increasing turnout among registered voters unexpectedly hospitalized around election time.

The group’s website features an interactive map of the United States with state-by-state information on voting while in the hospital. It also allows patients to check whether they are registered to vote.

Wong, an emergency room resident at Rhode Island Hospital in Providence, recalled that when she was a medical student working in an ER, patients who were about to be admitted to the hospital would tell her, “‘I can’t be admitted; I have let the dogs out, or I’m the sole caretaker of my grandmother.’” Then during the election of 2016, she heard, “‘I can’t stay. I have to go vote.’”

“That really caught my attention,” Wong said. She did research and learned patients could vote in the hospital using an emergency ballot — something none of her co-workers knew. “Our patients don’t know this, she said. “It should be our job to tell them.”

Some U.S. hospitals have been assisting patients with voting in major elections for two decades or more, part of a broader tendency in the health care industry toward civic engagement.

Community clinics register voters in their waiting rooms or at public registration drives. In an increasing number of ERs, patients and their families are offered the chance to register. Many hospitals, including LAC+USC, this year will have mobile voting units on-site, open to staff members, patients who are well enough to walk, and their families.

These efforts come against the backdrop of health care’s starring role in the nation’s heated political drama: COVID-19 has become a top presidential campaign issue, while the U.S. Supreme Court, its conservative majority fortified this week, prepares to hear a case — one week after the election — that could be the death knell for the Affordable Care Act.

The pandemic has made inpatient voting a challenge because of tight restrictions at hospitals and the many employees furloughed, laid off or working at home. And a significant increase in early voting and the use of mail-in ballots in many states may reduce the number of patients who need help.

“The majority of our patients, I am hoping, will have voted already, because that will alleviate the stress — for them, it’s one less thing to worry about,” said Camille Camello, associate director of volunteer services at the nearly 900-bed Cedars-Sinai Medical Center in Los Angeles, which has a program to help inpatients vote. In past elections, she said, over 200 patients have requested ballots.

At LAC+USC, administrators have been trying to ensure patients know they can get help voting. Posters line the walls of common spaces and staffers are handing out flyers with voting information to every patient who is admitted, said Gabriela Hernandez, the hospital’s director of volunteer services.

Hernandez said she and about 25 volunteers have been walking the halls in the inpatient units of the hospital for the past month, asking patients if they want help voting.

Patients who say yes get emergency ballot applications, which the hospital has been sending to the L.A. County Registrar-Recorder for verification. The ballot applications will continue to be made available to patients up to the morning of Election Day.

Hernandez and her team will collect the ballots and distribute them to patients, then return them to the registrar before the 8 p.m. deadline on Election Day.

Other hospitals have a more collapsed timeline.

At St. Jude Medical Center in Fullerton, California, hospital staffers will start asking patients Monday if they want voting assistance and bring them ballots on Election Day, said Gian Santos, manager of volunteer services at the hospital. In the 2016 election, only about seven or eight patients voted that way, Santos said.

St. Joseph Hospital in Orange, California, plans to do everything — applications and ballots — on Election Day.

For big hospitals, inpatient voting can be a massive undertaking. People often require assistance in multiple languages, and the hospitals frequently contract with translation services to accommodate them.

Many hospitals receive patients from numerous counties — and across state lines.

Lenox Hill Hospital in Manhattan plans to assist as many as 200 patients from nine counties in New York state and three in New Jersey, said Erin Smith, an obstetrical nurse navigator who, along with fellow OB nurse navigator Lisa Schavrien, is leading the effort.

The hospital will assign one or two “runners” to each of the 12 county election boards, Smith said. For her, enabling vulnerable patients to exercise their right to vote is worth the effort.

“If we’re not helping them do it, how many thousands of people are not voting in elections because they were in a car accident, because they had appendicitis, because they had unexpected brain surgery?” Smith asked.

“If we’re not making it happen in the hospital, it kind of feels to me like voter suppression.”



This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘It’s Science, Stupid’: A School Subject Emerges as a Hot-Button Political Issue

At the top of Dr. Hiral Tipirneni’s to-do list if she wins her congressional race: work with other elected officials to encourage mask mandates and to beef up COVID-19 testing and contact tracing. Those choices are backed up by science, said Tipirneni, an emergency room physician running for Arizona’s 6th Congressional District.

On the campaign trail, she has called on her opponent, Rep. David Schweikert (R-Ariz.), to denounce President Donald Trump’s gathering of thousands for a rally in Arizona and his comments about slowing down COVID-19 testing.

“I believe in data; I believe in facts,” Tipirneni told KHN. “I believe in science guiding us … whether it’s the opioid crisis or tax policy or immigration reform. Those decisions could be and should be driven by the data. Science is not partisan.”

Tipirneni is one of four Democratic physicians running as challengers for Congress in 2020, all in closely watched races mostly rated as toss-ups. And it’s not just doctors. The group 3.14 Action (named for the value of pi) is working to help elect more scientists to office, promoting on its website candidates such as Mark Kelly, an engineer and former astronaut, who is seeking a Senate seat in Arizona, and Nancy Goroff, who has a doctorate in chemistry and is running for Congress in New York. Science is an integral part of their policy platforms, with an emphasis on the coronavirus pandemic.

These candidates hope to become part of an expanding pro-science caucus that includes three Democratic physician incumbents facing election challenges.

The candidates present themselves as foils to Trump and other Republicans who they say have dismissed scientific evidence and public health recommendations to battle the pandemic. Although climate change has propelled some people with science backgrounds into politics in recent years, the coronavirus crisis has galvanized the movement in this election cycle.

Still, political scientists and pollsters said that while Democrats’ use of “pro-science” messaging in their campaigns could help them get elected, it also may ultimately lead to increased polarization.

“We’ve sometimes seen a modest difference in political parties when it comes to scientists generally, but it’s gotten a little bit bigger,” said Cary Funk, director of science and society research at the Pew Research Center.

Conservatives deny that they ignore science or downplay its significance. They say that, instead, Democrats often take positions that stifle scientific innovation by increasing taxes and regulation, citing research and development in the pharmaceutical field as an example.

“Democrats calling themselves the party of science sounds a bit like Trumpian self-flattery,” wrote Doug Badger, a visiting fellow in domestic policy studies at the Heritage Foundation, in an email. He doesn’t think Republicans and Democrats approach science differently since most research is conducted far from the political sphere.

This year, several Republican doctors are running for the first time for Congress, including Dr. Leo Valentín in Florida, Dr. Ronny Jackson, previously Trump’s White House physician, in Texas. Dr. Roger Marshall, a current member of the House, is facing Democratic physician Dr. Barbara Bollier in the race for Kansas’ open Senate seat. A cadre of Republican doctors already serve in Congress, with 11 in the House and three in the Senate.

Rep. Phil Roe (R-Tenn.), a physician who is a co-chair of the House GOP Doctors Caucus, said that sharing medical backgrounds has brought him together with Democratic doctors and other health professionals to work on health policy.

But new political action committees — for instance, Doctors in Politics — have cropped up with the goal of running up the score on the left.

Doctors in Politics was formed this year by a group of physicians who were frustrated by what they viewed as a failed federal response to COVID-19. The group’s aim is to elect 50 Democratic or independent doctors to political office by 2022, said Dr. Dona Murphey, one of the group’s founders and a neurologist. But for now, they’re focused on 2020.

According to David Lazer, a professor of political science and computer science at Northeastern University in Boston and one of the leaders of a COVID-19 polling consortium, their timing might be right.

“My intuition is that this is a good year to be running as a doctor or scientist,” he said, pointing to a September survey from the consortium that showed trust in doctors and scientists is higher than trust in any other American institution or political entity.

Much of that may be traced to COVID-19. But, as the science surrounding the disease has been on nearly everyone’s mind, differing attitudes among the American electorate are likely to play out at the polls.

“The growing political divide around coronavirus is also seen in terms of trust in medical scientists,” Funk said.

Funk pointed to a May report by the Pew Research Center that showed overall public trust increased in medical scientists since 2019, but that increase is attributed to a growing trust among Democrats. Republicans’ trust in scientists stayed about the same from 2019 through the first few months of the pandemic. A more recent survey from Pew showed that those on the political right are often less trusting of scientists than are those on the left.

Trump’s rhetoric around science may be contributing to the split. During the pandemic, the president has dismissed public health advice from experts, touted unproven coronavirus treatments and questioned the efficacy of masks.

“The Trump administration has systematically done everything it could to downplay, dismiss or deny science,” said Michael Gerrard, an environmental lawyer and professor at Columbia University. “This is most prominent with climate change and now with the coronavirus, but it’s all across the board.” Gerrard has tracked more than 300 situations in which he found scientific initiatives to be restricted or questioned by federal officials since 2016, 19 of them COVID-related.

Such frustration during the course of this election cycle has become palpable, with organizations that don’t normally step into the political fray doing so.

The presidents of the National Academy of Sciences and National Academy of Medicine, for instance, released a joint statement Sept. 24 expressing alarm over what they considered to be political interference in the response to COVID-19 by the president.

And a multitude of scientific publications have spoken out. Scientific American formally endorsed the Democratic presidential candidate, former Vice President Joe Biden — its first time making such a political pick in its 175-year history. The journal Nature has also endorsed Biden. The New England Journal of Medicine published a scathing critique — “Dying in a Leadership Vacuum” — of the federal government’s pandemic response. Although it was not a formal endorsement of any candidate, the editorial said, “Our current political leaders have demonstrated that they are dangerously incompetent.”

Such picking sides has led to another phenomenon, said Dominik Stecuła, an assistant professor of political science at Colorado State University.

“You’ll see yard signs that say ‘Science is real’ and with other messages clearly aligning scientists with a group on the political spectrum,” he said. But Stecuła said pro-science messaging by Democrats could lead to deeper fissures in public opinion.

“From a scientist’s point of view, it hurts the goals that you’re trying to achieve,” he said, “because what ends up happening is that, increasingly, Republicans treat scientists as an out-party group, a constituency of the Democrats.”

Others offer a different take.

“I really reject that premise,” said Rep. Lauren Underwood (D-Ill.), a registered nurse who flipped her district to Democratic when she was elected in 2018 on a pro-science platform. She’s running for reelection this year. “I just don’t think that’s true. The American people may be uncomfortable with some findings and recommendations, but this is a core value set in our community.”

“We learn science in every grade, in every level of education,” she said. “There may be some partisan differences in how we take partisan findings, but I think it’s dangerous if we start to presume that science is polarizing.”

She also thinks her background as a health professional helps her in Congress to work across the aisle. For instance, she worked with Rep. Roe last spring to introduce legislation on protecting the medical supply chain.

Roe also dismissed the idea that science — especially regarding the pandemic and the development of a COVID-19 vaccine — is further polarizing the electorate. In his view, it’s less about science and more about the race for the White House.

“Of course it’s been politicized, it’s a political year,” said Roe. “If we hadn’t had an election, I think it would look different.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN on the Air This Week

KHN chief Washington correspondent Julie Rovner discussed the current surge in COVID-19 cases, health policy in the election and the Affordable Care Act case before the Supreme Court with NPR’s “All Things Considered” on Sunday and WBUR’s “On Point.”

Columnist and California Healthline senior correspondent Bernard Wolfson discussed the possible impact of Judge Amy Coney Barrett and the Supreme Court on the ACA with KPCC’s “Take Two” on Tuesday.

KHN senior Colorado correspondent Markian Hawryluk discussed how health care may shape the U.S. Senate race in Colorado with Colorado Public Radio’s “Colorado Matters” on Thursday.

KHN senior correspondent Sarah Jane Tribble discussed KHN’s “Where It Hurts” podcast and COVID-19 in rural America with NPR’s “Weekend Edition” on Oct. 17. 

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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If They Sweep on Election Day, Dems Still Face a Challenge Meeting Health Promises

Democrats are favored to win both chambers of Congress after years of campaign-trail promises about health care. But with a pandemic, a more conservative Supreme Court and lingering disagreements between progressives and moderates, it could be difficult for Democrats to turn those promises into law.

In the final days of the campaign, COVID-19 and the threat posed to the Affordable Care Act and Roe v. Wade by the court’s bolstered conservative majority are consuming congressional Democrats — right down to keeping them in Washington well after they would usually go home to campaign.

Even if they capture the Senate in this election, Democrats are not expected to win a decisive enough majority to pass bills without some support from the GOP. The Senate’s filibuster rules could force Democrats to stick to legislation that can attract 60 votes — if they do not move to eliminate that requirement, as some are advocating.

Frederick Isasi, executive director of Families USA, a health consumer-focused organization that supported passage of the ACA more than a decade ago, said a slim margin could make it “exponentially more difficult” to pass major health care legislation.

Although progressives are pushing for more dramatic changes, Isasi said Democrats would have to consider, in particular, which measures their senators who won close races in more conservative states could support.

“There’s going to be a lot of focus on making sure that they can support this because the vote will be so tight,” he said.

Democrats argue that consumers’ concerns about health care, which led them to secure a House majority two years ago, will drive them to White House and Senate victories this fall. It has been 10 years since Democrats controlled both chambers of Congress and the White House. One week before the election, the political modeling website FiveThirtyEight gave former Vice President Joe Biden and Democrats an 87-in-100 chance of winning the presidency; a 73-in-100 chance of winning the Senate; and a 96-in-100 chance of holding the House.

A recent poll from KFF shows voters preferred Biden’s approach to health care over President Donald Trump’s on every key issue, including handling the pandemic. (KHN is an editorially independent program of KFF.)

Democrats set high expectations early in the presidential campaign, with progressive candidates during the primaries arguing over sweeping proposals for government-funded insurance before Biden won the nomination. He championed a more incremental approach of giving consumers an option to purchase a public insurance plan, which would also be free for some based on need. That plan is now part of the party platform.

But the pandemic, and the Trump administration’s decision to largely leave states to manage the health and economic repercussions, has changed the subject. On many popular issues like insuring more Americans and ending the practice of surprise medical billing, Democrats look no closer to agreement than they were months ago — even as the pandemic has made problems worse, with nearly 27 million people losing their employer-sponsored insurance in its first two months.

Sen. Patty Murray of Washington, expected to take over the Senate’s health committee if Democrats win, called health care affordability “a top priority for Democrats.”

“The bottom line for me is that everyone in this country should be able to get the health care they need without worrying about the cost — and I think this pandemic and economic crisis have underscored how important that is,” Murray said in a statement.

But the disagreements that pitted Biden against progressives like Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.) during the primaries remain, with the party’s more liberal voices pushing for dramatic reforms to drive corporations out of the health care system. And in the halls of Congress, Democrats from traditionally “red” states may find fixing the ACA an easier sell than a government-funded public insurance option.

There is a lot of “ideological diversity” among Democrats, said Rodney Whitlock, a health care consultant who spent years working as a Republican Senate aide. Although Democrats like to refer to themselves as an inclusive, “big tent party,” he said in a recent podcast that such diversity can make it harder to agree and get much done, even if the party is in the majority.

Observers warn the party’s calculations could change if Democrats move to eliminate the Senate filibuster, removing one of the minority party’s most effective means of opposition.

If Democrats win control of Congress and the White House, there would be “incredible support among Democrats” to eliminate the filibuster to achieve their goals, especially on health care, said Robert Blendon, a professor of health policy and public opinion at Harvard University who has a new article on the election in the New England Journal of Medicine.

Democrats will effectively have a year to advance their agenda before the next election, he said, and liberal voters, who make up about 50% of Democratic voters, are angry about how Republicans have managed power and eager to embrace universal health coverage.

Their argument boils down to this: “This is our chance in history, and we’re not going to do it because we can’t get three votes” in the Senate, Blendon said.

“Policies that currently would have no chance in the Senate could come into play in 2021 if the legislative filibuster is removed,” Whitlock recently wrote. If that happens, he added, the health care industry would need to reevaluate proposals “that would have once seemed highly theoretical and unlikely.”

Without the power to set the agenda or the numbers to pass their proposals, congressional Democrats have spent the Trump presidency telling Americans — in heartbreaking public testimony, impassioned floor speeches and reams of stalled legislation — that they are the party to trust with health care.

These days, Democrats are quick to mention the need to shore up the Affordable Care Act, which Republican attorneys general and the Trump administration are seeking to overturn through a case the Supreme Court will hear Nov. 10.

Though even conservative scholars say Republican arguments in the case are weak, Democrats worry the death of Justice Ruth Bader Ginsburg and the confirmation of Justice Amy Coney Barrett could endanger the law.

If the ACA is overturned, other legislative priorities likely would fall by the wayside as lawmakers address the potential elimination of coverage and consumer protections affecting millions of Americans.

While in the minority, Democrats have proposed numerous ideas to strengthen the ACA, leaving some measures on the table for Democratic leaders to revisit when in power.

In June, the Democratic-controlled House passed legislation aimed at increasing coverage and affordability, including by capping insurance costs at no more than 8.5% of income. The bill would grant Medicare the authority to negotiate drug prices — drawing from a proposal crafted by House Speaker Nancy Pelosi and House Democratic leaders in 2019 and included in Biden’s platform.

That proposal initially ran afoul of progressives, though, who argued they had been cut out of writing the bill and that it was not aggressive enough.

Democrats also have failed to reach a consensus on banning surprise medical billing, which generally occurs when patients receive care unknowingly from a doctor or provider who is not in their insurance network. House Democrats disagreed earlier this year on proposals to solve the problem. A bipartisan proposal in the Senate also stalled, and efforts to ban surprise billing during COVID-19 proved ineffective.

In the meantime, as Democratic candidates talk up ideas like the public option to energize voters as voting draws to a close, Democratic leaders are making less specific promises.

“For the last four years, Donald Trump and Republicans have sabotaged the Affordable Care Act in the hopes of causing our health care system to collapse,” Sen. Chuck Schumer of New York, the Democratic minority leader, said in a statement. “If we Democrats win back the White House and the majority in the Senate, we will strengthen and improve our health care system to make it cheaper and easier for everyday Americans to get the care and coverage they need.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Democrats Link GOP Challengers to Trump’s COVID Record, Efforts to Undo Obamacare

In a tweet to his 78,000 followers Sunday, U.S. Rep. Harley Rouda, a Democrat from Orange County, California, described his Republican opponent Michelle Steel’s attendance at an indoor fundraiser without a mask as “sickening.”

Democratic U.S. Rep. Gil Cisneros also blasted his Republican opponent, Young Kim, on Twitter for attending the “superspreader fundraiser,” calling it a “slap in the face to frontline workers” and his constituents in southern Los Angeles County and northern Orange County.

After President Trump’s superspreader event in Orange County last week, @YoungKimCA decided to host her own. The superspreader fundraiser—a crowded, indoor event with no social distancing/no masks—goes against CDC guidelines. It’s a slap in the face to frontline workers & #CA39. pic.twitter.com/1z2wd5Ohj4

— Gil Cisneros (@GilCisnerosCA) October 26, 2020

Earlier in the month, another Democrat, U.S. Rep. TJ Cox of Bakersfield, told a television debate audience that his GOP challenger, David Valadao, “is in lockstep with Donald Trump” and that Valadao aims to undo federal health protections.

These charges by incumbent lawmakers — who represent vast areas of California, from its inland farmlands to its coastal mansions and urban working-class neighborhoods — reflect a disciplined and widely used strategy Democratic congressional hopefuls are deploying across California and the nation: By associating their Republican opponents with the out-of-control coronavirus pandemic and threats to the Affordable Care Act, they hope to convince voters the Democratic Party is the one that can better protect Americans’ health.

In doing so, they are linking their challengers to President Donald Trump, who is deeply unpopular in the Golden State, with just 32% of likely voters approving of the way he is handling his job, according to a recent Public Policy Institute of California survey.

“Democrats have been able to tie the national conversation around the coronavirus pandemic with health care and with the economy and social unrest,” said David McCuan, a political science professor at California State University-Sonoma. “That allows Democrats to turn or hold individual districts.”

But the strategy isn’t a slam-dunk for Democrats, especially in the districts they flipped in 2018 — including seven in California. Despite the changing demographics in the once Republican strongholds of Orange County and the Central Valley, McCuan and other political analysts said Republican victories are possible if even a small number of residents who voted Democratic in 2018 swung back to the GOP.

Republicans have already taken back one of those seats. U.S. Rep. Mike Garcia (R-Santa Clarita) beat Christy Smith in a May special election — 55% to 45% — to fill the vacancy left after Katie Hill resigned from Congress amid allegations of inappropriate relationships with staff members. Voters in the district that includes Santa Clarita and Simi Valley will pick between the same two candidates in Tuesday’s election.

In these competitive districts, political analysts say the winner will come down to voter turnout and Trump’s approval ratings, which is now inextricably tied to his handling of the public health crisis. Nationwide, 26 congressional seats are ranked as toss-ups, according to the Cook Political Report, which tracks races.

“A lot of it’s about the president,” said Wesley Hussey, a political science professor at California State University-Sacramento. “And part of the component of the presidential election is health care, and that does trickle down to congressional races.”

Calls to the state Republican Party and the National Republican Congressional Committee were not returned. And none of the Republican challengers to the Democrats interviewed for this story responded to repeated interview requests.

In California’s southern Central Valley congressional district currently held by Cox, political analysts predict another nail-biter. Cox ousted Valadao from Congress in the last election by just 862 votes, in part by tying the three-term incumbent to Trump and criticizing Valadao’s votes to overturn the Affordable Care Act.

Now, Cox has added Trump’s handling of the pandemic as a reason for voters to reject Valadao again.

“He is in lockstep with Donald Trump,” Cox charged in a televised debate Oct. 20. “And I don’t know how you can stand behind a guy that’s saying, ‘Hey, we did a fantastic job and 200,000 Americans have died so far.’”

In the recent poll by the Public Policy Institute of California, California voters rated COVID-19 as the state’s top concern.

The tweets that Cisneros and Rouda penned Sunday, which included photos of their opponents at a fundraiser without masks, capitalize on that concern. Rouda, for example, reminded voters that his opponent, as the head of the Orange County Board of Supervisors, publicly questioned the local public health officer’s springtime recommendation that residents wear masks.

“Michelle Steel is Orange County’s top official and she violated public health orders to attend an indoor, maskless fundraiser just to receive a check,” Rouda told California Healthline on Monday. “The example she is setting shows that she lacks the leadership needed for her current position and the position she’s running for.”

Steel spokesperson Lance Trover accused Rouda of politicizing the pandemic, saying Steel has helped secure personal protective equipment for front-line workers, and food assistance and testing for the county’s most vulnerable residents.

Steel has publicly criticized Democratic Gov. Gavin Newsom for opening California’s economy too slowly, and her campaign has shared photos of Rouda socializing on a beach and in a restaurant without a mask. (Rouda said the only other people in the beach photo were close family members, and that the restaurant photo was taken before the pandemic.)

“Harley Rouda is a hypocrite who has spent the entire summer seeking to politicize the work of Orange County in battling the coronavirus,” Trover said.

While wearing a mask may resonate in California’s swing districts, there remain solidly red areas of California where defying a government mandate can score a candidate political points. U.S. Rep. Tom McClintock, a Republican who represents a sprawling conservative district spanning multiple northern and central counties, has called masks useless, balked at wearing one at a congressional hearing and asserted that state lockdowns have led to increased deaths.

So in addition to focusing on McClintock’s COVID response, his opponent, Brynne Kennedy, a first-time candidate and small-business owner, is targeting another health issue: his opposition to the ACA.

In her travels throughout the mostly rural district, Kennedy is highlighting his votes — 66 by her count — to weaken or overturn the Affordable Care Act.

“This is radically out of step with where our district is,” said Kennedy, whom political analysts describe as a long-shot candidate. “Talking about that to people, that’s very concerning to them, and it’s absolutely on the ballot this year.”

Kennedy’s focus on protecting the federal health care law, particularly preserving access to insurance for people with preexisting medical conditions, mirrors the messaging of her fellow Democrats.

And it’s putting a lot of Republicans on the defense, especially with Trump on the campaign trail advocating for the repeal of the Affordable Care Act, said GOP political consultant Rob Stutzman.

“Republicans are making a point of telling voters that they will support protecting preexisting conditions,” Stutzman said. “It’s clearly a vulnerability.”

U.S. Rep. Josh Harder (D-Modesto) has been talking about preexisting conditions since he first campaigned for his seat two years ago, referencing his brother’s health issues as a young child. He believes health care is once again the single-biggest issue in his race.

But Harder has recrafted his pitch from 2018, when he talked about backing “Medicare for All,” a position now seen as a vulnerability in swing districts where Republicans have labeled their opponents as liberal or socialist.

Now, Harder and other Democrats are talking about shoring up the ACA and creating a “public option” that would allow every American to enroll in a government-sponsored plan.

Harder said he is asking voters to reelect him to ensure Congress has the votes to protect the federal health care law if the Supreme Court invalidates it.

“We need to make sure that people understand that the stakes couldn’t be higher,” he said. “The only way that we get a legislative solution that prioritizes people with asthma, cancer and other preexisting conditions is if we elect Democrats to the House, to the Senate and the presidency.”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What the Health?’: As Cases Spike, White House Declares Pandemic Over

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White House chief of staff Mark Meadows said this week that “we’re not going to control the pandemic,” effectively conceding that the administration has pivoted from prevention to treatment. But COVID-19 cases are rising rapidly in most of the nation, and the issue is playing large in the presidential campaign. President Donald Trump is complaining about the constant news reports about the virus, prompting former President Barack Obama to say Trump is “jealous of COVID’s media coverage.”

Meanwhile, as the case challenging the constitutionality of the Affordable Care Act heads to the Supreme Court on Nov. 10, open enrollment for individual health insurance under the law begins Sunday.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Tami Luhby of CNN and Anna Edney of Bloomberg News.

Among the takeaways from this week’s podcast:

  • Whichever candidate wins the presidency next week will have a heavy lift in mounting a strong public response to battle COVID-19. Polls suggest about a third of people do not believe some of the basic science about the virus or its prevention, such as that using masks can help stem transmission.
  • Dr. Scott Gottlieb, who once served as Food and Drug Administration commissioner under Trump, called for a temporary national mask mandate in his column in The Wall Street Journal. He suggested that masks should not be a political issue.
  • Gottlieb’s column has been supported by other commentators who suggest that masks need to become a social and cultural norm and compare the debate over their use to similar debates in the past about seat belts, smoking bans and harsh punishments for driving while intoxicated. Those measures all faced opposition from people who complained about civil liberties but gradually became accepted. The difference now is that public health advocates are looking for a quick acceptance of masks.
  • Part of the resistance to wearing face masks is that many people don’t understand their purpose and presume masks are for their own protection. But public health officials advocate masks as a way to protect others, especially vulnerable people, from any virus a mask wearer might shed, often without even realizing it.
  • Drugmakers and health experts are rolling back expectations about the timing of a COVID vaccine as the trials seek more data. One issue may be that not enough people in the placebo groups have contracted the coronavirus. That could be because people who volunteer for such an endeavor may be more aware of health issues and cautious about the disease.
  • Once a vaccine is approved, FDA and other federal health officials will face a number of complicating issues. Among them: How should trials of other vaccine candidates continue and how should the vaccine be distributed?
  • Enrollment for insurance plans on the Affordable Care Act’s marketplaces begins Sunday, but many consumers could be forgiven for not knowing that. There is precious little marketing or advertising for the plans, and some people think the Supreme Court is going to overturn the ACA, anyway, and its plans will go away. That’s not known yet and it may well be summer 2021 before there is an answer on that.

Also this week, Rovner interviews KHN’s Anna Almendrala, who reported the latest NPR-KHN “Bill of the Month” installment, about a patient who did everything right and got a big bill anyway. If you have an outrageous medical bill you would like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The New York Times’ “A Chance to Expand Medicaid Rallies Democrats in Crucial North Carolina,” by Abby Goodnough

Joanne Kenen: The New Yorker’s “A President Looks Back on His Toughest Fight,” by Barack Obama

Tami Luhby: KHN’s “Florida Fails to Attract Bidders for Canada Drug Importation Program,” by Phil Galewitz

Anna Edney: The Wall Street Journal’s “Health Agency Halts Coronavirus Ad Campaign, Leaving Santa Claus in the Cold,” by Julie Wernau, James V. Grimaldi and Stephanie Armour

To hear all our podcasts, click here.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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A $10,000 Obamacare Penalty? Doubtful.

“Because our family couldn’t afford health insurance, Obama/Biden penalized us about $10,000, then took that $10,000 and used it to pay for others’ free Obamacare. Trump ended that theft.”

In a Facebook post, Oct. 20, 2020

A viral Facebook post claims that former President Barack Obama’s health insurance law penalized a family a large amount of money for not buying health insurance and that President Donald Trump was responsible for stopping the practice.


This story was produced in partnership with PolitiFact. It can be republished for free.

The post features writing on the back of a car windshield that says, “Because our family couldn’t afford health insurance, Obama/Biden penalized us about $10,000, then took that $10,000 and used it to pay for others’ free Obamacare. Trump ended that theft.”

The post was flagged as part of Facebook’s efforts to combat false news and misinformation on its News Feed. (Read more about  PolitiFact’s partnership with Facebook.) We found a similar post on Instagram.

The post appears to refer to the individual mandate penalty, a tax under the Affordable Care Act placed on those who chose not to get health insurance. At the end of 2017, Republican-backed tax legislation, also supported by Trump, zeroed out the fine. Beginning in 2019, people could no longer be penalized for not having health insurance. Thus, the mandate hasn’t been in effect for about two years.

But $10,000 — the hefty amount this family was supposedly penalized for not having health insurance — raised questions for us. And was that money really used to pay for other people’s health insurance? We decided to look into it.

The History of the Individual Mandate

The ACA was implemented in 2010 during the Obama administration. The aim of the health care law — often referred to as Obamacare — was to ensure everyone had health insurance.

To that end, the law used what health policy experts call a “carrot-and-stick” approach. For low-income and middle-income individuals who had difficulty affording health insurance, the government would provide tax subsidies to reduce the cost of insurance — that was the carrot. And to make sure everyone enrolled in a health insurance plan, those who didn’t sign up were fined, under what was known as the individual mandate provision. That was the stick.

The individual mandate, which didn’t kick in until 2014, was unpopular with the American public, according to polling at the time. A 2017 KFF poll showed that 55% of Americans supported the idea of eliminating the requirement that everyone must have health insurance or pay a fine. (KHN is an editorially independent program of KFF.)

Although one of Trump’s key campaign promises was to repeal and replace the ACA, efforts to do so failed in 2017 when the Republican-held Senate failed to get the votes it needed.

Instead, in their 2017 tax bill, Republicans set the penalty for the individual mandate to $0. Starting in 2019, Americans no longer had to pay a fine for not having health insurance. Trump signed the 2017 tax bill into law. So, it is true that Trump and congressional Republicans were responsible for neutralizing the penalty.

However, experts pointed out that the individual mandate is still in place, it’s just that the penalty is set to $0. In fact, the end of the penalty is behind the justification for a court case attempting to overturn the ACA, brought by Republican attorneys general and supported by the Trump administration. The plaintiffs argue that the health care law is no longer constitutional because the penalty no longer “produces at least some revenue” for the federal government. The Supreme Court will hear oral arguments on the case Nov. 10.

The Math

The viral social media posts claim that the family “couldn’t afford health insurance” and was penalized $10,000.

Health policy experts told us that while the social media post doesn’t give all the specifics needed to know if this was absolutely true, it seems unlikely a penalty would be this high.

One issue is the post doesn’t specify whether the $10,000 penalty was incurred in one year or over multiple years. It also doesn’t say how many individuals were part of the family.

Assuming the $10,000 penalty was incurred in one year, multiple experts told us that the family would have had an annual income above $400,000 and at least one person would have had to be uninsured for the entire year. That math is based on the penalty structure in place in 2018, the last year the mandate was enforced.

In 2018, the penalty was calculated one of two ways. The fine was the greater of the two results:

  • $695 for an adult and $347.50 for a child, up to a max of $2,085 per family annually, or
  • 2.5% of family income above a certain tax filing threshold (KFF estimated the tax filing threshold was $10,650 for a single individual or $21,300 for joint filers in 2018).

The first way to calculate the penalty obviously doesn’t apply since the max was $2,085 per year. So, the second would be the only way to get a $10,000-a-year penalty. To arrive at such a number, you would have to take 2.5% of the family’s income. In this case, 2.5% of a $400,000 income gets you close to $10,000.

And experts said it is highly unlikely that a family with a $400,000 income would have had difficulty affording health insurance.

“So I would highly doubt the veracity of what is written on that car windshield,”Karen Pollitz, a senior fellow in health reform and private insurance at KFF wrote in an email. “People with that much income almost always have job-based health benefits and, if not, generally are inclined to insure themselves very well in order to protect assets — otherwise, if hospitalized and uninsured, they could owe many multiples of the penalty amount in medical bills.”

Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill, also pointed out that a $10,000 penalty would have been rare.

“Very few American families would have paid anything close to that amount in penalty for not having insurance — the average penalty per person in 2017 was around $700,” Oberlander wrote in an email. “Moreover, only a small percentage of Americans ever paid the penalty for not having health insurance — in 2017, 4.6 million persons,” or about 1% of the population. (In 2017, 325 million people lived in the U.S., according to the Census Bureau.)

It’s also unclear whether it would have just been cheaper for the family to pay for health insurance rather than incur a $10,000 penalty, said Matthew Fiedler, a health policy scholar at the Brookings Institution.

“It depends on the ages of the members of the family, where they live, what year (or years) we are talking about, and the family’s income,” Fiedler wrote in an email. “There are conceivable scenarios where the family could have found a bronze plan for $10k or less. But there are also plenty of plausible scenarios where they could not have. Without knowing more about the family’s circumstances, it’s just hard to say with any confidence.”

Where Did the Penalty Money Go?

Experts also told us that the post’s assertion that the penalties paid for not having health insurance were directly applied to fund other people’s health insurance was off the mark.

The individual mandate penalties were assessed during each annual tax filing, and then payments were made the year after there was a lapse in insurance coverage.

Those penalties were collected just like any other tax payment.

“As a strict accounting, keep in mind, everything gets dumped into the Treasury regardless of the source, and then it is appropriated out of the Treasury by Congress,” said Edmund Haislmaier, a senior research fellow in health care policy at the Heritage Foundation. “It’s not like money goes into one account and then another.”

So, while it’s certainly possible that the penalty money could have been used to help pay for some of the ACA subsidies for other people, the money also could have gone to any other number of things the government pays for, like the military, disaster relief or education.

“You don’t know exactly where your taxes or penalties go,” said Evan Saltzman, an assistant professor in economics at Emory University. “Maybe a small share went to Obamacare, but that’s a stretch. You can’t track where every dollar you spent on your taxes is going.”

It’s also misleading to say that other individuals received “free Obamacare” from the penalty payment. The experts said that while Medicaid expansion, which was a part of the ACA, does provide health care coverage for low-income people who are eligible, those who bought insurance on the marketplace would still likely have paid for some part of their coverage after subsidies were applied.

Our Ruling

A viral social media post claims that a family was penalized $10,000 for not being able to afford health insurance. It also claimed the penalty money was taken to pay for others’ “free ObamaCare” and Trump stopped that practice.

It is true that Trump and Congress did zero out the individual mandate requirement, so people could no longer be penalized for not having health insurance. But after that, skepticism abounds.

For instance, it’s very unlikely that a family would face a $10,000 penalty in one year. Moreover, if such a family did face this penalty for not having health insurance, they would likely be in a high-income bracket for which health insurance tends to come from an employer or be affordable. And the charge that the penalty was used to provide “free coverage” for others doesn’t fit with federal accounting processes.

Experts said, though, that the lack of specifics about this family’s situation makes it difficult to be completely definitive.

We rate this claim Mostly False.

SOURCES

Census Bureau, QuickFacts United States,  accessed Oct. 27, 2020

The Commonwealth Fund, “The Effect of Eliminating the Individual Mandate Penalty and the Role of Behavioral Factors,” July 11, 2018

Email interview with Christine Eibner, the Paul O’Neill Alcoa chair in policy analysis at Rand Corp., Oct. 23, 2020

Email interview with Jonathan Oberlander, professor of health policy and management at the University of North Carolina-Chapel Hill, Oct. 25, 2020

Email interview with Karen Pollitz, senior fellow in health reform and private insurance at KFF, Oct. 26-27, 2020

Email interview with Matthew Fiedler, fellow with the USC Brookings-Schaeffer Initiative for Health Policy at the Brookings Institution, Oct. 26, 2020

5th Circuit Court of Appeals’ technical revisions of opinion, accessed Oct. 27, 2020

H.R.1 — 115th Congress (2017-18), accessed Oct. 27, 2020

IRS.gov, “Individual Shared Responsibility Provision — Reporting and Calculating the Payment,” accessed Oct. 27, 2020

KFF, “Explaining California v. Texas: A Guide to the Case Challenging the ACA,” Sept. 1, 2020

KFF, Individual Mandate Penalty Calculator, Nov. 17, 2017

KFF, “Kaiser Health Tracking Poll — November 2017: The Role of Health Care in the Republican Tax Plan,” Nov. 15, 2017

LeadStories.com, “Fact Check: Trump, Congress DID End Tax Penalty for Non-Insured, but $10,000 Penalty NOT Likely,” Oct. 22, 2020

Phone interview with Edmund Haislmaier, Preston A. Wells Jr. senior research fellow at the Heritage Foundation, Oct. 23, 2020

Phone interview with Evan Saltzman, assistant professor in economics at Emory University, Oct. 23, 2020

PolitiFact, Repeal Obamacare Trump-O-Meter, July 15, 2020

Rand Corp., “How Does the ACA Individual Mandate Affect Enrollment and Premiums in the Individual Insurance Market?” published in 2015

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Despite COVID Concerns, Teams Venture Into Nursing Homes to Get Out the Vote

RALEIGH, N.C. — Each time Beverly Tucker visited a nursing home or long-term care facility this fall, she brought along a rolling tote bag packed with supplies from the Durham County Board of Elections.

Boxes of face masks and face shields. Latex gloves and cleaning wipes. Hand sanitizer from Mystic Farm & Distillery, a local facility that was among the first to switch from producing liquor to hand sanitizer in the early days of the pandemic. And most important — even if they were dwarfed by the cleaning supplies — the absentee ballots and ballot request forms that Tucker would help residents complete in time for the election.

“The equipment is clearly different this year,” Tucker said. “But I’m doing whatever is possible to help people vote.”

Seniors in such facilities across the country have struggled to find safe ways to vote amid the pandemic. In North Carolina, it’s a particular challenge. The state is one of two (the other being Louisiana) where facility staffers are prohibited by law from assisting residents with voting. A 2013 voter ID law makes it a felony for staff to even sign as the witness on an absentee ballot.

That’s where community members like Tucker come in. The 66-year-old Durham resident is a member of the county’s multipartisan assistance team, often called a MAT, which helps residents in nursing homes, assisted living and other facilities complete mail-in or absentee ballots. The teams are appointed by the county board of elections and must include at least two people who have different political party affiliations or are unaffiliated. Some counties pay the teams, while others ask members to volunteer.

This year, the convergence of coronavirus concerns and the election has unexpectedly thrust team members to the front lines. They are entering some of the state’s hardest-hit sites, with nursing home residents accounting for about 40% of North Carolina’s COVID deaths, as cases continue to rise. The added risk has disrupted this crucial system in some areas. At least one county was unable to recruit a team, and members in another county have been unwilling to visit facilities with documented COVID cases.

But those who do venture inside say the risk is worth it to help people vote.

Kevin Marr, 66, has been volunteering with the voting assistance team in Wake County since 2017. He recognizes many of the residents now, even behind their masks. Although the visits are different this year, he said the residents’ enthusiasm to vote and receive their “I Voted” stickers is not. That’s what keeps him going, visiting about two facilities a day in recent weeks.

Tucker, of neighboring Durham County, has worked in public health for decades, including during the AIDS epidemic. She understood it was safer to go to residents in nursing homes and long-term care facilities than to risk them coming to polling sites with more people.

Still, when she first thought about holding voters’ hands to help them grasp a pen or sign a ballot, “I was instinctively reluctant to touch them,” she said. At the first nursing home Tucker visited, she felt anxious as a resident approached her without a mask.

But her concerns have eased over time, she said, and she simply focuses on ways to protect herself and her team. They conduct most of the visits outdoors, in the parking lot or front lawn. They put up plexiglass barriers between themselves and the voters, passing papers through an opening at the bottom. And they now carry masks for residents who may not have one.

It’s difficult to maintain social distancing when one team member is working with a resident to mark a ballot and the other is observing to ensure accuracy, but they do their best.

Foreseeing these challenges, the North Carolina Board of Elections asked the state legislature and courts earlier this year to temporarily suspend restrictions on facility staff assisting with voting. But neither request was fulfilled. A recent lawsuit contesting the restriction won accommodations for the plaintiff, who was a nursing home resident, but left the broader law intact.

At Brian Center Health and Rehabilitation in Goldsboro, administrator Julia Batts worried that MAT members would not be allowed to visit, since the facility has a designated COVID-positive unit with about a dozen residents. But when statewide visitation regulations eased in September, she eagerly reached out to them.

The plan was careful and clinical. Have the team set up in the dining hall of the COVID-free building and bring in any residents who had tested negative to meet with them, two at a time, in alphabetical order.

But on the day the team arrived, it felt more like a celebration. Several women asked the staff to do their hair, and many residents “began wheeling themselves or taking their walkers to go vote,” Batts said. “They were almost racing.”

By the end of the day, the team helped about 20 residents vote. They’ll return next week to assist more residents, including new entrants who finished their two-week quarantine and those who have recovered from COVID, Batts said.

For Linda Williamson in Durham County, seeing the enthusiasm of voters reminds her of her grandparents. They took her along when they cast their first ballot in the 1960s, after African Americans won the right to vote. The then-9-year-old Williamson dressed in her Sunday best: hair ribbons and patent-leather shoes. As she watched her grandparents disappear behind the voting curtain, she couldn’t wait for it to be her turn someday.

This year, she couldn’t bear to think that nursing home and assisted-living residents — many of whom likely fought for their right to vote just like her grandparents — would be robbed of that opportunity.

So Williamson, 64, put her apprehension about COVID aside, donned her face mask and gloves, and visited five facilities this fall.

To each resident she’d say, “Gosh, you picked a great day to vote.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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App-Based Companies Pushing Prop. 22 Say Drivers Will Get Health Benefits. Will They?

App-based driving services such as Uber, Lyft, DoorDash and Instacart are bankrolling California’s Proposition 22, which would keep their drivers classified as independent contractors, not employees.

Leading into the Nov. 3 election, the ballot measure — which has become the most expensive in state history — is mired in controversy and the subject of a lawsuit from Uber drivers alleging that the company inappropriately pressured them to vote for the initiative.

But what’s occasionally lost in the debate over Proposition 22 are the claims about what it will mean for app-based drivers.

Detractors, like unions and driver advocacy groups, say Proposition 22 would strip drivers of the protections of AB-5, a 2019 California law delayed by legal challenges. The law requires drivers to be classified as employees, which would afford them the associated benefits like paid sick leave, workers’ compensation and access to unemployment insurance.

Supporters, such as ride-sharing companies and the California Chamber of Commerce, say Proposition 22 would give drivers benefits, like a guarantee of minimum earnings and compensation when they are hurt on the job, while allowing them to maintain the flexible schedule of independent contractors.

In an online ad paid for by Lyft, the company says “Prop. 22 will give them … health care benefits.”

That sounds like drivers with Uber, Lyft and other app-based companies will automatically get health insurance if Proposition 22 passes. The truth is a little more complicated.

What Does ‘Health Care Benefits’ Mean?

We reached out to Lyft to back up its claim, and the company directed us to the “Yes on 22” campaign. This is how the campaign explained “health care benefits”:

Under Proposition 22, drivers who qualify — more on that in a minute — would get a stipend they could use to buy an insurance plan from Covered California, the state’s health insurance marketplace.

That stipend would be calculated like this: App-based companies would look at the statewide average monthly premium of bronze-level plans sold on the Covered California exchange.

The companies would then give qualified drivers a stipend of 82% of the average premium, said Geoff Vetter, a spokesperson for the Yes on 22 campaign. (On average, U.S. employers covered 82% of premiums costs for single coverage in 2019.)

So hypothetically, if bronze plans cost an average of $100 per month, Uber, Lyft or a similar company would provide qualifying drivers with $82 per month.

Drivers would be eligible for the full stipend — all $82 in the hypothetical case — if they average 25 hours per week of “engaged” time, which is time spent driving while there’s a passenger in the car. Time spent driving between passengers would not count.

“Most drivers work part time” and spend about one-third of their time waiting for rides and deliveries, according to the nonpartisan state Legislative Analyst’s Office. Using that equation, drivers would need to work an average of 37.5 hours per week for a single company in order to receive the full stipend.

A driver who averages at least 15 but less than 25 hours of engaged time each week would be eligible for 50% of the stipend — or $41 per month.

The stipend would be similar to employer-sponsored insurance because both employers and employees would contribute to the cost of insurance, Vetter said.

“For the people who do work closer to full time, it does give them that ability to receive health care coverage by getting a typical employer contribution for that coverage,” Vetter said.

Does a Stipend Equal Coverage?

But this stipend bears little resemblance to traditional employer-based insurance, which is what drivers would get if they were considered employees instead of gig workers, said Ken Jacobs, chair of the University of California-Berkeley Center for Labor Research and Education.

“It has very, very little relationship to what anyone would think of as job-based coverage,” Jacobs said. “It’s really wrong to think of this as health insurance.”

For instance, under Proposition 22, the stipends would be calculated and distributed quarterly, based on drivers’ hours. That could force drivers to periodically reassess what kind of coverage they would qualify for and could afford.

With traditional employer-sponsored insurance, a driver would enroll in a plan once per year and the premium wouldn’t change.

A vacation or illness could mean that drivers can’t maintain the hours required by the measure, costing them their stipend — and perhaps their insurance — for the quarter, and stripping them of the stability usually associated with job-based coverage, Jacobs said.

And getting money to buy an individual plan isn’t the same as participating in a large group plan offered by an employer, said Jen Flory, a policy advocate at the Western Center on Law & Poverty, a nonprofit organization that advocates for low-income Californians and opposes Proposition 22.

Covered California plans are typically less generous than the policies employees usually get through work, she said. And bronze-level plans, which have the lowest monthly premiums, also have the highest out-of-pocket costs for medical services.

Consider the deductible, which is how much a person needs to pay out-of-pocket before insurance starts paying for care.

In 2018, fewer than half of Californians who had work-based insurance had a deductible, and on average, that deductible was $1,402 for a single person, according to research from the California Health Care Foundation. (California Healthline is an editorially independent service of the California Health Care Foundation.)

The deductible on a Covered California bronze plan for an individual in 2021 will be $6,300 for medical services plus $500 for prescription drugs. Proposition 22 ties the stipend “to the highest deductible, highest out-of-pocket plans on the market,” Flory said. “And it’s for workers who aren’t making a whole lot of money.”

Drivers could use the stipend to buy a more generous plan, but the monthly premium would be higher and the stipend would cover less of it.

Depending on their incomes and other factors, drivers may also be eligible for tax credits and state and federal subsidies to help them afford plans on the individual market. But Flory said this amounts to the government subsidizing health insurance that employers should be paying for themselves.

It’s also problematic to base the stipends on a statewide average of bronze premiums because that doesn’t take into account the huge regional differences in the cost of care, said Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research.

“In the Bay Area, that contribution is going to buy a lot less than it would in Southern California,” Kominski said. “We’re a big state and have a lot of variation of health care costs.”

Our Ruling

The stipend offered under Proposition 22 is a “health care benefit,” but the wording is misleading and ignores critical information.

While neither Lyft nor the Yes on 22 campaign says the proposition will give drivers health insurance, saying that it will offer them “health care benefits” gives the impression that the stipend is similar to traditional job-based coverage. It’s not.

Drivers who value the ability to make their own schedules would have to figure out how to work an average of nearly 40 hours a week — essentially full time — to receive the full stipend. The stipend would cover a fraction of the premiums for health insurance that’s typically less generous than what they’d get as employees.

Moreover, because drivers’ stipends could change quarterly based on their driving time — which could be affected by vacation or illness — any coverage purchased with the stipend could carry a cloud of uncertainty.

We rate this claim as Half True.



This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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For People With Visual Impairments, Truly Secret Ballots Are Elusive

Norma Crosby remembers when she relied on blind faith to cast her vote.

The 64-year-old Texan was born virtually without sight, a side effect of her mother catching rubella while pregnant with her. Friends and relatives stood beside her and filled out her ballot at polling precincts for more than half of her voting life. Then, accessible voting machines rolled out around the year 2000, enabling her to vote in person on her own.

Now, the COVID-19 pandemic makes going to the polls a risky proposition for Crosby. She also has a condition called sarcoidosis that requires her to take immunosuppressant drugs, she said. However, the state does not have a mail-in voting system that accommodates Crosby’s visual impairment.

“It communicates to me that I’m not valued as much as other citizens,” said Crosby, president of the National Federation of the Blind of Texas, “that I’m a second-class citizen.”

A projected 7 million Americans who are eligible to vote in the presidential election live with visual impairments, according to researchers from Rutgers university. For those, like Crosby, who also deal with illnesses that place them at a higher risk of falling seriously ill with COVID-19, voting this year will be especially difficult.

The pandemic exposed glaring holes in absentee and mail-in voting systems around the nation. In some jurisdictions, voters who have what’s known as print disabilities — conditions that make it difficult to process printed content, such as blindness, low vision or learning or physical disabilities — could not cast a ballot remotely without asking for help, thereby compromising their privacy.

Outcry and lawsuits from disability advocates prompted at least 11 states to update their mail-in and absentee ballot systems in an attempt to accommodate these voters. Some changes enable voters to use text-reading software with their ballots and submit them online through a secure portal.

However, some states have been slow to address these needs. In Iowa, voters cannot vote confidentially using the mail-in system because the state requires the use of paper ballots. Texas residents like Crosby must find someone to fill out their ballot and mail it in or take it to the sole drop box in the county — all during a pandemic that has required people to physically distance themselves to stay safe.

“We should not have to choose,” said Chris Danielsen, director of public relations for the National Federation of the Blind, “between endangering our health and going to the polls in person, or not voting at all.”

Several federal laws affirm the right of all people, regardless of disability, to vote in an accessible manner. The Americans with Disabilities Act, passed in 1990, requires state and local governments to make the voting process user-friendly to voters of various abilities. This includes providing accessible parking spaces and placing voting machines where people using wheelchairs have enough space to move and at a height reachable by all.

In 2002, Congress passed the Help America Vote Act. The law built on the previous legislation by requiring every polling place to have at least one voting machine available during federal elections that accommodates a range of disabilities. These gadgets vary in features by manufacturer, but they can include touch screens, buttons labeled in Braille and audio capabilities. Voters using them must have the same privacy and independence enjoyed by people who don’t have such challenges.

However, states largely retained the power to decide how to comply with these federal mandates, said Lisa Schur, co-director of the Program for Disability Research at Rutgers. The result, she said, is an uneven patchwork that voters with disabilities must navigate.

With COVID-19 creating a reason to avoid in-person voting, some states, such as Texas, still failed to take steps to make it possible for a voter with visual or print impairments to fill out a mail-in ballot without assistance. The state government is also embroiled in a lawsuit regarding its decision to limit ballot drop-off boxes to one per county.

Harris County, where Houston is located, covers more than 1,700 square miles and is home to 4.7 million people. The distance becomes an added hardship for voters who opted to vote remotely and would prefer to drop off their ballot to make sure it is counted.

The state declined to comment due to the pending litigation.

Iowa also has fallen short in making systemic changes to improve access, according to disability advocates. Like Texas, the state provides only paper ballots for voters wishing to vote absentee.

Scott Van Gorp, president of the National Federation of the Blind in Iowa, said he initially felt resigned to his lack of privacy when he started voting. He was born three months early, leaving him with little more than light perception for sight. As a college student in the 1990s, Van Gorp rallied his friends to help him cast his vote.

“I kept thinking, ‘That’s not a secret ballot. Why?’”

In a written statement, a spokesperson for the Iowa secretary of state said it has made efforts to even the field by creating a large-print voter registration form and how-to videos on using accessible voting machines at polling locations. It cannot unilaterally make a change to improve accessibility without legislative approval, he added.

Election officials in several other states, though, including the battlegrounds of Nevada, Pennsylvania and Michigan, adopted changes this year to their mail-in ballot systems to accommodate people with visual disabilities.

In Maine, voters with impairments can request, fill out and submit their votes electronically through a new online platform. The ballots are compatible with various types of screen-reader software and will be counted through the same system used for absentee and overseas military voters.

This option became available in early October after the state was notified of confidentiality issues with paper ballots and sued by disability advocates.

Kristen Muszynski, a spokesperson for Maine’s secretary of state office, said some of the plaintiffs named in the lawsuit helped test the system. Litigation is now on hold, she said, and she is hopeful the new voting option will help resolve some of the issues.

“We’re hopeful that the word is starting to get out,” Muszynski said.

A few jurisdictions around the nation offer Braille ballots. However, said Douglas Kruse, co-director of the Program for Disability Research at Rutgers, voters may still need someone to help them fill one out and submit it. These ballots would also need to be counted separately, compromising the voter’s privacy.

One of the few states that have not needed to make drastic changes to accommodate voters with disabilities during the pandemic is Oregon, where mail-in ballots have been the primary form of voting for years.

Voters with disabilities can access and fill out ballots electronically using assistive technology like screen readers and sip-and-puff systems — through which a person with limited mobility controls the device using their breath and a straw — to vote. Then, the ballots must be mailed in.

Sean Carlson, 42, president of the Portland Central Chapter of the National Federation of the Blind, said he has never encountered issues while voting in his home state. He and his colleagues are focused on bringing awareness to the importance of “having a say in our democracy,” he said.

“It should not be that if someone has a disability that they should be locked out of that process.”

For now, Norma Crosby, who lives outside Houston, plans to vote in person, and she will need to bring a sighted friend to make sure she maintains social distance. After all, she can’t see whether other people are wearing masks.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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If Trump Wins, Don’t Hold Your Breath Waiting for That ACA Replacement Plan

If President Donald Trump wins reelection next week, it seems unlikely he will unveil the health plan he’s been promising since before his election in 2016. Still, other aspects of health care could be featured in his second-term agenda.

Not having a replacement plan for the Affordable Care Act may be just fine with many of his supporters and conservatives. Most Republicans don’t want the federal government to remake the nation’s health system, said Grace-Marie Turner, of the conservative Galen Institute. “It’s a different philosophy from Democrats, who think it needs to be a big program,” she said. “Conservatives, we think of it in a more targeted way.”

Trump, of course, repeatedly promises something big. “We will have Healthcare which is FAR BETTER than ObamaCare, at a FAR LOWER COST – BIG PREMIUM REDUCTION,” he tweeted Oct. 12 — hardly the first time he’s made a similar promise. “PEOPLE WITH PRE EXISTING CONDITIONS WILL BE PROTECTED AT AN EVEN HIGHER LEVEL THAN NOW. HIGHLY UNPOPULAR AND UNFAIR INDIVIDUAL MANDATE ALREADY TERMINATED. YOU’RE WELCOME!”

But Trump needs a contingency plan if the Supreme Court accepts his argument that the ACA should be overturned. The justices are scheduled to hear the case the week after Election Day. Administration health officials have pledged to have an alternative if the high court does as they ask. But they have refused to publicly share any details.

In September, Trump unveiled a package of health care proposals at a speech in North Carolina. The “America First Healthcare Plan” is less than an actual plan, though. It’s a vague set of claims about things that have not happened yet — like bringing down prescription drug prices — along with a laundry list of some of his administration’s lesser accomplishments on health issues, such as the initiative to help Americans with severe kidney disease and efforts to improve the availability of health care in rural areas.

As part of that overall health plan, Trump issued an executive order declaring “it has been and will continue to be the policy of the United States … to ensure that Americans with pre-existing conditions can obtain the insurance of their choice at affordable rates.” But there is nothing in the order — or in the broader outline — to ensure that would be the case if the ACA were struck down. It would take congressional action to guarantee that.

The current court controversy over the ACA arose because Congress in its 2017 tax bill eliminated the financial penalty for not having health insurance. But Congress didn’t have the votes to get rid of the mandate itself under the rules for the tax bill. Republican state officials then sued, arguing that since the Supreme Court had once upheld the ACA’s mandate, calling it a tax, once the penalty was gone, the law should also be invalidated.

Trump frequently heralds his actions, erroneously saying he killed the mandate and arguing that he got rid of the most detested part of the law.

“He likes to use words, but I don’t think there’s been a substantive policy yet,” said Len Nichols, a health policy professor at George Mason University. “I have no clue what he would do” in a second term “other than trying to repeal the ACA.”

One thing Trump accomplished in his first term is a set of potentially far-reaching regulatory actions, many of which have been challenged in federal courts. Those include allowing states to implement work requirements for people who receive Medicaid health benefits and requiring hospitals and other health providers to make their negotiated prices available to the public.

Legal analysts have doubted the administration’s authority to implement many changes Trump has proposed. But considering Trump has appointed hundreds of federal judges, including Supreme Court justices, the legal landscape may be changing and more of those proposals could be allowed to proceed.

Still, Trump faces uphill battles on some of his preferred health initiatives, even if Republicans control Congress.

For example, said Dan Mendelson of the consulting group Avalere Health, “I would expect that if he’s reelected there would be a drug pricing agenda he continues to push.” Among his proposals is having Medicare pay for drugs based on what the medicines sell for in countries that negotiate prices. That would be complicated, Mendelson said, by the fact that “the broader Republican Party doesn’t want to move to a regulatory model in this country.”

But the Galen Institute’s Turner said not to discount the changes Trump has made, such as allowing broader sales of short-term health plans that are less expensive but offer fewer benefits than ACA plans. She said to expect actions in a similar vein in a second term. “He really has done a lot, using his executive authority, based on trying to make markets work better and give people more choice,” she said. “They are strategic, targeted approaches to specific problems.”

He’ll certainly have a specific problem if the ACA is struck down. Americans losing their insurance won’t want to wait to find out if he has a plan.

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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North Carolina Treasurer Took On the Hospitals. Now He’s Paying Political Price.

Cartel is a term frequently associated with illegal narcotics syndicates. In North Carolina, it has become the favored word of State Treasurer Dale Folwell to describe the state’s hospital industry, the antagonist in his quest to lower health care prices for state employees.

The treasurer manages the state employees’ health plan, which insures about 727,000 teachers, police officers, current and retired state workers and dependents. Folwell, a Republican, has tried to persuade hospitals to accept lower payments, but he has struggled to discover the existing rates the plan pays each hospital.

“These organizations’ business model is secrecy,” Folwell said, “from the billing all the way up to the way these hospitals’ organizations receive their tax-exempt status.”

Now, as Folwell, 62, seeks a second four-year term, the state’s hospitals are coming after him.

The North Carolina Healthcare Association, the hospital trade group, has endorsed Folwell’s Democratic challenger. It is a rare instance of a health care lobby seeking to topple an incumbent. Over 26 years, North Carolina’s hospital association donated $2.1 million to sitting officeholders but bestowed just $29,700 to challengers, according to a tally from the National Institute on Money in Politics, a Montana-based nonprofit. All donations made this year will not be fully disclosed until after the election.

In many states, hospital associations are political powerhouses, with stables of lobbyists and the influence that comes with often being the largest employer in many legislative districts. In the previous election cycle of 2018, the hospital industry across the country donated $71 million to local and state candidates, political parties and ballot initiatives, according to the Money in Politics data. That amounted to a fifth of all spending by the health care industry and nearly three times that spent by pharmaceuticals and health products companies.

“The hospitals have very strong political clout in North Carolina, and increasingly so as they get bigger,” said Aaron McKethan, a resident scholar at the Margolis Center for Health Policy at Duke University’s Fuqua School of Business. “They are huge sources of employment. If anything, COVID has reinforced and strengthened them — the job of wagging your finger at hospitals over their prices has gotten harder.”

Nationally, hospitals account for a third of health care spending. The prices hospitals charge private insurers including the state health plan are driving much of the increase in health care premiums. In North Carolina, hospital inpatient prices for private insurers rose by 10% from 2014 to 2018, according to the Health Care Cost Institute.

Folwell’s critics complain that, despite his verbal provocations about hospital power, his efforts to transform health care pricing have mostly fizzled. They also lament that he has made no effort to try to persuade the legislature to expand Medicaid, which would help shore up hospital finances.

“The treasurer has, for some reason, insisted on taking a ‘my way or the highway’ approach, rather than engage in honest conversations and negotiations,” Cynthia Charles, the hospital association’s spokesperson, said in an email. “As we have repeatedly said, we are willing to work together to redesign the plan in a manner to advance goals for cost reductions, price transparency and provider inclusion.”

Folwell’s Democratic challenger, Ronnie Chatterji, and the hospital industry insist a better way to bring health costs under control would be to tie payments to the quality of care, an approach Blue Cross and Blue Shield of North Carolina has begun experimenting with. With blunt cuts, “you’re just going to put people’s health care access in jeopardy,” said Chatterji, an economist at the Fuqua School who served on former President Barack Obama’s Council of Economic Advisers.

The bad blood between Folwell and North Carolina hospitals primarily traces back to 2018, when the treasurer told hospitals, doctors and other medical providers that to avoid having to ask the legislature for more money or raise employee contributions, he wanted to reduce by $300 million the amount the $3.3 billion health plan paid medical providers each year.

Folwell proposed to base prices on Medicare rates, an approach known as reference pricing. His plan offered to pay most hospitals 175% of what Medicare reimbursed them for inpatient services and 225% for outpatient services, on average. Rural hospitals, which tend to be in worse financial shape, would have received more, but their rates would also have been pegged to Medicare.

The plan would have amounted to a pay cut for most hospitals. A recent Rand Corp. study of hospital prices found that North Carolina hospitals in 2018 were paid on average 221% of Medicare rates for inpatient services and 334% of Medicare rates for outpatient services — well above what the treasurer was proposing.

The state’s two big nonprofit systems, Atrium Health and Novant Health, earned substantially more, according to the Rand data. For example, Atrium Health Mercy hospital in Charlotte collected 423% of Medicare outpatient prices. Forsyth Medical Center in Winston-Salem, owned by Novant, collected 377% of what Medicare paid for outpatient services.

In its newsletter, the hospital association told its members that it tried to negotiate with the treasurer but that “Folwell has responded with disinterest and hostility towards these overtures and is instead engaging in a public campaign to malign hospitals.”

The hospitals warned customers that if no agreement could be reached with the state plan, the hospitals would be classified as out-of-network providers and state employees would end up having to pay far more for their services.

Those arguments about financial penury obscured the fact that North Carolina’s major hospital systems run huge surpluses in most years. Financial disclosure documents show that Atrium, which owns 36 hospitals in the state, ended 2019 with a $370 million surplus, a 6% margin. Novant, which owns 12 hospitals in North Carolina, that year earned $155 million, a 3% margin.

UNC Health, which amassed $271 million — a 6.4% margin — in its 2019 fiscal year, said in a statement that the treasurer’s plan would have cost it $47 million in its 2020 fiscal year and “jeopardized the financial viability of some of our rural hospitals.”

“We’re overpaying for no reason but to build multimillion reserves for these hospital corporations,” said Ardis Watkins, executive director of the State Employees Association of North Carolina.

Ultimately, the hospitals maintained a solid wall of opposition. Only three of North Carolina’s 108 hospitals signed on to the treasurer’s plan.

Duke’s McKethan said it was “predictable” that the hospitals would refuse to give up the negotiating advantages they held. “On the diagnosis of the problem — we’ve got these opaque prices that vary — he’s on solid ground,” he said about Folwell. “But when a good idea runs into the disadvantageous structure of the health care market, it doesn’t go anywhere.”

Apart from hospitals, the treasurer had some success in persuading about 25,000 of the state’s 60,000 doctors, therapists and other medical providers to accept the new payment system, which he named the Clear Pricing Project. Dr. Dale Owen, CEO of Tryon Medical Partners, a large independent physicians’ group based in Charlotte, said his group’s reimbursements will come out about the same under the plan.

“Quite honestly, even if it had been a tiny loss, no big deal because it was the right thing to do for everybody,” said Owen, who formed his group with fellow physicians who seceded from Atrium. “What he’s doing is, he’s opening a sore and a problem that people have not been willing to deal with and pushed under the rug.”

The Clear Pricing Project has yet to demonstrate the ability to save the state money. In fact, the effort may be costing the state more because many of the providers that signed on — such as primary care doctors and behavioral health specialists — are getting higher reimbursements than they had been while those that would have lost money, like hospitals, have stayed away.

Asked why he thought the hospitals would volunteer to forgo higher payments, Folwell said he had hoped they would realize that their long-term survival is endangered by the unsustainable increase in health care costs.

“I thought they would want to be partnering with a solution instead of the same old way,” he said in an interview. “I don’t think they accept the notion that they’re going to be on the wrong side of history.”

The hospital industry has been taking steps to try to make Folwell and his proposal history. During his attempt to get hospitals to agree to the pricing plan, the industry’s allies in the legislature introduced a bill that would have blocked the state health plan from instituting any reference pricing plan through 2021. That effort ultimately died.

Folwell has continued to rankle the hospitals with his opposition to further concentration of hospital ownership. He has opposed the pending sale of a county-owned hospital based in Wilmington, which Novant is purchasing. That followed his 2018 attempt to challenge an ultimately unsuccessful merger of Atrium and UNC Health by requesting a $1 billion performance bond if the deal ultimately raised prices for the state health plan.

Last month, the hospital association gave Chatterji its endorsement with a clear swipe at Folwell. The association’s president, Steve Lawler, said in the statement that “it is apparent that Mr. Chatterji genuinely wants to collaborate.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Colorado Initiative Would Further Limit Access in Middle America’s ‘Abortion Desert’

Colorado voters are deciding a ballot question that seeks to limit how far into pregnancy an abortion can be legally performed. While the measure would change the law only in Colorado, it would resonate throughout the Rocky Mountain states and Midwest amid an intensifying national fight, fueled by a Supreme Court vacancy, over the future of abortion.

In 1967 — six years before the Supreme Court’s Roe v. Wade decision protected the right to an abortion in the U.S. — Colorado became the first state to pass a law widening access to legal abortion. More than 50 years later, it remains one of just seven states without gestational limits on the procedure, making Colorado one of the few options for people nationwide who need abortions later in pregnancy.

Proposition 115 seeks to change that. It would outlaw abortion in the state after 22 weeks. The proposition makes an exception to save the life of the pregnant person, but none for cases of rape or incest or to protect the health of the pregnant individual or fetus.

But the impact of the measure also would be felt by neighboring states where people have little or no access to abortion. Kelly Baden, vice president of reproductive rights at the left-leaning policy group State Innovation Exchange, called the surrounding region an abortion desert.

“Colorado really plays an important role in the region in being a haven for access for people who live in those highly restrictive states, some of which neighbor us, like Kansas, Nebraska — that whole swath of the Midwest from the Dakotas on down to Texas,” Baden said.

A study published in the Journal of Medical Internet Research in 2018 found the Midwest has fewer abortion clinics per capita than any other U.S. region, with 92 facilities across 10 states.

Colorado providers have stepped in, and approximately 1 in 10 abortions are performed on people from out of state. A billboard on Interstate 70 welcomed visitors from Utah with the message “Welcome to Colorado, where you can get a safe, legal abortion.”

Colorado voters have rejected three abortion-related ballot measures since 2008, which advocates pointed to as evidence that the state’s residents are fine with the status quo.

“Colorado has already voted on ridiculous abortion restrictions multiple times and said, ‘We don’t want them.’ It’s insulting that these extremists keep trying,” said Whitney Woods, speaking on her own behalf while on maternity leave from Planned Parenthood of the Rocky Mountains.

Over the past decade, however, those measures have been rejected by smaller and smaller margins, said Bob Enyart, a spokesperson for Colorado Right to Life — one of several groups pushing for Proposition 115 to pass.

“Coloradoans increasingly voted to recognize each unborn child as a person from 2008 to 2010 to 2014,” said Enyart.

Indeed, 2008’s Amendment 48, which proposed redefining personhood in the state constitution as starting at conception, received support from 27% of voters. Six years later, that support grew to 35% for Amendment 67.

A recent poll by 9News in Denver and Colorado Politics showed that voters are more evenly divided about the new proposition, with 45% saying they’ll vote no, 42% planning to vote yes, and a crucial 13% still undecided.

Randi Davis, a mom in Aurora, is one voter whose own experience illustrates how personal and nuanced the question can be. When she was pregnant, Davis was advised to have an abortion, as her baby’s odds of survival were slim to none. She said she opted against abortion and went on to give birth to a full-term stillborn baby.

“I’m not necessarily for abortion,” Davis said. “However, I do believe every woman should have their own choice to abort for whatever reason.”

She said she’s voting against the proposition.

Dr. Thomas Perille heads the medical advisory team for the Coalition for Women and Children (also known as Due Date Too Late), the group that petitioned to put Proposition 115 on the ballot and calls abortions later in pregnancy “too extreme.” Perille contends the new proposition “bears no relation” to the previous measures, giving it a better chance of passing.

“Those were bans on abortion, and Prop 115 is a reasonable restriction of abortion after fetal viability,” he said.

Abortion-rights activists worry that bans of abortions after the first trimester aim to gradually shift public opinion and gain traction to fully outlaw the procedure.

“They’re hoping that they can slide this under the radar and really cast it as a compromise between anti-abortion and pro-choice voters,” said Fawn Bolak, spokesperson for ProgressNow Colorado. “But that’s not what this is. This is a violation of Roe v. Wade.”

Perille said that, while first-trimester abortions are “relatively safe,” late abortions pose a “substantial risk” to the people having them. Advocates for the initiative said studies show the risk of death to the pregnant person from an abortion increases with each week of gestation.

Opponents point to another study that shows legal abortions overall tend to be safer and pose less of a threat to pregnant people’s lives than childbirth.

Colorado isn’t the only state voting on an abortion initiative this election cycle. Voters in Louisiana are considering a constitutional amendment that says nothing in the state constitution can be interpreted as protecting a right to, or requiring funding of, abortion.

The measure’s advocates say that, if Roe v. Wade is overturned, the legality of abortion in Louisiana would be up to state lawmakers. Opponents say the measure, if it passes, would eliminate legal access to abortion in the state if Roe v. Wade is dismantled.

“Constitutions are supposed to be about preserving and enshrining freedom, but this amendment takes away freedom and rights while allowing the government to tell people what they can and cannot do with their body,” said Michelle Erenberg, executive director for Lift Louisiana, a group that advocates for abortion rights.

Abortion-rights advocates also point out that Louisiana passed its own 22-week abortion ban a decade ago, and worry that Colorado could follow a similar path toward even greater restrictions.

The decisions before voters in Colorado and Louisiana come amid renewed attention nationwide on abortions since Supreme Court Justice Ruth Bader Ginsberg’s death last month. Senate Republicans are now pushing through President Donald Trump’s nominee, Judge Amy Coney Barrett. That has led voters and activists on both sides of the issue to become heavily focused on what Barrett’s appointment could mean for the future of Roe v. Wade.

Abortion opponents contend it’s not clear that Barrett’s confirmation would doom Roe.

“We have seen no evidence that Amy Coney Barrett has ever recognized that the unborn child is a person or has a right to life,” Enyart said. “We are concerned that she may disagree with the Roe opinion merely as a matter of process, not morality.”

But The Guardian recently reported on Barrett’s previous involvement with an anti-abortion organization, noting she signed a newspaper ad that called Roe “barbaric,” which put abortion-rights advocates on edge.

Erika Christensen, who helped pass New York’s Reproductive Health Act, said she is concerned but added that these new threats to abortion rights have become a rallying point for advocates.

Baden agreed, saying the renewed energy is particularly strong locally.

“We need to turn to the state level, and do whatever we can to prepare for what might come one day, be it from the Supreme Court or from another Trump executive order, or something else coming,” she said. “Roe is the floor, not the ceiling, right?”

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Déjà Vu for California Voters on Dialysis

SACRAMENTO, Calif. — The survival of California’s dialysis clinics is in the hands of its voters this November.

Sound familiar?

Voters heard the same dire campaign claim two years ago, when the dialysis industry spent a record $111 million to defeat a statewide ballot measure that would have limited clinic revenues.

Industry giants DaVita and Fresenius Medical Care are back on the defense again this year with their checkbooks open, flooding voters’ mailboxes and screens with political ads highlighted by heartfelt testimonials from patients against Proposition 23. With just a week left before Election Day, the industry is on track to break its own spending record.

This time, the measure’s sponsor, the Service Employees International Union-United Healthcare Workers West, which represents more than 95,000 health care workers in California, focused the ballot measure less on dialysis clinic profits and more on patient safety.

The union, which has tried but failed to organize dialysis clinic workers, has been the driving force behind both ballot measures, putting voters squarely in the middle of a long-running brawl — and forcing them to make decisions that could affect the health of tens of thousands of Californians.

“There’s no reasonable evidence that this would improve patient health,” said Erin Trish, associate director of the University of Southern California’s Leonard D. Schaeffer Center for Health Policy & Economics. “It seems largely to be driven by retaliation by SEIU-United Healthcare Workers West, who are mad the dialysis facilities wouldn’t let their workers unionize.”

Proposition 23 would require dialysis clinics to have a licensed physician on-site during all dialysis treatments, but that doctor wouldn’t need to be a nephrologist, a kidney specialist. Clinics would have to report infection data every three months to the California Department of Public Health, and those that plan to close would need state approval.

About 80,000 patients visit the state’s 600 licensed chronic dialysis clinics, three-quarters of which are owned or operated by DaVita or Fresenius, the largest dialysis companies in the country, according to a report by the nonpartisan state Legislative Analyst’s Office.

Patients with kidney failure often need a dialysis machine to filter toxins and remove excess fluid from their blood when their kidneys can no longer do the job. The treatment is arduous, taking roughly four hours at least three times a week.

Dialysis patients are susceptible to infection for a variety of reasons: Their immune systems are already compromised by their kidney failure, they are around other sick patients while receiving treatment, they require catheters to access their veins, and their blood is cycled through a machine.

Even though mortality rates have dropped among outpatient dialysis patients nationwide, infections remain a leading cause of death. In California, about one-third of outpatient clinics have fallen short of federal performance standards so far this year, resulting in lower Medicare payments to those clinics, according to federal payment records.

“With this initiative, we’ll make sure that they put more of those huge profits back into the clinics to improve safety and improve care,” said Steve Trossman, spokesperson for the union.

Dialysis clinics are once again threatening to close if the measure passes and they’re faced with higher operating costs.

Shama Aslam, 50, spoke at the behest of the union. Aslam, who visits a dialysis clinic in Stockton three times a week, described swatting fruit flies off her face and arms for hours while hooked up to a dialysis machine. She has polycystic kidney disease and has been waiting three years for a kidney transplant.

“It was really bad today,” Aslam said on a recent October afternoon. “It’s very uncomfortable. And because we’re dealing with blood all the time, we don’t want any infection. That’s a huge thing, at least for me.”

Aslam wishes she could see a doctor more than once a month. Nephrologists oversee their patients’ dialysis care, but clinic staff members administer the treatments. Federal regulations require a medical director, who is a board-certified physician, to oversee every dialysis clinic in the country. But there is no requirement that those directors remain physically present at the clinic when it is open. That’s what the California ballot measure would mandate.

Rick Barnett, chief executive officer and president of Satellite Healthcare, which operates 80 dialysis clinics in Texas, Tennessee, New Jersey and California, including Aslam’s clinic, said he had not heard of fruit flies at that Stockton facility. Medicare has not penalized that clinic this year, according to the payment database.

Many nonprofits like San Jose-based Satellite Healthcare could not afford to hire on-site doctors if Proposition 23 passes, Barnett said. Currently, medical directors often oversee multiple clinics in addition to their other job responsibilities.

The Legislative Analyst’s Office estimated it would cost each clinic several hundred thousand dollars a year, while the industry says $600,000 a year. Each clinic likely would have to hire more than one doctor to cover all hours.

Barnett estimates Satellite would close up to 40% of its 67 clinics in California should the ballot measure pass.

“It comes down to an attack on the industry,” he said. “This is one of the few sectors of health care they haven’t organized.”

Trossman vehemently disagreed that the union is trying to punish the dialysis companies over its failed unionization effort, saying the union invests in improving people’s lives.

“In terms of the idea that we would spend millions of dollars because essentially we’re ticked off is just ludicrous,” he said. “We don’t spend money that way.”

The California Medical Association, which represents physicians, opposes the measure, saying it would exacerbate the state’s doctor shortage by diverting physicians into dialysis clinics.

“This will bring physicians who are not trained in kidney disease or dialysis to just be present without any role or purpose, or even a clear path to any intervention because they won’t know what to do,” said Dr. Edgard Vera, a nephrologist and the medical director of DaVita dialysis clinics in Southern California’s High Desert towns of Hesperia and Victorville.

Critical emergencies, such as wild swings in blood pressure, already are handled by technicians and nurses certified in dialysis care, Vera said. Should a patient go into cardiac arrest, “if a physician is there, they are going to call the ambulance anyway,” he said.

DaVita alone had given nearly $67 million to the “No on 23” campaign as of Wednesday, more than half of the $105 million raised so far by the industry, according to campaign finance reports filed with the California secretary of state. The campaign’s other contributors include Fresenius, Satellite Healthcare, U.S. Renal Care and Dialysis Clinic Inc.

The “Yes on 23” campaign has reported just a fraction of that, with nearly $9 million in contributions. SEIU-United Healthcare Workers West gave the bulk of the money, with the rest — about $40,000 — coming from non-monetary donations from the California Democratic Party.

Proposition 23 follows an uneven record of wins and losses for the union on dialysis issues in California. The union tried but failed to organize dialysis workers three years ago, arguing that they needed safer working conditions and job protection. It also lost its 2018 ballot initiative that would have capped dialysis clinic profits.

But, last year, the union helped persuade state lawmakers to adopt a bill that aimed to stop a billing practice dialysis companies use to get higher insurance reimbursements for some low-income patients. A federal judge in January temporarily blocked the law from taking effect while the court considers its constitutionality.

“It’s not unusual for us to be voting on similar issues over and over again if they’re backed by powerful enough interests,” said Danielle Joesten Martin, associate professor of political science at California State University-Sacramento, pointing to other repeat ballot measures on the November ballot, such as the Realtor-backed Proposition 19. That measure would give Californians over 55 years old a property tax break when buying a new home.

They’re “powerful interest groups who didn’t get what they wanted the last time around.”



This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Arguing to Undo the ACA. Harming Medicare. Do They Go Hand in Hand?

It’s a tried-and-true campaign strategy.

Candidates go on the attack, claiming their opponent will do harm to Medicare. After all, people 65 and older are good about making it to the polls on Election Day. These voters are also generally motivated to protect the federal health insurance program for seniors.

It’s no surprise, then, that in an ad released this month, former Vice President Joe Biden’s campaign played the Medicare card.

“Donald Trump is lying about Medicare and Social Security,” an ominous, mature, male voice warns viewers in the ad. He goes on to say that “Trump’s pushing to slash Medicare benefits.”

Clearly, we’ve heard this dire message before — from candidates of both parties through the years.

We issued a skeptical rating of a claim that Trump promised to gut Social Security and Medicare if re-elected, noting that his deferral of payroll taxes did not mention Medicare at all. But Trump has not mentioned cuts to Medicare benefits on the trail, and he’s promised to make cuts to the program in the future. So what is Biden’s claim talking about?

As a rationale for the statement, a Biden campaign spokesperson pointed us to the Trump administration’s support of Republicans’ efforts in a court case, California v. Texas, which seeks to overturn the Affordable Care Act. But the ad does not include any reference or explanation of how the case would affect Medicare benefits.

The legal challenge, brought by a group of Republican attorneys general, is pegged to the 2017 tax bill, which zeroed out the tax that functioned as a penalty for not having health coverage — known as the individual mandate. Without this linchpin tax, the Republicans argue, the entire law should be struck down. They based that on the Supreme Court decision in 2012 that the law was constitutional because the penalty was a valid use of Congress’ ability to levy taxes.

In the current case, lower courts have found the law unconstitutional, and a group of Democratic attorneys general appealed to the Supreme Court.

Oral arguments are scheduled for Nov. 10. The Trump administration filed a brief in support of invalidating the entire law unconstitutional.

Though best known for its vast expansion of health coverage through marketplace plans and Medicaid, the ACA also included a range of consumer protections — such as the ban on discrimination against people with preexisting conditions — and an estimated 165 Medicare-related provisions.

The Biden spokesperson pointed to one, which ended Medicare’s so-called doughnut hole.

We asked experts for their take. Immediately, we found differences in opinion.

That’s a “perfectly fair claim,” said Nicholas Bagley, a professor at the University of Michigan Law School. Closing the doughnut hole matters to many people, he said.

Case Western Reserve University law professor Jonathan Adler took a different view. The argument that Medicare would be affected “is a very aggressive reading of the filing in this case,” he said, referring to the Trump administration’s brief in support of nullifying the ACA.

The next step seemed to be getting a better grasp of what’s at stake.

A Quick Review of the Doughnut Hole, Other Medicare Provisions

The Medicare doughnut hole refers to the gap in Part D prescription drug coverage that begins after a beneficiary spends a set amount — usually a few thousand dollars. Before the ACA, beneficiaries who reached that threshold were responsible for 100% of their medication costs until they spent enough for catastrophic coverage to kick in, which could be more than $1,000 in additional spending. Even with this coverage, beneficiaries were responsible for 5% of their drug expenditures. (If beneficiaries were responsible for 100% of costs today, people with high drug costs would obviously pay a lot more without the ACA provision.)

The ACA would have gradually ended that coverage gap. But, in 2018, Congress adopted changes to expedite the process. As of 2019, the doughnut hole was closed. Adler pointed to that congressional intervention as a step that could keep the doughnut hole closed if the ACA were overturned. Based on this legislative history, the argument could be made that closing the coverage gap was something Congress had an interest in apart from the ACA. Since the doughnut hole is officially closed, some analysts said this provision may not be vulnerable to the upcoming Supreme Court decision on the ACA.

“You can make a lot of claims,” said Gail Wilensky, a former head of the Centers for Medicare & Medicaid Services. “That one is really a stretch.”

Other ACA provisions tied to Medicare benefits seem more at risk, such as the one that mandated annual wellness visits and certain preventive services, such as mammograms, bone mass measurement for those with osteoporosis, and depression and diabetes screening, with no patient cost sharing.

“It’s not clear that the administration actively supports any change to the Medicare benefits with the case before SCOTUS,” said Tricia Neuman, KFF senior vice president and executive director of the KFF’s program on Medicare policy. “But if they didn’t explicitly seek to wall off certain provisions, it is at least conceivable — though maybe not likely — that Medicare benefits in the ACA could be collateral damage.” (KHN is an editorially independent program of KFF.)

According to an amicus brief filed by the AARP, the Center for Medicare Advocacy and Justice in Aging in 2016, an estimated 40.1 million Medicare beneficiaries received at least one preventive service and 10.3 million had an annual wellness visit with no copay or deductible.

Other experts pointed to a troubling implication for Medicare: the nullification of the ACA provisions related to costs and slowing the growth of the program’s spending. Those efforts had been credited with extending the solvency of the Health Insurance Trust Fund and slowing the growth in Medicare premiums.

It “would impair the financial fitness” of the trust fund, said Paul Van de Water, a senior fellow at the Center on Budget and Policy Priorities.

Trump “may not say it is his intent to slash Medicare benefits,” agreed David Lipschutz, associate director of the Center for Medicare Advocacy, but overturning the ACA entirely would “cause chaos writ large.” And, because of the program’s size, that chaos “would upend the financial markets and the entire health care system,” according to the brief filed by Medicare advocates.

What Comes Next Is Complicated

Enter the concept of severability. Many court watchers are quick to say the high court’s decision could go beyond upholding the entire law or declaring it unconstitutional. Instead, the justices could separate or sever parts of it not directly related to the zeroed-out tax penalty, the so-called individual mandate.

Of course, the Trump administration argued in its brief that the interwoven nature of the ACA’s provisions demanded that the entire law be invalidated.

“If you just go on that basis, they are not arguing for severability,” said Van de Water.

But others point out another layer that warrants consideration.

“Everyone who comments on this focuses on the administration’s argument for inseverability,” Adler said. But he said it was more complicated than that.

The Trump administration’s position is “simultaneously that the entire ACA should be invalidated” and also that relief should be provided only where injury to the plaintiffs is shown. (The administration defines the plaintiffs as the two individuals who signed on to the original challenge.)

Another view is that this point in the administration’s argument is not clear-cut, mostly because it gives no hint as to which programs or provisions would fit into the category of harming the plaintiffs.

Ultimately, the fate of the sweeping health law is in the hands of the Supreme Court.

“Legal analysts didn’t anticipate the case getting as far as it has,” said Lipschutz.

But “the White House threw its weight behind the lawsuit,” said Bagley, at the University of Michigan. “So, they own the consequences. Especially in the context of this presidential campaign.”

Our Ruling

An attack ad by the Biden campaign states that Trump is “pushing to slash Medicare benefits” and ties this charge to the administration’s position on the pending legal challenge to the ACA.

The Biden campaign pointed to an ACA provision that sought to close the Medicare doughnut hole to support this claim. It may not be the best example, though, because some experts suggest it may not be as vulnerable as other parts of the law.

Experts outlined a range of other Medicare provisions that either provided new benefits or shored up the program’s financial fitness. If the whole law were to be nullified, as the administration has advocated, these changes could also be erased — a step that would affect benefits and potentially cause premiums to rise.

Overall, the Biden ad seems plausible, even though the link between Trump’s position on the legal challenge and its impact on Medicare benefits is less straightforward than in similar claims we have checked regarding preexisting conditions.

We rate the claim Half True.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Did Trump Confuse the Public Option With ‘Medicare for All’?

During the final presidential debate, President Donald Trump claimed that 180 million people would lose their private health insurance to socialized medicine if the Democratic presidential nominee, former Vice President Joe Biden, is elected president.

“They have 180 million people, families under what he wants to do, which will basically be socialized medicine — you won’t even have a choice — they want to terminate 180 million plans,” said Trump.

Trump has repeated this claim throughout the week, and we thought the linkage of Biden’s proposed health care plan with socialism was something we needed to check out. Especially since Biden opposed “Medicare for All,” the proposal by Sen. Bernie Sanders (I-Vt.) that would have created a single-payer health system run completely by the federal government, and has long been attacked by Republicans as “socialist.”

The Trump campaign did not respond to our request asking where the evidence for this claim came from. Experts called it a distortion of Biden’s plan.

Where the Number Comes From

Experts agreed the number of people who have private health insurance either through an employer-sponsored plan or purchased on the Affordable Care Act’s health insurance marketplace is around 180 million people.

KFF, a nonpartisan health policy organization, estimated in 2018 that about 157 million Americans had health insurance through their employer, while almost 20 million had insurance they purchased for themselves. Together, that adds up to about 177 million with private health insurance. (KHN is an editorially independent program of KFF.)

What Does Biden Support?

Biden supports expanding the ACA through several measures, including a public option. Under his plan, this public option would be a health insurance plan run by the federal government that would be offered alongside other private health insurance plans on the insurance marketplace.

“The marketplace is made up of multiple insurers in areas,” said Linda Blumberg, a health policy fellow at the Urban Institute. “Sometimes there are five or more [plans]; sometimes there is only one. Biden is talking about adding a public option in the marketplace. You could pick between these private insurers or you could pick the public option.”

Getting rid of the so-called employer firewall is also part of Biden’s proposal.

This firewall was implemented during the rollout of the ACA. It was designed to maintain balance in the insurance risk pools by preventing too many healthy people who have work-based coverage from opting instead to move to a marketplace plan. And it all came down to who qualified for the subsidies that made these plans more affordable.

Currently, those who are offered a health insurance plan through their employer that meets certain minimum federal standards aren’t eligible to receive these subsidies, which come in the form of tax credits. But that leaves many low-income workers with health care plans that aren’t as affordable or comprehensive as marketplace plans.

Biden’s plan would eliminate that firewall, meaning anyone could choose to get health insurance either through their employer or through the marketplace. That’s where many Republicans argue that we could start to see leakage from private health insurance plans to the public option.

“The problem is healthy people leaving employer plans,” said Joseph Antos, a scholar in health care at the conservative-leaning American Enterprise Institute. That could mean the entire workplace plan’s premiums would go up. “You could easily imagine a plan where it spirals, the premiums go up, and then even more people start leaving the plans to go to the public option.”

Blumberg, though, said that because the marketplace would still include private health insurance plans alongside the public option, it doesn’t mean everyone who chooses to leave their employer plan would go straight to the public option.

She has done estimates based on a plan similar to the one Biden is proposing. She estimates that only about 10% to 12% of Americans would choose to leave their employer-sponsored plans, which translates to about 15 million to 18 million Americans.

KFF also did an estimate and found that 12.3 million people with employer coverage could save money by buying on the exchange under the Biden plan.

But “it’s not clear all of those people would choose to leave their employer coverage, though, as there are other reasons besides costs that people might want to have job-based insurance,” Cynthia Cox, vice president and director of the program on the ACA at KFF, wrote in an email.

Either way, none of the estimates are anywhere close to the 180 million that Trump claimed.

Is This Type of Public Option Socialism?

Overall, experts said no, what Biden supports isn’t socialized medicine.

“Socialized medicine means that the government runs hospitals and employs doctors, and that is not part of Biden’s plan,” Larry Levitt, executive vice president for health policy at KFF, wrote in an email. “Under Biden’s plans, doctors and hospitals would remain in the private sector just like they are today.”

However, Antos said that, in his view, the definition of socialism can really vary when it comes to health care.

“I would argue in one sense, we would already have socialized medicine. We have massive federal subsidies for everybody, so in that sense, we’re already there,” said Antos. “But, if socialized medicine means the government is going to dictate how doctors practice or how health care is delivered, we are obviously not in that situation. I don’t think the Biden plan would lead you that way.”

And in the end, Antos said, invoking socialism is a scare tactic that politicians have been using for years.

“It’s just a political slur,” said Antos. “It’s meant to inflame the emotions of those who will vote for Trump and meant to annoy the people who will vote for Biden.”

Our Ruling

Trump said 180 million people would lose their private health insurance plans to socialized medicine under Biden.

While about 180 million people do have private health insurance, there is no evidence that all of them would lose their private plans if Biden were elected president.

Biden supports implementing a public option on the health insurance marketplace. It would exist alongside private health insurance plans, and Americans would have the option to buy either the private plan or the public plan. While estimates show that a number of Americans would likely leave their employer-sponsored coverage for the public plan, they would be doing that by choice and the estimates are nowhere near Trump’s 180 million figure.

Experts also agree that the public option is not socialized medicine, and it’s ridiculous to conflate Biden’s plan with Medicare for All.

We rate this claim Pants on Fire.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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In Tamer Debate, Trump and Biden Clash (Again) on President’s Pandemic Response

In the second and final debate of the 2020 presidential race, President Donald Trump and former Vice President Joe Biden sparred over Trump’s handling of the pandemic and Biden’s plan to reform health care. In stark contrast to the first debate, there was more policy talk. There was also less interrupting.

Trump said a COVID-19 vaccine is “ready” and will be announced “within weeks,” shortly before conceding that it is “not a guarantee.”

Biden said Trump still has no comprehensive plan to deal with the pandemic, even as case counts continue to climb. “We’re about to go into a dark winter, and he has no clear plan,” Biden said.

Trump claimed Biden’s health care plan would lead to “socialized medicine,” conflating Biden’s proposal to introduce a government insurance option with more progressive proposals that would eliminate private insurance. “I support private insurance,” Biden said, promising, “Not a single person with private insurance would lose their insurance under my plan.”

You can read a full fact check for the evening, done in partnership with PolitiFact, here.

Meanwhile, we broke down the candidates’ closing coronavirus and other health-related claims so you can do your part: vote.

Here are the highlights:

Trump: “We are rounding the turn [on the pandemic]. We are rounding the corner.”False.“Rounding the corner” suggests that significant and sustained progress is being made in the fight against the coronavirus, and that’s not the case, according to the data.

The number of COVID cases is climbing once again, after falling consistently between late July and mid-September. Cases are now at their highest point since early August, with almost 60,000 new confirmed infections a day. That’s only about 10% lower than the peak in late July.

New daily hospitalizations today are lower than in previous spikes, but in the past few weeks there has been a modest increase. The positivity rate, which measures the percentage of tests that come up positive for the virus, has also been going up again in the past few weeks. Higher positivity rates are an indicator of community spread.

The one encouraging change is that, since a peak in August, deaths have fallen fairly consistently. That’s due to a combination of factors, including improved understanding of how to treat the disease. Yet COVID deaths have settled in at about 800 a day, keeping total deaths per week in the U.S. above normal levels.

Trump: His administration has done “everything” Biden suggested to address COVID-19. “He was way behind us.”We rated a similar claim Pants on Fire. While there are some similarities between Biden’s and Trump’s plans to combat COVID-19, experts told us any pandemic response plan should have certain core strategies. The Trump administration has released no comprehensive plan to battle the disease, except with regard to the development and distribution of vaccines. Trump’s main intervention was implementing travel restrictions, while efforts to roll out a widespread testing plan faced difficulties.

Biden released a public COVID plan; the first draft was published March 12. It included public health measures such as deploying free testing and personal protective equipment, as well as implementing economic measures such as emergency paid leave and a state and local emergency fund.

Trump: “As you know, 2.2 million people were expected to die. We closed the greatest economy in the world to fight this horrible disease that came from China.”His claim about the estimated deaths rates Mostly False. Trump frequently refers to this number to claim that his administration’s moves saved 2 million lives. However, the number is from a mathematical model that hypothesized what would happen if, during the pandemic in the U.S., neither people nor governments changed their behaviors, a scenario that experts considered unrealistic. The U.S. has the highest death toll from COVID-19 of any country, and one of the highest death rates. Also, credit for shutting down the economy doesn’t go primarily to Trump, but rather to states and local jurisdictions. In fact, Trump encouraged states to open back up beginning in May, even when there were high rates of COVID transmission in those areas.

Trump: “We cannot lock ourselves in a basement like Joe does.”We rated a similar claim False. It is one of Trump’s favored shots to say Biden isolated himself in his basement. In the first few months of the pandemic, Biden did run much of his campaign from his Delaware home. He built a TV studio in his basement to interact with voters virtually. But that changed.

In September alone, Biden gave remarks and held events in, among other places, Kenosha, Wisconsin; Lancaster, Pennsylvania; Warren, Michigan; Tampa, Florida; and Charlotte, North Carolina. We counted 14 locations.

Trump: Said of Dr. Anthony Fauci, “I think he’s a Democrat, but that’s OK.”This is wrong. Fauci, director of the National Institute of Allergy and Infectious Diseases, is not affiliated with a political party. He hasn’t endorsed any parties or candidates.

Biden: “We are in a circumstance where the president still has no plan, no comprehensive plan.”This is largely accurate. When Biden claimed during the first debate that Trump “still won’t offer a plan,” we noted the Trump administration’s “Operation Warp Speed” for vaccine development as well as its more detailed plan for vaccine distribution. But the administration has not released a comprehensive plan to address COVID-19.
Trump: “There was a spike in Florida. That is gone. There was a spike in Texas. That is gone. There was a spike in Arizona. It is gone.” 
This is inaccurate. Over the summer, Florida, Texas and Arizona experienced record surges in cases that later eased — but now they are all seeing new surges. Over the past week, The New York Times’ tracker notes, as of Friday, new infections are up 37% in Florida, 13% in Texas and 47% in Arizona, from the average two weeks earlier.
Trump: “When I closed [travel from China], he said I should not have closed. … He said this is a terrible thing, you are a xenophobe; I think he called me racist. Now he says I should have closed it earlier.”
Mostly False. Joe Biden did not directly say he thought Trump shouldn’t have restricted travel from China to stem the spread of the coronavirus.

Biden did accuse Trump of “xenophobia” in an Iowa campaign speech the same day the administration announced the travel restrictions — Jan. 31 — but his campaign said that his remarks were not related and that he made similar comments before the restrictions were imposed. Biden didn’t take a definitive stance on the subject until April 3, when his campaign said he supported Trump’s decision to impose travel restrictions on China.
Trump: “They have 180 million people, families under what he wants to do, which will basically be socialized medicine — you won’t even have a choice — they want to terminate 180 million plans.” 
Pants on Fire. About 180 million people have private health insurance. But there is absolutely no evidence that under Biden’s health care proposal all 180 million would be removed from their insurance plans. Biden supports creating a public option, which would be a government-run insurance program that would exist alongside and compete with other private plans on the health insurance marketplace.

Under Biden’s plan, even people with employer-sponsored coverage could choose a public plan if they wanted to. And estimates show that only a small percentage of Americans would likely leave their employer-sponsored coverage if a public option were available, and certainly not all 180 million. Experts said it is not socialized medicine.
Biden: “Not one single person with private insurance” lost their insurance “under Obamacare … unless they chose they wanted to go to something else.”
This is inaccurate. This is a variation of a claim that earned President Barack Obama our Lie of the Year in 2013. The Affordable Care Act tried to allow existing health plans to continue under a complicated process called “grandfathering,” but if the plans deviated even a little, they would lose their grandfathered status. And if that happened, insurers canceled plans that didn’t meet the new standards.

No one determined with any certainty how many people got cancellation notices, but analysts estimated that about 4 million or more had their plans canceled. Many found insurance elsewhere, and the percentage was small — out of a total insured population of about 262 million, fewer than 2% lost their plans. However, that still amounted to 4 million people who faced the difficulty of finding a new plan and the hassle of switching their coverage.

This story includes reporting by KHN reporters Victoria Knight and Emmarie Huetteman, and Jon Greenberg, Louis Jacobson, Amy Sherman, Miriam Valverde, Bill McCarthy, Samantha Putterman, Daniel Funke and Noah Y. Kim of PolitiFact.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN on the Air This Week

KHN chief Washington correspondent Julie Rovner discussed the impact of the election and the upcoming Supreme Court challenge on the Affordable Care Act with New Hampshire Public Radio’s “The Exchange” and WNYC’s “The Brian Lehrer Show” on Wednesday. Rovner also spoke with Newsy’s “Morning Rush” on Thursday about the roles of health care and COVID-19 in the presidential campaign.

KHN Midwest correspondent Lauren Weber discussed COVID vaccine distribution with “Newsy Reports” on Oct. 16.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Want to protect people with preexisting conditions? You need the full Affordable Care Act.

In this perspective published by the Washington Post, KFF Executive Vice President for Health Policy Larry Levitt explains why the popular Affordable Care Act provisions that ensure people with pre-existing conditions can access affordable health insurance can’t easily be preserved if other related provisions are overturned.

Californians Asked to Pony Up for Stem Cell Research — Again

SACRAMENTO, Calif. — In an election year dominated by a chaotic presidential race and splashy statewide ballot initiative campaigns, Californians are being asked to weigh in on the value of stem cell research — again.

Proposition 14 would authorize the state to borrow $5.5 billion to keep financing the California Institute for Regenerative Medicine (CIRM), currently the second-largest funder of stem cell research in the world. Factoring in interest payments, the measure could cost the state roughly $7.8 billion over about 30 years, according to an estimate from the nonpartisan state Legislative Analyst’s Office.

In 2004, voters approved Proposition 71, a $3 billion bond, to be repaid with interest over 30 years. The measure got the state agency up and running and was designed to seed research.

During that first campaign, voters were told research funded by the measure could lead to cures for cancer, Alzheimer’s and other devastating diseases, and that the state could reap millions in royalties from new treatments.

Yet most of those ambitions remain unfulfilled.

“I think the initial promises were a little optimistic,” said Kevin McCormack, CIRM’s senior director of public communications, about how quickly research would yield cures. “You can’t rush this kind of work.”

So advocates are back after 16 years for more research money, and to increase the size of the state agency.

Stem cells hold great potential for medicine because of their ability to develop into different types of cells in the body, and to repair and renew tissue.

When the first bond measure was adopted in 2004, the George W. Bush administration refused to fund stem cell research at the national level because of opposition to the use of one kind of stem cell: human embryonic stem cells. They derive from fertilized eggs, which has made them controversial among politicians who oppose abortion.

Federal funding resumed in 2009, and thus far this year the National Institutes of Health has spent about $321 million on human embryonic stem cell research.

But advocates for Proposition 14 say the ability to do that research is still tenuous. In September, Republican lawmakers sent a letter to President Donald Trump urging him to cut off those funds once again.

The funding from California’s original bond measure was used to create the new state institute and fund grants to conduct research at California hospitals and universities for diseases such as blood cancer and kidney failure. The money has paid for 90 clinical trials.

A 2019 report from the University of Southern California concluded the center has contributed about $10.7 billion to the California economy, which includes hiring, construction and attracting more research dollars to the state. CIRM funds more than 56,500 jobs, more than half of which are considered high-paying.

Despite the campaign promises, just two treatments developed with some help from CIRM have been approved by the Food and Drug Administration in the past 13 years, one for leukemia and one for scarring of the bone marrow.

But it’s a bit of a stretch for the institute to take credit for these drugs, said Jeff Sheehy, a CIRM board member who does not support the new bond measure. He said the agency funded the researcher whose lab discovered and developed the drugs, but CIRM holds no rights to those drugs and doesn’t receive royalties from them.

The state has received about $518,000 in revenue from licensing other institute-funded discoveries, such as devices, McCormack said.

McCormack also pointed to some promising stem cell therapies still in clinical trials, such as a treatment that has cured 50 children of severe combined immunodeficiency, a genetic disorder often called “bubble baby” disease, and others that have led to “dramatic” improvements in paralysis and blindness, he said.

The campaigns for both bond measures may be giving people unrealistic expectations and false hope, said Marcy Darnovsky, executive director of the Center for Genetics and Society. “It undermines people’s trust in science,” Darnovsky said. “No one can promise cures, and nobody should.”

Robert Klein, a real estate developer who wrote both ballot measures, disagrees. He was inspired to invest in stem cell research after he lost his youngest son to Type 1 diabetes. He said some of CIRM’s breakthroughs are helping patients right now.

“What are you going to do if this doesn’t pass? Tell those people we’re sorry, but we’re not going to do this?” Klein said. “The thought of other children needlessly dying is unbearable.”

Sheehy, who has served on the agency’s board for 16 years, said he’s proud of the work the institute has done but believes it should be funded through the legislature, not by borrowing more money.

“The promise was that it would pay for itself and it hasn’t,” Sheehy said. “We can’t really afford it, and this is the worst way to pay for it.”

Even if CIRM isn’t turning a profit, some researchers and private companies are benefiting from the public money. Take the company Forty Seven Inc., named after a human protein and co-founded by Irving Weissman, director of Stanford University’s stem cell research program. The state stem cell agency awarded more than $15 million to Forty Seven, and $30 million to Weissman at Stanford for research.

That money fueled research that uncovered a promising treatment for several different cancers. Gilead Sciences, the pharmaceutical giant, bought Forty Seven in 2018 for $4.9 billion. Of that, $21.2 million went back to CIRM to pay back Forty Seven’s research grants, with interest.

“Gilead will make far more than that if it turns out to be lucrative,” said Ameet Sarpatwari, a professor of medicine at Harvard Medical School who studies drug development.

Because this kind of work is both expensive and risky, private companies are reluctant to pay for early research, when scientists have no idea if their work will yield results, let alone profits, Sarpatwari said. So the state pays for this work, and drug companies come in to finance later-stage research once a molecule looks promising — and ultimately reap the profits.

Case in point: Fedratinib, one of the two FDA-approved drugs funded partly by CIRM, can cost about $20,000 for 120 capsules, according to GoodRx.

“We’re socializing the risk of drug development and privatizing the gains,” Sarpatwari said.

On paper, the institute has stricter pricing regulations than the NIH, which does not require that drugs developed with public money are accessible to the public. In California, companies have to submit plans for how uninsured patients will get medicine and are required to sell those medications to the state’s public health programs at a specified rate.

But in practice, the regulations have never really been tested.

Proposition 14 would add a new rule. It would take the money California makes from royalties and use it to help patients afford those treatments. It also benefits drug companies: Whatever revenue the state makes from these drugs will go back to the companies in the form of state-financed patient subsidies.

The measure also would establish a new working group (complete with 15 new, full-time staffers) that would help make clinical trials more affordable for patients by paying for lodging and transportation to the trials.

And it would increase the size of CIRM’s governing board from 29 to 35. This contradicts recommendations from the Institute of Medicine, which suggested shrinking the board to avoid conflicts of interest. Klein argues the extra board positions are necessary to represent different regions and areas of expertise.

Ultimately, California voters must weigh the possibility of new treatments against the cost of financing them with debt.

“We want to develop new therapies, and initiatives like what California is doing are well positioned to do that,” Sarpatwari said. “But at the end of the day, they’re only as good as people being able to access them affordably.”



This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Biden’s Big Health Agenda Won’t Be Easy to Achieve

If Joe Biden wins the presidency in November, health is likely to play a high-profile role in his agenda. Just probably not in the way he or anyone else might have predicted.

Barring something truly unforeseen, it’s fairly certain that on Jan. 20 the U.S. will still be in the grip of the coronavirus pandemic — and the economic dislocation it has caused. Coincidentally, that would put a new President Biden in much the same place as President Barack Obama at his inauguration in 2009: a Democratic administration replacing a Republican one in the midst of a national crisis.

Obama had only a financial crisis to deal with. Still, Biden would have a couple of advantages his Democratic predecessor lacked, including the fact that, as vice president, he helped guide the country through that financial meltdown. He’s also had time to plan how to address the crisis, which was not the case in 2009, when the economy was in freefall just as the new administration was taking office.

But like Obama before him, Biden will face a long must-do list on taking office. He will have to tackle the pandemic and economic crisis before he can turn to some of the big health changes he’s promised, such as expanding the reach of the Affordable Care Act, creating a “public option” that would allow every American to enroll in a government-sponsored plan and lowering the eligibility age for Medicare from 65 to 60.

And even if Democrats do retake the Senate majority and keep control of the House, it is unlikely the majority in either chamber will be as large as in 2009, when Obama had 60 Senate votes.

Still, no matter what the partisan makeup of Congress, “priority one is to get the COVID response going,” said Len Nichols, a professor of health policy at George Mason University.

Biden’s COVID plan includes taking major responsibility for the pandemic back from the states. His federal response would include more money for, and coordination of, testing and contact tracing; ensuring adequate protective equipment for health professionals; and assuring the public that new treatments and vaccines will be based on science, not politics.

In an updated version of his plan, Biden has also promised that one of his first calls if he is elected will be to Dr. Anthony Fauci, the government’s top infectious disease expert, who has been derided by President Donald Trump. “Dr. Fauci will have full access to the Oval Office and an uncensored platform to speak directly to the American people — whether delivering good news or bad,” says Biden’s website.

Biden’s COVID plan also addresses the economy — including calls for emergency paid leave for workers dislocated by the pandemic and more financial aid for workers, families and small businesses.

“If we’ve learned anything, it is that the health sector and the economy are not two separate spheres. They are connected,” said Nichols. “I think health care and the economy are complementary and will be for the foreseeable future.”

Assuming Biden gets beyond the pandemic and recession, he could move onto some of his bigger health promises, including expanding eligibility for Medicare, creating a “public option” health plan and boosting premium subsidies for the ACA.

Biden took heat throughout the primaries for his “moderate” approach to improving health insurance access and costs, compared with the “Medicare for All” plans for a government-run system supported by his top rivals, Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.). But that doesn’t mean his far less sweeping approach would be easy to get through Congress.

“There’s a really big difference when you’re running the government than when you’re running for office,” said Dan Mendelson, a former Clinton administration health official and founder of the health consulting firm Avalere Health.

Many of Biden’s proposals, including a public option and larger subsidies to help low- and middle-income people pay for insurance, are the very things that an overwhelmingly Democratic Congress could not pass as part of the original Affordable Care Act in 2010. Conservative Democratic senators objected to the plan.

“We pushed,” Obama said in a recent interview on the podcast “Pod Save America,” talking about the public option. “I needed 60 votes to get it through the Senate. Joe Lieberman, Ben Nelson and a couple others said, ‘I’m not voting for a public option.’”

Mendelson said another big obstacle is that for all the detail Biden has in his health plan, concepts like the public option “are not well-defined, and there are many different theories of what it should be and where it should be fielded. There’s no common vision about what it really means.”

The same thing is true, he added, for something that seems as simple as reducing the Medicare eligibility age. “More than half these people have commercial insurance,” he said. “What will happen to them?”

Grace-Marie Turner, of the conservative Galen Institute, suggested Biden — or Trump, if he’s reelected — might be better served by pursuing one of the more bipartisan health issues that already have broad support from the public, like prescription drug prices or “surprise” medical bills patients receive after getting care from a doctor outside their insurance network while being treated at an in-network facility. “It would be a big statement,” she said. “Whoever wins would then have the wind at their back.”

But even those issues have a way of getting complicated. Both Democrats and Republicans say they want to bring down drug prices, but Republicans are vehemently against one of the Democrats’ preferred ways of doing that: by allowing Medicare to negotiate with drugmakers. And surprise medical billing has so far defied efforts to fix it, as Congress seems unable to choose between health insurers and health providers, who each want the other to bear the additional costs.

As always, even when health is at the top of the agenda, it proves difficult to address.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Despite Pandemic Threat, Gubernatorial Hopefuls Avoid COVID Nitty-Gritty

Just 15 days ahead of the election, Montana Lt. Gov. Mike Cooney laid out his ideas on how he’d handle the COVID-19 pandemic if elected governor. Details were few, but the Democrat’s plan became one of only a handful being offered by candidates in the 11 U.S. governor’s races about how they’ll approach what’s certain to be the dominant issue of their terms, should they win.

While much of the nation’s focus is on who will be president come January, voters who are deciding the next occupant of their governor’s mansion are also effectively choosing the next leader of their state’s COVID-19 response. The virus has made governors’ power highly visible to voters. As the states’ top executives, they decide whether to issue mask mandates, close businesses and order people to stay home.

All but two races for governor feature incumbents running for reelection: Montana’s Democratic Gov. Steve Bullock can’t run again because of term limits and Utah’s Republican Gov. Gary Herbert decided not to run for another term. In several other competitive races for governor this year, such as those in North Carolina and Missouri, opponents clash on the role of state mandates in slowing the virus. Still, COVID-19 often fades into the backdrop of many long-standing platforms or primarily comes up as candidates talk about the need to revive the economy.

Cooney’s proposal, released Monday, suggested using the National Guard to transport patients in extreme weather and subsidizing heating bills to help those quarantining at home. But other parts vaguely described how he would “develop a robust plan” to come.

His opponent, Republican U.S. Rep. Greg Gianforte, has acknowledged the health crisis but has focused primarily on the economy, saying the state has to “cure the economic pandemic” the virus caused.

Bryce Ward, a health economist with the University of Montana, said Cooney’s list was one of the first times he’s seen long-term planning for COVID-19 come up in what appears to be the nation’s tightest governor’s race. But, he added, neither Montana candidate has offered a concrete plan to deal with the dual crises that risk public health when people gather and businesses’ bottom lines when they don’t. Meanwhile, the state’s number of COVID-19 cases climbs and its economy suffers.

“Whoever wins, this is going to be the bulk of their term,” Ward said. “How are the candidates going to keep people afloat as long as they can? What are we doing in terms of planning for what we think our post-COVID world is going to look like?”

An October KFF poll found 29% of registered voters said the economy was the most important issue in choosing a president, while 18% said the coronavirus outbreak was their top issue. Republican voters were more likely to pick the economy, the survey found, and Democrats were more likely to pick the coronavirus. (KHN is an editorially independent program of KFF.)

“There are voters that feel that the government needs to lead, and there are voters that feel that the government is utilizing a pandemic to become too invasive,” said Capri Cafaro, a former Democratic Ohio state senator now teaching in American University’s public administration and policy department. “People are not necessarily making their decisions on ‘Did you do contact tracing? Are you going to slow the spread?’”

Among the incumbent governors seeking reelection this year, most of their campaigns’ focus on COVID-19 has been on how well they’ve responded to the crisis. Several pledge more of what they’ve been doing. “We’ll continue to follow the science and wear masks,” Delaware Democratic Gov. John Carney said in a recent debate.

Meanwhile, their challengers generally seek to cast the incumbents as mismanaging their states’ response and promising to undo what’s been done. Those who have put out actual plans to handle the pandemic are Democratic challengers to Republican governors, and their plans are similar to what Cooney released — some specific ideas and promises to fill in the gaps later.

In Missouri, Democratic challenger Nicole Galloway, who is the state auditor, made health care the center of her campaign and released a plan to respond to the virus with a statewide mask mandate and a limit on when public school classes can meet in person based on the community’s rate of infection.

Republican Gov. Mike Parson is the apparent front-runner in that state’s race. He has pledged to lead “the greatest economic comeback that we’ve ever seen in Missouri history.” The former Polk County sheriff also has focused on supporting law enforcement amid backlash against police brutality and racial injustice.

Curbing the coronavirus has taken a back seat to boosting the economy in Parson’s campaign. And, as governor, Parson has refused to issue a statewide mask mandate, despite a White House recommendation to do so. In late September, the governor and his wife tested positive for COVID-19. Parson has returned to work, which includes traveling across the state.

One of the more heated races is in North Carolina, where Democratic Gov. Roy Cooper is defending his seat against a challenge by his lieutenant governor, Republican Dan Forest. Forest sued Cooper this year to challenge the governor’s authority to impose COVID-related restrictions by executive order.

Forest dropped the lawsuit in August after a judge made a preliminary ruling against his case, then said on Twitter, “I did my part. If y’all want your freedoms back you’ll have to make your voices heard in November.”

Cooper’s campaign called the lawsuit “a desperate tactic to garner attention” for Forest’s political campaign. Since then, the governor has slowly eased COVID restrictions, updating an executive order to allow a limited number of people in bars, sporting events, movie theaters and amusement parks. Cooper is leading the race in recent polls.

Back in Montana, the pandemic surfaced in the gubernatorial campaign after health officials announced on Oct. 16 that a Helena concert, which Gianforte attended, was linked to several COVID-19 cases. More than 100 health professionals blasted him in an open letter for flouting local health restrictions, going maskless and making light of safety precautions at campaign events. Cooney called on him to suspend his campaign events until tested. Gianforte’s campaign has said he’s taking proper precautions and accused Cooney of politicizing a public health issue.

Cooney has said he’ll keep Montana’s COVID-19 response on the track he is helping set as lieutenant governor, with science guiding that work. Gianforte, who built a tech startup in Bozeman, has touted his business experience as proof he can lead Montana’s comeback. Both have said more needs to be learned about this virus and have pitched themselves as the one to steer the state’s economy through the crisis.

Ward, the University of Montana health economist, said the details are missing, such as how the winner will support businesses through the winter without federal aid. Or what the new governor would cut from the state budget if the economic crisis hits its coffers.

The state has a public mask mandate and a plan for reopening the economy with no apparent thresholds or timelines. The option for stricter rules has been left to county governments as the state sees its largest COVID surge yet.

Jeremy Johnson, a political scientist at Carroll College in Helena, said the initial lack of detailed pandemic policy in the state’s race could be attributed to both candidates trying to win over swing voters with safe themes. President Donald Trump won Montana in 2016 by 20 points, but the state has also had a Democratic governor for 16 years. While polls show Gianforte leading Cooney slightly, election handicappers Real Clear Politics and the Cook Political Report still consider the race a toss-up.

Yet as Election Day nears, the question of how to address the pandemic only looms larger. Montana’s case count is rising, adding to its total of more than 23,000 cases in the state of roughly 1 million.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Health Care Groups Dive Into Property Tax Ballot Fight, Eyeing Public Health Money

SACRAMENTO — A November ballot initiative to raise property taxes on big-business owners in California is drawing unconventional political support from health care power players and public health leaders.

They see Proposition 15 as a potential savior for chronically underfunded local health departments struggling to respond to the worst public health crisis in more than a century. The initiative would change California’s property tax system to tax some commercial properties higher than residential properties, which backers say could generate billions to help local governments pay for critical public health infrastructure and staffing.

Without such additional state or federal funding, local governments could be forced to make deeper budget cuts in health and other departments next year as the COVID-19 pandemic continues to strain city and county finances.

“When you’re talking about health care, you’re talking about money,” said Anthony Wright, executive director of Health Access California, a Sacramento-based consumer advocacy group. “This is the major revenue measure on the ballot this year, and it’s an opportunity to fund public health at the place where the main responsibility for public health lies — at the county level.”

At least that’s how health care advocates are casting the tax hike. But there’s no guarantee that if the measure passes counties would use new revenue to address COVID-19 or other health care needs. And some rural counties fear they would lose money if the ballot measure passes, which could undercut public health efforts.

Support within the health care and local government worlds is not unanimous. The powerful California Hospital Association opposes the measure because it would result in higher taxes on private and investor-owned hospitals, said spokesperson Jan Emerson-Shea. Nonprofit hospitals, including those run by Sutter Health, Kaiser Permanente and Dignity Health, are exempt from paying property taxes despite their regular high revenue. They would remain exempt under the initiative. (KHN, which produces California Healthline, is not affiliated with Kaiser Permanente.)

“This new tax will mean millions of dollars will be taken away from patient care, in perpetuity,” Emerson-Shea said.

Proposition 15 would amend California’s landmark 1978 property tax initiative, Proposition 13, which capped commercial and residential property tax rates at 1% of assessed value at the time of purchase, and limited annual increases thereafter to 2%. The drop in property taxes as a result of the initiative decimated a major revenue source for public schools and social welfare programs, leaving many underfunded.

Voters are now being asked to allow higher taxes for business owners with commercial holdings valued at more than $3 million. If passed, the measure could generate up to $11.5 billion a year, according to the nonpartisan state Legislative Analyst’s Office. It would not apply to residential properties.

Forty percent of annual revenue would be distributed to K-12 schools and community colleges, with 60% sent to cities and counties. Nothing in the measure would require new local revenue to be spent on health care, but supporters say it’s their best hope after losing $134 million in state public health money this year as one-time funding for specific programs expired. At the same time, slammed by a projected $54 billion deficit, Gov. Gavin Newsom and state lawmakers declined this year to increase funding for local health departments to combat COVID-19 and rebuild public health infrastructure.

Sponsors of Proposition 15, including the California Teachers Association and the Service Employees International Union California, argue it’s an overdue change that would tax wealthier enterprises in exchange for funding vital school and health care programs. They point out that the initiative, supported by Newsom and Democratic presidential nominee Joe Biden, would require schools and local governments to disclose all new revenue they receive and how money is spent.

If passed, money from the measure would begin flowing to schools and counties in 2022 at the earliest.

Opponents of the measure, including the California Chamber of Commerce, the California Republican Party and the Howard Jarvis Taxpayers Association, say hiking taxes on commercial property owners would harm struggling businesses hit hard by COVID-related closures.

“This is being pushed as a panacea cure-all, but at the end of the day, there is no accountability for where these funds go,” said Michael Bustamante, a spokesperson for the “No on Prop 15” campaign. “There are, without question, an infinite number of needs, but there is no specificity with what it can or can’t be spent on.”

Kat DeBurgh, executive director of the Health Officers Association of California, which represents the state’s 61 local health officers and has not taken a position on the initiative, said ongoing, unrestricted revenue could actually benefit counties by allowing them to spearhead public health programs that address local needs.

At present, counties are limited in what they can do with their public health dollars, she said. Most additional funding in recent years has largely been earmarked for specific programs or diseases, such as hepatitis C and HIV, and counties are not allowed to spend it on their COVID-19 response or other public health activities.

“Maybe your community’s highest priority is not something easily funded by one of these grants. Many rural areas in our state don’t have access to clean drinking water, for example,” DeBurgh said. “And our greatest demand — more public health workers — can’t be funded with grants or one-time money.”

Health care leaders also argue the initiative could help support community clinics and public hospitals that provide care for uninsured people, who have also suffered financially during the pandemic.

“What we’re really trying to avoid is having to balance the budget on the backs of people who need services,” said Jodi Hicks, president and CEO of Planned Parenthood Affiliates of California. “Our public health system has clear inequities that we need to address, and additional funding can help fill in the gaps at the county level.”

Hicks said Planned Parenthood, which provides sex education in California public schools, is supporting the initiative not only to improve public health, but also because she worries programs like sex education will be on the chopping block as the state experiences unprecedented job and economic losses.

“Those types of programs are the first to get cut when there’s not enough funding,” she said.

Small, rural counties could also lose funding, county assessors said.

While the initiative would likely raise taxes on large commercial property owners who have seen their land and property appreciate in value over the years, it would eliminate property taxes for other business assets, such as machinery and equipment, for the first $500,000 in value.

Counties that haven’t seen land values climb as high as those in coastal regions like the Bay Area may not collect more property taxes while also losing revenue from the tax cut on other business assets.

Chuck Leonhardt, the elected assessor for rural Plumas County, projects that his county could be one of the losers.

“This would take $90 million in assessed value from our tax roll at the beginning, and then I’d have to reassess 2,000 commercial properties,” he said. “Many of us rural counties don’t feel we’ll benefit from doing these reappraisals and my expectation is we could lose some money.”

Even among supporters in public health, some fear that any potential windfall for counties would be allocated based on the whims of local politics.

“Even though I support it, I am skeptical that this money will go to the public health programs and basic infrastructure we so desperately need because public health has no constituency,” said Bruce Pomer, a public health expert and chief lobbyist for the California Association of Public Health Laboratory Directors.

He pointed to Sacramento County, where the sheriff’s department received a larger share of the $181 million in federal COVID-19 relief money than the county public health department.

“I’m worried we’ll see the same thing we saw with Sacramento County,” Pomer said.



This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Al sopesar los temas de salud, la mayoría de los votantes se inclinan hacia Biden

Al menos la mitad de los votantes prefiere el enfoque de la atención médica del ex vicepresidente Joe Biden al del presidente Donald Trump, lo que sugiere que la preocupación por reducir los costos y manejar la pandemia podría influir en el resultado de esta elección, según revela una nueva encuesta.

Los hallazgos, de la encuesta mensual de KFF, indican que los votantes no confían en las garantías del presidente de que protegerá a las personas con condiciones preexistentes de las compañías de seguros si la Corte Suprema anulara la Ley de Cuidado de Salud a Bajo Precio (ACA).

Un mes antes de que el tribunal escuche los argumentos de los fiscales generales republicanos y la administración Trump a favor de revocar la ley, la encuesta muestra que el 79% del público no quiere que el Supremo cancele las protecciones de cobertura para los estadounidenses con afecciones preexistentes. La mayoría de los republicanos, el 66%, dijo que no quiere que se anulen esas garantías.

Además de dejar a unos 21 millones de estadounidenses sin seguro, revocar ACA podría permitir a las compañías de seguros cobrar más o negar cobertura a las personas porque tienen condiciones preexistentes, una práctica común antes que se estableciera la ley, y que un análisis del gobierno reveló en 2017 que podría afectar hasta a 133 millones de estadounidenses.

Casi 6 de cada 10 personas dijeron que tenían un familiar con una condición preexistente o crónica, como diabetes, hipertensión, o cáncer, y aproximadamente la mitad dijo que les preocupa que un ser querido no pueda pagar la cobertura, o la pierda por completo, si se anulara la ley.

La encuesta revela una preferencia sorprendente por Biden sobre Trump cuando se trata de proteger a las personas con condiciones preexistentes, un tema que el 94% de los votantes dijo que ayudaría a decidir por quién votar. Biden tiene una ventaja de 20 puntos: un 56% prefiere su enfoque, contra un 36% para Trump.

De hecho, el sondeo muestra una preferencia por Biden en todos los problemas de atención médica que se plantean, incluso entre los mayores de 65 años y en temas que Trump ha dicho que eran sus prioridades mientras estuviera en el cargo, lo que indica que los votantes no están satisfechos con el trabajo del presidente para reducir los costos de la atención médica, en particular. El apoyo a los esfuerzos de Trump para reducir el precio de los medicamentos recetados ha disminuido, y los votantes ahora prefieren el enfoque de Biden, del 50% al 43%.

La mayoría de los votantes dijeron que prefieren el plan de Biden para lidiar con el brote de COVID-19, 55% a 39%, y para desarrollar y distribuir una vacuna para COVID, 51% a 42%. Trump ha delegado en gran medida la gestión de la pandemia a los funcionarios estatales y locales, al tiempo que prometió que los científicos desafiarían las expectativas y producirían una vacuna antes del día de las elecciones.

Cuando se les preguntó qué tema era más importante para decidir por quién votar, la mayoría de los encuestados señaló a la atención médica. El 18% eligió el brote de COVID-19 y el 12% mencionó el cuidado de salud en general. Casi una proporción igual, el 29%, optó por la economía.

La encuesta se realizó del 7 al 12 de octubre, después del primer debate presidencial y el anuncio de Trump de que había dado positivo para COVID-19. El margen de error es más o menos 3 puntos porcentuales para la muestra completa y 4 puntos porcentuales para los votantes.

(KHN es un programa editorialmente independiente de KFF).

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Majority of Voters Tilt Toward Biden as Health Issues Weigh Heavily

At least half of voters prefer former Vice President Joe Biden’s approach to health care over President Donald Trump’s, suggesting voter concern about lowering costs and managing the pandemic could sway the outcome of this election, a new poll shows.

The findings, from KFF’s monthly tracking poll, signal that voters do not trust assurances from the president that he will protect people with preexisting conditions from being penalized by insurance companies if the Supreme Court overturns the Affordable Care Act. (KHN is an editorially independent program of KFF.)

Coming a month before the court will hear arguments from Republican attorneys general and the Trump administration that the health law should be overturned, the poll shows 79% of the public does not want the court to cancel coverage protections for Americans with preexisting conditions. A majority of Republicans, 66%, said they do not want those safeguards overturned.

In addition to leaving about 21 million Americans uninsured, overturning the ACA could allow insurance companies to charge more or deny coverage to individuals because they have preexisting conditions — a common practice before the law was established, and one that a government analysis said in 2017 could affect as many as 133 million Americans.

Nearly 6 in 10 people said they have a family member with a preexisting or chronic condition, such as diabetes or cancer, and about half said they worry about a relative being unable to afford coverage, or lose it outright, if the law is overturned.

The poll reveals a striking preference for Biden over Trump when it comes to protecting preexisting conditions, an issue that 94% of voters said would help decide who they vote for. Biden has a 20-point advantage, with voters preferring his approach 56% to 36% for Trump.

In fact, it shows a preference for Biden on every health care issue posed, including among those age 65 and older and on issues that Trump has said were his priorities while in office — signaling voters are not satisfied with the president’s work to lower health care costs, in particular. Support for Trump’s efforts to lower prescription drug costs has been slipping, with voters now preferring Biden’s approach, 50% to 43%.

A majority of voters said they prefer Biden’s plan for dealing with the COVID-19 outbreak, 55% to 39%, and for developing and distributing a vaccine for COVID-19, 51% to 42%. Trump has largely left it up to state and local officials to manage the outbreak, while promising that scientists would defy expectations and produce a vaccine before Election Day.

Asked which issue is most important to deciding whom to vote for, most pointed to health care issues, with 18% choosing the COVID-19 outbreak and 12% saying health care overall. Nearly an equal share, 29%, selected the economy.

The survey was conducted Oct. 7-12, after the first presidential debate and Trump’s announcement that he had tested positive for COVID-19. The margin of error is plus or minus 3 percentage points for the full sample and 4 percentage points for voters.

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KFF Health Tracking Poll – October 2020: The Future of the ACA and Biden’s Advantage On Health Care

The poll examines the public’s views on the Supreme Court case to overturn the Affordable Care Act and its protections for people with pre-existing conditions. Less than a month from the results of the 2020 presidential election, this poll examines the top issues for voters (the economy, the coronavirus pandemic, health care, criminal justice and policing, among others) as well as which candidate, Biden or Trump, they think has the better approach to handle key health care policy areas.

Election 2020: State Health Care Snapshots

Health care is a top issue for voters in the 2020 election. To understand the health care landscape in which the 2020 election policy debates will unfold, these state health care snapshots provide data across a variety of health policy subjects, including health care costs, health coverage—Medicaid, Medicare, private insurance—and the uninsured, women’s health, health status, and access to care.

Outnumbered on High Court Nomination, Democrats Campaign for a Different Vote

Democrats on the Senate Judiciary Committee know that, barring something unexpected, they lack the votes to block President Donald Trump from installing his third justice in four years on the Supreme Court and creating a 6-3 conservative majority.

They also know that, in a normal year, by mid-October Congress would be out of session and members home campaigning. But 2020 is obviously no normal year. So, while the rest of Congress is home, Democratic Judiciary members are trying something very different in the hearings for nominee Amy Coney Barrett. Rather than prosecuting their case against Barrett, currently a federal appeals court judge, they are refighting the war that helped them pick up seats in 2018 — banging on Republicans for trying to eliminate the Affordable Care Act.

Conveniently, the ACA is relevant to the Supreme Court debate because the justices are scheduled to hear a case that could invalidate the law on Nov. 10 — exactly a week after Election Day.

As California Sen. Kamala Harris, a member of the Judiciary Committee and the Democratic vice presidential candidate, put it to Barrett on Tuesday, “Republicans are scrambling to confirm this nominee as fast as possible because they need one more Trump judge on the bench before Nov. 10th to win and strike down the entire Affordable Care Act. This is not hyperbole. This is not hypothetical. This is happening.”

Said Sen. Richard Durbin (D-Ill.), also on Tuesday: “We really believe the Supreme Court’s consideration of that case is going — could literally change America for millions of people.”

To be sure, Republicans too were playing to their electorate during the questioning of Barrett, as they expounded on her conservative credentials on issues such as gun rights.

Nonetheless, Democrats were uniformly disciplined in their assault on her potential vote in the ACA case. They chided both Barrett and the Republicans who are rushing her nomination to the floor literally days before a presidential election. In addition, Democrats criticized Republicans for spending time on a nonemergency nomination while continuing to ignore the need for financial and other relief for the COVID-19 pandemic.

And they raised what in more normal times would be the featured talking point for Democrats: the threat to abortion and other reproductive rights from Barrett, who before her elevation to the federal bench publicly opposed abortion and taught law at Notre Dame, one of the nation’s preeminent Catholic universities.

“For many people, and particularly for women, this is a fundamental question,” said Sen. Dianne Feinstein (D-Calif.), the committee’s top Democrat.

Barrett, like every other Supreme Court nominee for the past three decades, declined to offer positions that could suggest which way she might rule on hot-button issues, including abortion and the ACA.

She repeatedly cited what has come to be called the “Ginsburg rule” — after the justice she would replace, Ruth Bader Ginsburg — saying “no hints, no previews, no forecasts.”

Still, Democrats suggested that she may have tipped her hand on the Affordable Care Act case. In pointing out that the issues in the case, now known as California v. Texas, are different from the previous cases upholding the health law in 2012 and 2015, she said the current case will turn on “severability.”

She was referring to the question of whether, if one portion of a law is found to be unconstitutional, the rest of the law can stand without it. In the current ACA case, a group of Republican attorneys general — and the Trump administration — are arguing that when Congress reduced the ACA’s penalty for not having insurance to zero, the requirement to be covered no longer had a tax attached, and therefore the law is now unconstitutional. They based their argument on Chief Justice John Roberts’ 2012 conclusion that the ACA was valid because that penalty was a constitutionally appropriate tax.

The law’s opponents say the rest of the law cannot be “severed” and must therefore fall, too. A federal district judge in Texas agreed with them.

But merely saying the case turns on severability suggests that Barrett has already prejudged major parts of the case, Democrats said. Sen. Chris Coons (D-Del.) noted, “You don’t get to the question of severability if you haven’t already determined the question of constitutionality.”

Barrett insisted repeatedly that despite an article she wrote in 2017 suggesting that the 2012 case upholding the law was wrongly decided, “I have no animus to nor agenda for the ACA,” as she told Sen. Amy Klobuchar (D-Minn.) on Wednesday.

In their rare show of unity of message, Democrats made clear that their primary audience in these hearings was not their Senate colleagues, but the voting public. While this battle looks lost, they hope to win the War of Nov. 3.

HealthBent, a regular feature of KHN, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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COVID-19: las farmacéuticas elogiadas por Trump mandan dinero a Biden

Los gigantes farmacéuticos Regeneron y Gilead Sciences obtuvieron el tipo de publicidad que el dinero no puede comprar luego que el presidente Donald Trump tomara sus medicamentos experimentales para tratar su infección por coronavirus, y se declarara completamente recuperado después de dejar el hospital.

“Fue increíble. Me sentí bien de inmediato”, dijo Trump el miércoles 7 de octubre en un video posteado en Twitter. “Yo llamo a eso una cura”.

Trump elogió el cóctel de anticuerpos monoclonales de Regeneron, que imita elementos del sistema inmunológico, y mencionó un fármaco similar que Eli Lilly & Co. está investigando. El presidente también tomó remdesivir, de Gilead, un antiviral que ha acortado los tiempos de recuperación de los pacientes con COVID-19 en una investigación preliminar.

No hay evidencia científica de que alguno de estos medicamentos haya contribuido a la recuperación del presidente, ya que muchos pacientes se sienten bien sin consumirlos. Tampoco se sabe si el presidente se ha “curado”, ya que la Casa Blanca ha publicado pocos detalles sobre el curso de su enfermedad.

Sin embargo, cuando su campaña para la reelección está en la recta final, Trump no está sintiendo el afecto de las farmacéuticas a través de contribuciones. Regeneron, Gilead, Lilly y la industria en su conjunto están enviando más dinero en otra dirección.

Revirtiendo una tendencia en las contribuciones de las farmacéuticas, que enviaban mucho dinero a los republicanos, en lo que va de 2020 la industria se ha inclinado hacia los demócratas.

El cambio puede reflejar las expectativas de la industria de que gane el candidato presidencial demócrata Joe Biden, dijo Steven Billet, quien imparte cursos de cabildeo corporativo y donaciones políticas en la Universidad George Washington. Las farmacéuticas podrían usar esta “generosidad” a su favor si Biden cumple sus promesas de abordar los altos precios de los medicamentos, agregó.

En un año en el que las quejas sobre los altos precios de los medicamentos de venta bajo receta se vieron ensombrecidas por la pandemia, los donantes vinculados con las farmacéuticas han dado alrededor de $976,000 a Biden, según datos del Center for Responsive Politics (CRP).

Eso es casi tres veces las contribuciones de las farmacéuticas a Trump, quien recientemente pasó de llamar a los altos precios “estafas”, a describir a las farmacéuticas como “grandes empresas”.

“Tradicionalmente, la industria tiende a favorecer a los republicanos”, dijo Sarah Bryner, directora de investigación de CRP. “Pero este ciclo, estamos viendo que cambió”, lo que refleja en parte el mayor éxito general de los demócratas en la recaudación de fondos, explicó.

Las compañías farmacéuticas y sus grupos comerciales tienen un historial de apoyo a Trump y otros republicanos indirectamente a través de organizaciones sin fines de lucro de “dinero oscuro” difíciles de rastrear. Pero esas contribuciones pueden no ser divulgadas hasta mucho después de la elección, si es que alguna vez se conoce.

De los $177,000 que Regeneron ha otorgado hasta ahora a los candidatos federales de 2020, cuatro quintas partes se han destinado a los demócratas, incluidos $35,203 para Biden, según CRP.

Leonard Schleifer, director ejecutivo de Regeneron, un multimillonario que conoce a Trump desde hace años y pertenece al Trump National Golf Club Westchester, en Nueva York, tiene una larga historia de donaciones a los demócratas. Dio $5,400 a la carrera presidencial de Hillary Clinton en 2016 y $120,000 en 2018 a un comité de acción política que intentaba que los demócratas volvieran a controlar el Senado.

Schleifer no ha hecho donaciones políticas registradas desde el año pasado, cuando sus contribuciones fueron principalmente para su hijo, Adam Schleifer, un demócrata que se postulaba para el Congreso y que perdió en una primaria este verano.

El senador de Carolina del Norte Thom Tillis, que representa a un estado con una gran industria biotecnológica y que se postula para la reelección en una contienda reñida, ha sido el mayor receptor republicano de dólares de Regeneron para las elecciones de 2020, con un total de $5,526 hasta ahora.

“Esta es una compañía que parece que siempre ha estado comprometida con los demócratas”, dijo Billet, un ex cabildero de AT&T que enseña administración de PAC. “Y supongo que solo tienen una cultura demócrata en esta empresa”.

Un vocero de Regeneron, que solicitó una autorización de uso de emergencia para eludir el proceso de aprobación de la Administración de Alimentos y Medicamentos (FDA) para su medicamento, se negó a comentar sobre las donaciones de la campaña y dijo que la compañía continuará los ensayos clínicos.

Se espera que una dosis del medicamento cueste miles de dólares. “Los tendrás gratis”, dijo Trump sobre los medicamentos para COVID-19 que tomó. El gobierno acordó hacer que las dosis iniciales del tratamiento con anticuerpos de Regeneron “estén disponibles para el pueblo estadounidense sin costo”, dice la compañía.

Pero los detalles del contrato, incluido el precio, permanecieron en secreto. En cualquier caso, si los pacientes obtienen el medicamento sin costo directo, “no significa que no lo estén pagando”, dijo James Love, director de Knowledge Ecology International, una organización sin fines de lucro que trabaja para ampliar el acceso a la tecnología médica. “Simplemente lo pagan a través de impuestos”.

El gobierno le está dando a Regeneron $450 millones para fabricar y suministrar el cóctel de anticuerpos.

Los donantes con vínculos con Gilead también se inclinan hacia la izquierda, dando dos tercios de sus aproximadamente $284,000 en contribuciones hasta ahora en este ciclo a candidatos demócratas al Congreso y a la presidencia, muestran datos de CRP, incluidos alrededor de $36,000 a Biden.

En Lilly, donde el secretario de Salud y Servicios Humanos, Alex Azar, dirigió una vez la división estadounidense, el 54% del dinero se destinó a los demócratas y el 46% a los republicanos. Los empleados de Lilly han donado  $45,000 a Biden y $13,000 a Trump, según CRP.

Biden no acepta donaciones de PAC corporativos; todos sus dólares de Regeneron, Lilly y Gilead fueron de empleados de la farmacéutica.

Gran parte del cambio general de los laboratorios este año hacia los demócratas se produce en la carrera presidencial. Los datos de Pharma Cash to Congress de KHN que monitorea a los miembros en funciones todavía muestran una preferencia hacia los republicanos del Congreso, $6 millones hasta ahora en comparación con $4,7 millones otorgados a los demócratas.

“Joe Biden tiene a las grandes farmacéuticas, así como a las grandes tecnológicas y a los grandes bancos, en su bolsillo porque ha trabajado para ellos durante casi 50 años, en lugar de para el pueblo estadounidense”, dijo Samantha Zager, vocera de la campaña de Trump.

En la campaña electoral, Biden se ha centrado principalmente en mejorar el seguro médico. Pero también propone dejar que Medicare negocie los precios de los medicamentos, vincular los aumentos de precios a la inflación y permitir que los pacientes compren medicamentos importados.

Biden “reducirá aún más los costos de atención médica mientras expande la cobertura, pone fin a prácticas de facturación sorpresa, primas más bajas y se enfrentará a los abusos de poder de las farmacéuticas”, dijo Rosemary Boeglin, vocera de la campaña.

Antes que Trump asumiera el cargo, dijo que las compañías farmacéuticas se estaban “saliendo con la suya” por los precios que cobran. A pesar de las afirmaciones y promesas del presidente, ha hecho poco para reducir los precios de los medicamentos recetados, según expertos y verificadores de datos.

Una orden ejecutiva de Trump este mes requeriría que Medicare no pague más por los medicamentos que otras naciones desarrolladas, pero comienza con un programa de prueba y su implementación podría demorar meses o años.

Las farmacéuticas estuvieron entre los mayores beneficiarios del recorte de impuestos de 2017 de Trump, ahorrando miles de millones al poder traer a casa efectivo extranjero libre de impuestos y miles de millones más con tasas más bajas.

Elizabeth Lucas, editora de datos de KHN, colaboró con este informe.

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KHN on the Air This Week

KHN reporter Victoria Knight discussed this week’s vice presidential debate with Newsy’s “Morning Rush” on Thursday.

KHN chief Washington correspondent Julie Rovner discussed Trump’s COVID-19 diagnosis on WFAE’s “Charlotte Talks” on Monday. She discussed the public’s right to know about the president’s health with Wisconsin Public Radio’s “Central Time” on Tuesday.

KHN correspondent Rachana Pradhan discussed COVID testing at the White House with Newsy’s “Morning Rush” on Tuesday.

KHN Montana correspondent Katheryn Houghton discussed Seeley Lake’s long-term wildfire smoke health effects on Los Angeles Times’ “Second Opinion” on Oct. 2.

KHN correspondent Aneri Pattani discussed COVID-19 and herd immunity on Newsy’s “The Briefing” on Oct. 1.

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As Trump Touts His ‘Great’ COVID Drugs, the Pharma Cash Flows to Biden, Not Him

Pharmaceutical giants Regeneron and Gilead Sciences got the kind of publicity money can’t buy this week after President Donald Trump took their experimental drugs for his coronavirus infection, left the hospital and pronounced himself fully recovered.

“It was, like, unbelievable. I felt good immediately,” Trump said Wednesday in a tweeted video. “I call that a cure.”

He praised Regeneron’s monoclonal antibody cocktail, which mimics elements of the immune system, and mentioned a similar drug under investigation by Eli Lilly and Co. The president also took Gilead’s remdesivir, an antiviral that has shortened recovery times for COVID-19 patients in early research.

There is no scientific evidence that any of these drugs contributed to the president’s recovery, since many patients do fine without them. It is also not known whether the president has been “cured,” since the White House has released few specifics about the course of his illness.

Yet as his campaign for reelection enters its final stretch, Trump is not feeling the love in campaign contributions. Regeneron, Gilead, Lilly and the industry as a whole are sending more money elsewhere.

Reversing a trend in which contributions from drugmakers’ political committees and their employees have gone largely to Republican candidates for president and Congress, so far for 2020 the industry has tilted toward Democrats.

The shift may reflect industry expectations that Democratic presidential candidate Joe Biden will win, said Steven Billet, who teaches courses in corporate lobbying and political donations at George Washington University. Pharma companies may see campaign largesse as leverage if Biden follows through on promises to address high drug prices, he said.

In a year when complaints about high prescription drug prices have been overshadowed by the pandemic, donors with ties to pharma manufacturers have given around $976,000 to Biden, according to data from the Center for Responsive Politics. That’s nearly three times the pharma contributions to Trump, who recently switched his tune from complaining about “rip-off” prescription prices to describing drug firms as “great companies.”

“Traditionally the industry tends to favor Republicans,” said Sarah Bryner, CRP’s research director. “But this cycle, we’re seeing that flipped,” partly reflecting Democrats’ overall greater success in fundraising, she said.

Of $177,000 given so far to 2020 federal candidates by Regeneron’s employees and political action committee, four-fifths have gone to Democrats, including $35,203 to Biden, according to CRP.

Regeneron CEO Leonard Schleifer, a billionaire who has known Trump for years and belongs to the Trump National Golf Club Westchester in New York’s Westchester County, has a long history of giving to Democrats. He gave $5,400 to Hillary Clinton’s 2016 presidential run and $120,000 in 2018 to a political action committee attempting to flip the Senate to Democratic control.

Schleifer has made no registered political donations since last year, when his contributions went mainly to his son, Adam Schleifer, a Democrat running for Congress who lost in a primary this summer.

North Carolina Sen. Thom Tillis, representing a state with a large biotech industry and running for reelection in a tight race, has been the biggest Republican recipient of Regeneron dollars for 2020 races, tallying $5,526 so far.

“This is a company that looks as though they’ve always been committed to Democrats,” said Billet, a former AT&T lobbyist who teaches PAC management. “And my guess is they just have a Democratic culture in this company.”

A spokesperson for Regeneron, which has applied for emergency use authorization to bypass the Food and Drug Administration approval process for its drug, declined to comment on campaign donations and said the company will continue clinical trials.

The drug is expected to cost thousands of dollars per dose. “You’re going to get them for free,” Trump said of the COVID-19 drugs he took. The government has agreed to make initial doses of Regeneron’s antibody treatment “available to the American people at no cost,” the company says.

But details of the contract, including the price, remained secret. In any event, if patients get the drug at no direct cost, “it doesn’t mean they’re not paying for it,” said James Love, director of Knowledge Ecology International, a nonprofit that works to expand access to medical technology. “They’re just paying for it through taxes.”

The government is giving Regeneron $450 million to make and supply the antibody cocktail.

Donors with Gilead ties also lean left, giving two-thirds of their roughly $284,000 in contributions so far this cycle to Democratic candidates for Congress and president, the CRP data shows, including about $36,000 to Biden.

At Lilly, where Health and Human Services Secretary Alex Azar once ran the U.S. division, 54% of the money has gone to Democrats and 46% to Republicans. Lilly employees have given $45,000 to Biden and $13,000 to Trump, according to CRP.

Biden does not accept donations from corporate PACs; all his Regeneron, Lilly and Gilead dollars came from their employees.

Much of this year’s overall pharma shift to Democrats comes in the presidential race. KHN’s Pharma Cash to Congress data tracking sitting members still shows a preference this cycle of pharma PACs targeting congressional Republicans, $6 million so far compared with $4.7 million given to Democrats.

“Joe Biden has Big Pharma — as well as Big Tech and big banks — in his pocket because he’s worked for them for nearly 50 years, rather than the American people,” said Samantha Zager, a spokesperson for the Trump campaign.

On the campaign trail, Biden has focused largely on improving health insurance. But he also proposes letting Medicare negotiate drug prices, tying drug-price increases to inflation and allowing patients to buy imported pharmaceuticals.

Biden “will further reduce health care costs while expanding coverage, end practices like surprise billing, lower premiums and stand up to abuses of power by prescription drug companies,” said campaign spokesperson Rosemary Boeglin.

Before Trump took office, he said pharma companies were “getting away with murder” over the prices they charge. Despite the president’s claims and promises, he has done little to lower prescription drug prices, according to experts and fact-checkers.

A Trump executive order this month would require Medicare to pay no more for drugs than other developed nations, but it starts with a test program and could take months or years to implement.

Pharma companies were among the biggest beneficiaries of Trump’s 2017 tax cut, saving billions by being able to bring home untaxed foreign cash and billions more in lower rates.

KHN data editor Elizabeth Lucas contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Pandemic Erects Barriers for Prized Bloc of Voters in Nursing Homes, Senior Facilities

The convergence of the coronavirus pandemic and election season has complicated this year’s voting for residents of nursing homes, assisted living facilities and other long-term care centers.

Many seniors who need help to get or fill out their ballots may be stymied by shifting rules about family visits. Voting procedures — whether in person or by mail — are under increased scrutiny, adding to the confusion. Facilities that used to host voting precincts likely won’t do so this year because of concerns about the spread of COVID-19.

“We’re basically not allowed to go out into the public right now, we’re more vulnerable, and our immune systems are compromised anyway,” said Janice Phillips, a 14-year resident of Village Square Healthcare Center, a skilled nursing facility in San Marcos, California. “We’re basically locked in.”

Phillips, 75, who has rheumatoid arthritis, has voted by absentee ballot for years without problems. This year she is encouraging her fellow residents to vote by mail as well. She works with the facility’s activities staff, going resident by resident, to make sure folks are registered. As president of the resident council, Phillips has also raised the issue at community meetings.

Older Americans are a consistent voting bloc courted by both parties.

According to AARP, 71% of Americans 65 and older voted in the 2016 presidential election, compared with 46% of people 18-29. “For many older adults, it’s a point of pride for them that they’ve voted in every election since they were 18,” said Leza Coleman, the executive director of California’s Long-Term Care Ombudsman Association.

But hardly anyone has been allowed inside skilled nursing facilities since the start of the pandemic, except for staff members and the occasional state health official, or family members in certain circumstances. In California and beyond, facilities are beginning to open up in counties with low transmission rates, since federal rules changed in September to allow for more lenient visiting policies.

At the same time, outbreaks continue to plague some senior facilities, despite improved testing of staff and other safety measures. On Wednesday, Santa Cruz County health officials reported a major outbreak at the Watsonville Post-Acute Center, which has infected 46 residents, killing nine of them, and infecting 15 staff members.

California officials are pressing nursing homes and senior centers to give residents who want to vote the opportunity. The Department of Public Health on Oct. 5 sent a letter to all those facilities, explaining they have an obligation to inform and assist residents with voting, including what actions are permissible for staffers to undertake in helping voters. It also includes advice about maintaining a safe environment through the election by limiting nonessential visitors, properly using protective gear such as gloves and handling ballots as little as possible.

In years past, civic groups such as the League of Women Voters would stop by to give presentations on what’s on the ballot. Candidates for local office would hit nursing homes to make pitches. “In the context of a pandemic, we just can’t do it this year,” said Michelle Bishop, voter access and engagement manager with the National Disability Rights Network.

Before the pandemic, nursing homes and assisted living facilities also often served as polling places. Residents could easily access voting booths, often set up in a lobby or community room. That was especially important because nursing homes are likely to be accessible to people with mobility problems, Bishop said.

Otherwise, facilities would often organize bus trips and outings to polling places.

In California, the last day to register to vote online or by mail is Oct. 19, though voters can register in person up to and including Election Day. All registered voters will receive a ballot in the mail, and those postmarked by Nov. 3 will still be counted in California for 17 days after the election. Advocates say it’s important for newer residents at skilled nursing facilities to make sure they’ve registered at their new address or have plans to get their ballot delivered to them from their former homes.

Other states are also sending ballots to all registered voters by mail this year on various time frames. All states permit seniors or people who have trouble reaching polling stations to request an absentee ballot.

Once they have a ballot in hand, some older adults need help from family or staff at their facilities to complete it correctly and send it back to election officials. The federal directive to relax visiting rules could ease some of that pressure, but the situation varies by facility. For people whose relatives cannot help them, it may fall to staff members to set up calls and video chats between residents and their families, or provide the assistance to residents themselves.

Some states don’t allow nursing home staffers to help with ballots to avoid influencing votes. Even if they can assist, employees may be stretched too thin to help. In a year when nursing home staff members are spending an extra hour each day putting on protective gear, there isn’t always extra time to make sure every resident is registered and voting, said Dr. Karl Steinberg, chief medical officer for Mariner Health Central, a nursing home management company in California.

“There’s a perennial workforce shortage in nursing homes and it’s been exacerbated by this” pandemic, Steinberg said. “This year with all the chaos, there may be less staff time available to help people with voting.”

Tracy Greene Mintz, whose business, Senior Care Training, trains senior care workers, is responsible for staffing at 100 nursing homes in California. She said she started ringing alarm bells about voting rights in August.

“Elected officials do not care about nursing homes, period,” Greene Mintz said. “They assume residents don’t vote and don’t make contributions.”

She asked the California Department of Public Health, which surveys skilled nursing facilities every six weeks about COVID-19 infection control, to add a question on how facilities were planning for elections. The department declined.

So she set up webinars with facility administrators and the Los Angeles County Registrar-Recorder/County Clerk to go over information on how to submit and track absentee ballots.

She has also urged state officials to provide a statewide plan that facilities could use as a blueprint. She wrote one herself that was emailed out by a trade group, the California Association of Health Facilities.

Still, California is in better shape than some other states, said Raúl Macías, a lawyer with the Democracy Program at the Brennan Center for Justice, a law and public policy institute. Elsewhere, residents may have to apply for an absentee ballot, and sometimes must provide a reason they can’t vote in person.

California also has the Voter Bill of Rights, which allows individuals to designate someone to help them fill out and drop off their ballot. In some states, such as North Carolina, assistance can come only from designated bipartisan voting assistance teams, which may be harder to recruit during a pandemic, Macías said.

No matter the state, state and county elections officials and facility administrators should draft voting plans, said Bishop, of the Disabilities Rights Network. It will help staff know the proper way to assist residents without influencing their votes, and residents know their voting rights.

“There is a bit of a gray area on whose responsibility this is,” Bishop said. “It’s one of the years when we start asking ‘Whose responsibility is it?’ Who cares? We have to get it done.”

If they can’t get access to ballots or need help, California residents can contact the state’s long-term care ombudsman program, which can investigate complaints, help them resolve the issue and take the problem to the Department of Public Health if it can’t be fixed.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What the Health?’: Trump vs. COVID

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President Donald Trump’s COVID-19 diagnosis — and that of two dozen or more other officials in the White House and Capitol Hill — has scrambled an already confusing autumn. The president’s illness has thrown into doubt the remaining two presidential debates, and positive tests for several Republican senators may threaten the effort to push through a new Supreme Court justice before Election Day.

Meanwhile, it looks increasingly unlikely Congress will approve another round of economic relief before the election, even though that would be good for the president’s political fortunes and could help Democrats, too. And the Food and Drug Administration and the Centers for Disease Control and Prevention continue to fight for scientific credibility.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Kimberly Leonard of Business Insider and Erin Mershon of Stat News.

Among the takeaways from this week’s podcast:

  • Trump’s physician, Dr. Sean Conley, has been heavily criticized for his lack of transparency about the president’s health while battling the coronavirus. Conley repeatedly said federal rules under the HIPAA law limited his ability to answer reporters’ questions. That’s because HIPAA (the Health Insurance Portability and Accountability Act of 1996) requires a patient’s consent to release medical information.
  • Nonetheless, Trump’s COVID diagnosis renews questions about whether the public has a right to know the details of a president’s health status, especially this year when both candidates are older than 70. Trump’s opponent, former Vice President Joe Biden, has released only limited information, too.
  • Trump’s decision to unilaterally call off negotiations on a coronavirus relief package baffled and concerned Republican lawmakers and strategists because it undermines their narrative that the Democrats have refused to budge during talks.
  • Although the president has said he would support smaller stimulus bills that would help specific industries or consumers, it’s not clear what Congress would be willing to push out before the election. So, many Republican lawmakers are turning their attention to the upcoming hearings on the Supreme Court nomination of Amy Coney Barrett to rally support.
  • The widespread cases of COVID-19 tied to the White House highlight the president’s messages about masks, social isolation and other protective measures and have the potential to alienate voters, especially those who have lost loved ones or know people who have been afflicted with the disease.
  • Trump’s comments after coming home from the hospital urging the public to not be afraid of the virus or let it “dominate your life” have tapped into frustration by many people who have suffered from the economic consequences of the pandemic and are eager to put the issue behind them.
  • In the vice presidential debate Wednesday, Democratic Sen. Kamala Harris was criticized by Vice President Mike Pence for undermining public confidence in a vaccine when she said she wouldn’t take it if it were being pushed by Trump and not endorsed by public health officials. It’s a tricky issue for Democrats who believe Trump is using the vaccine trials to generate political support and his promise of approval by Election Day is politicizing the process. Yet, they know the public is eager for a successful vaccine.

This week, Rovner also interviews Amy Howe, co-founder of SCOTUSblog and host of the “SCOTUStalk” podcast. Howe explains what the Supreme Court might do with the latest case challenging the constitutionality of the Affordable Care Act.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The Atlantic’s “Trump’s Doctor Comes From a Uniquely American Brand of Medicine,” by Eleanor Cummins

Alice Miranda Ollstein: The New York Times’ “How Much Would Trump’s Coronavirus Treatment Cost Most Americans?” by Sarah Kliff

Kimberly Leonard: Business Insider’s “Meet the 30 Leaders Under 40 Who Are Transforming the Future of Hhealthcare in 2020,” by Lydia Ramsey Pflanzer

Erin Mershon: Kaiser Health News’ “Not Pandemic-Proof: Insulin Copay Caps Fall Short, Fueling Underground Exchanges,” by Markian Hawryluk

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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In Debate, Pence and Harris Offer Conflicting Views of Nation’s Reality

The Trump administration’s pandemic response: decisive action that saved lives, or the greatest failure of any presidential administration? During Wednesday’s vice presidential debate, Vice President Mike Pence and the Democratic challenger, Sen. Kamala Harris of California, offered drastically different takes — from behind  plexiglass screens — on how the president has handled the COVID-19 crisis.

Pence touted problematic claims, such as that President Donald Trump’s ban on travel from China helped the nation respond to the coronavirus (PolitiFact rated a similar claim “False”) and that the country would have a vaccine in less than a year (the director of the Centers for Disease Control and Prevention said a vaccine, yet to be approved, will not be widely available until next year).

Harris said the Trump administration misled the public about how serious the virus is, pointing to briefings Trump and Pence received in January. Trump told journalist Bob Woodward in a recorded interview that he purposely downplayed it.

Our partners at PolitiFact broke down a whole gamut of claims — on fracking, the economic recovery and the Supreme Court. The highlights regarding health care and coronavirus policies follow:

Kamala Harris: “The president said [the coronavirus] was a hoax.”Rating: False

This often-repeated statement falsely attributed to Trump has its roots in a Feb. 28 rally in North Carolina. But it’s a mischaracterization of what he actually said, which was an attack on Democrats’ response to the virus.

Trump cast the Democrats’ criticism of his work as foisting a hoax on the public. “They tried the impeachment hoax,” he said. “That was not a perfect conversation. They tried anything. They tried it over and over. They’d been doing it since you got in. It’s all turning. They lost. It’s all turning. Think of it. Think of it. And this is their new hoax.”

Mike Pence: The Rose Garden event with Judge Amy Coney Barrett “was an outdoor event, which all of our scientists regularly and routinely advised.”Wrong

The event included an indoor component, during which Trump, Barrett and others posed for photos without masks. Public health officials do say outdoor activities are less risky — provided masks are worn — than indoor events, where it might be harder to keep people apart and there’s less ventilation. But attendees of the Sept. 26 White House event for the nomination of Barrett to the Supreme Court did not practice social distancing, and many did not wear masks throughout the event.

Pence: Trump “suspended all travel from China. … Joe Biden opposed that decision. He called it xenophobic and hysterical.”Misleading

There were exemptions in Trump’s travel restrictions on China. On Jan. 21, the CDC confirmed the first U.S. case of the new coronavirus: a patient in Washington state who had traveled from Wuhan, China. On Jan. 31, the Trump administration announced a ban on travelers from China, but it exempted several categories of people, including U.S. citizens and lawful permanent residents. It took effect Feb. 2.

According to The New York Times, about 40,000 people traveled from China to the United States in the two months after Trump announced travel restrictions, and 60% of people on direct flights from China were not U.S. citizens.

As for the “xenophobic and hysterical” comment, Biden has not directly said the travel restrictions were xenophobic. Around the time the Trump administration announced the restrictions, Biden said Trump had a “record of hysteria, xenophobia and fearmongering.” Biden also used the word “xenophobic” in reply to a Trump tweet about limiting entry to travelers from China in which the president described the coronavirus as the “Chinese virus.”

Harris: Obama “created within the White House an office that basically was responsible for monitoring pandemics. They got rid of it. There was a team of disease experts that President Obama and Vice President Biden dispatched to China to monitor what is now predictable and what might happen. They pulled them out.” Largely accurate

Harris described two pieces of Washington’s operation to protect against new viral threats. There was a division within the White House National Security Council. And there was a CDC office in China.

In May 2018, the top White House official in charge of the U.S. response to pandemics left the administration. Then-national security adviser John Bolton reorganized the White House global health team. Homeland security adviser Tom Bossert, who recommended strong defenses against disease and biological warfare, had left in April 2018. Neither Bossert nor the official overseeing the U.S. pandemic response was replaced. Nor were their teams, some of whose responsibilities were farmed out to other corners of the administration.

In China, the CDC program specifically charged with spotting new infectious diseases went from four American staff members in 2017 to none by 2019.

Pence: Biden’s “own chief of staff, Ron Klain, would say last year that it was pure luck, that they did everything possible wrong [with H1N1]. And we learned from that.”Needs context

Klain, Biden’s former chief of staff, spoke about H1N1 during a biosecurity conference in May 2019: “A bunch of really talented, really great people working on it, and we did every possible thing wrong. And it’s, you know, 60 million Americans got H1N1 in that period of time. And it’s just purely a fortuity that this isn’t one of the great mass casualty events in American history. It had nothing to do with us doing anything right. It just had to do with luck.”

Klain has since told Politico and FactCheck.org that his comments were taken out of context, and that they were specifically in reference to the Obama administration’s difficulties meeting the public demand for an H1N1 vaccine. He was not talking about Biden directly.

Pence: The Obama administration “left the strategic national stockpile empty.”Rating: Mostly False

The Obama administration did not leave an “empty” national stockpile. Just months before COVID cases popped up in the U.S., the former director of the stockpile described it as an $8 billion enterprise with extensive holdings of many needed items. But N95 masks, for example, had been depleted after the H1N1 outbreak in 2009.

Pence: On the nation’s COVID response, “the reality is, when you look at the Biden plan, it reads an awful lot like what President Trump and I and our task force have been doing every step of the way.”Misleading

At first glance, the Biden plan does track closely with some of the talking points advanced by the Trump administration: the need to develop and distribute a vaccine, provide COVID tests free, reduce costs for COVID treatments, and produce necessary protective equipment and ventilators. But Biden’s plan proposes many other priorities that the Trump administration has not pursued. Biden also has, throughout the campaign, followed recommendations about mask-wearing and social distancing that the administration has defied — a pattern that’s being blamed for Trump’s own infection with COVID-19 and the outbreak at the White House.

Pence: The Obama administration “left an empty and hollow plan.”Misleading

The Obama administration left a “playbook” that detailed steps to take in the event of an infectious disease outbreak. The 69-page document from 2016 was a National Security Council guidebook created to assist leaders “in coordinating a complex U.S. government response to a high-consequence emerging disease threat anywhere in the world.”

Harris: “Today they still don’t have a plan” to deal with the pandemic.Needs context

Biden said the same thing during the first presidential debate. The Trump administration does have a plan to distribute vaccines once they are produced. But experts say the administration has failed to produce a national testing plan or a national strategy to address the COVID pandemic. The administration maintains its emphasis has been on helping the economy reopen. However, it has fallen short in executing a coordinated response between the federal government and states to combat the coronavirus. More than 210,000 Americans have died of COVID-19, more deaths than in any other country.

Pence (to Harris): “The fact that you continue to undermine public confidence in a vaccine, if a vaccine emerges during the Trump administration, I think is unconscionable.”Needs context

Harris said during the debate that she would not take Trump’s word that a vaccine is effective, insisting she would instead trust the opinion of an expert, such as Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases: “I will be the first in line to take it, absolutely.” Harris recently suggested Trump would push a vaccine before it was ready to help his electoral chances. But Harris is voicing concerns shared by many Americans. Last month, a Pew poll found Americans are divided on whether to get a COVID vaccine, with 78% saying they are worried it will be approved too quickly.

Harris: “The president hasn’t been transparent in terms of health records.” Accurate

After Trump announced his COVID diagnosis and was admitted to Walter Reed National Military Medical Center for treatment, his physician, Dr. Sean Conley, briefed reporters on the president’s health. Conley provided selective information and declined to answer questions, such as when the president first tested positive for the disease or the condition of his lungs. Conley said he couldn’t share this information, citing HIPAA — the Health Insurance Portability and Accountability Act of 1996. Experts told us HIPAA does prohibit Conley from sharing any health information the president hasn’t authorized him to share. However, if Trump wanted his doctor to be transparent, he could waive HIPAA protections. Beyond the recent questions about his COVID infection, Trump has shared less general health information than past presidents. But no law requires presidents to disclose information about their health.

Pence: Biden and Harris support abortion “all the way up to the moment of birth.”Misleading

Biden and Harris have not said they support abortion up to the moment of birth. They say they support Roe v. Wade, the landmark Supreme Court case that legalized abortion while giving states the ability to regulate it after a certain point. Biden and Harris say they want to codify Roe v. Wade into law and are against state laws that they say violate the rulings in the case. Supporting Roe is not the same as supporting abortion up to the moment of birth, experts say.

“Because Roe allows states to prohibit abortion once a fetus is viable, agreement with the case does not indicate support for abortions ‘up to the moment of birth,’” said Darren Hutchinson, a professor at the University of Florida’s Levin College of Law.

KHN reporters Emmarie Huetteman and Victoria Knight and PolitiFact staff writers Daniel Funke, Jon Greenberg, Louis Jacobson, Noah Y. Kim, Bill McCarthy, Samantha Putterman, Amy Sherman and Miriam Valverde contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Does the Federal Health Information Privacy Law Protect President Trump?

Within one day, President Donald Trump announced his COVID diagnosis and was admitted to Walter Reed National Military Medical Center for treatment. The flurry of events was stunning, confusing and triggered many questions. What was his prognosis? When was he last tested for COVID-19? What is his viral load?

The answers were elusive.

Picture the scene on Oct. 5. White House physician Dr. Sean Conley, flanked by other members of Trump’s medical team, met with reporters outside the hospital. But Conley would not disclose the results of the president’s lung scans and other vital information, invoking a federal law he said allows him to selectively provide intel on the president’s health.

“There are HIPAA rules and regulations that restrict me in sharing certain things for his safety and his own health,” he told the reporters.

The law he’s referring to, HIPAA, is the Health Insurance Portability and Accountability Act of 1996, which includes privacy protections designed to shield personal health information from disclosure without a patient’s consent.

Because this is likely to remain an issue, we decided to take a look. In what cases does HIPAA restrict the sharing of information — and is the president covered by it?

Experts agreed that he is, but several noted there are exceptions to its protections — stirring debate over the airwaves and on Twitter regarding what information about the president’s health should be released.

Explaining the Protections

HIPAA and the rules for its implementation apply to medical providers — such as doctors, dentists, pharmacists, hospitals — and most health plans that either provide or pay for medical care.

In some cases, the law permits the sharing of medical information without specific consent, such as when needed for treatment purposes or billing. Examples include doctors or hospitals sharing information with other physicians or facilities involved in the patient’s care, or information shared about tests, drugs or other medical care so bills can be sent to patients.

Other than that, without specific patient consent, the law is clear.

“The default rule under HIPAA is that health care providers may not disclose a patient’s health information. Period,” said Joy Pritts, a consultant in Washington, D.C., and a former privacy official in the Obama administration.

The experts we consulted all agreed that Trump’s doctors are bound by HIPAA. Since he is their patient, they cannot share his medical information without his consent.

Patients can allow some information to be released while demanding that other bits be withheld.

That may be why the public has been given only select details about Trump’s COVID-19 status, such as when Conley discussed the president’s blood pressure reading but not the results of his lung scans.

Trump “can pick and choose what he wants to disclose,” Pritts said.

So it is up to Trump to give his doctors the green light to report to the public on his condition.

“HIPAA does not prevent the president of the United States from authorizing the disclosure of all publicly relevant information,” said Lawrence Gostin, a professor of global health law at Georgetown University. “He can share it if he wanted to and he can tell his doctors to share it.”

Elizabeth Gray, a teaching assistant professor of health policy and management at George Washington University, said that because Conley shared some medically private information with the American public, there must have been a conversation between the president and his doctors about what was OK to include in their press briefings.

“He would have had to have given his authorization,” said Gray. In other words, Trump OK’d the details his doctors mentioned, but when follow-up questions were asked, she said, HIPAA was “a shield” because “the president hadn’t authorized the release of anything else.”

Still, beyond HIPAA, other factors could lead to less-than-complete disclosure of the president’s health.

For starters, Trump is the commander in chief, and his personal physician is a member of the military.

“If your commander in chief says, ‘I’m giving you a command — forget about HIPAA,’” said Thomas Miller, a resident fellow with the American Enterprise Institute.

Pritts and others also said the president’s physician may not be covered by HIPAA if his care is provided by the White House medical unit, which does not bill for its services or involve health insurance.

But, “whether covered by HIPAA or not, a physician has an ethical obligation to maintain patient confidentiality,” Pritts said.

And Leaks?

It’s also important to note that HIPAA applies only to health care professionals and related entities working within that sphere.

So, when Sean Spicer, former White House press secretary, tweeted on Oct. 5 that a journalist had violated HIPAA (he misspelled it as “HIPPA”) by reporting that a member of the White House press shop had COVID-19, he was wrong, said the experts.

“Journalists are not bound by HIPAA,” said Gostin.

Gray likened HIPAA in that way to a door.

“Behind that door is health care information. Hypothetically, only doctors have access to that information, and HIPAA prevents health care providers from unlocking that door,” she said. “But, once the info gets out of that door, then HIPAA no longer applies.”

And the information is likely to come out — sooner or later, said Miller. “Leaking will take care of most reporting and disclosure” about the president’s health, he said.

The Exceptions

Within HIPAA are a couple of exceptions identifying when health information can be disclosed without the authorization of the patient.

For example, the law does allow for disclosure if it “is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.”

Might that apply here, given that Trump took a ride around Walter Reed in a government SUV with Secret Service agents, or returned to a White House filled with other employees?

Jonathan Turley, a professor of public interest law at George Washington University Law School, said he doesn’t think the public health exemption would apply in this case.

“If a patient is contagious and noncompliant, doctors can make disclosure in the interest of public health,” Turley wrote in an email. “However, the team of doctors stated that they felt that it was appropriate to send President Trump back to the White House to continue to recover.”

Moreover, Turley noted that nothing was withheld that would have qualified for this exception. “The world knows that the president is COVID-positive and still likely contagious,” he wrote. “It is unclear what further information would do in order to put the world on notice.”

Some experts, however, expressed a different view. They argued that the details of when the president last tested positive would provide insight into who may have been exposed and how long he should be considered infectious and asked to isolate. Even so, the law’s public health exemption is usually interpreted to mean such information would be shared only with state and local health officials.

There are two HIPAA exceptions that apply specifically to the president, said Gray.

“They could make that disclosure to people who need to know, to the Secret Service or the vice president, but it is essentially only to protect [the president],” said Gray. “There is also an armed forces exception, but disclosures are in regards to carrying out a military mission, which doesn’t apply here.”

What about national security?

Miller, at AEI, said concerns about national security could be among the reasons for more disclosure, such as questioning a president’s ability to carry out duties. But HIPAA wasn’t designed to address this point.

Some argue that because the president is not just an average citizen, he should waive his right to medical privacy.

“The president is not just an individual; the president is the chief executive,” said Charles Stevenson, an adjunct lecturer on American foreign policy at Johns Hopkins University. “The president loses a lot of privacy because our political system, our governmental system demands it. The president always has to be available to the military and that means the state of his health is a matter of national security.”

Historical precedent

Trump is one in a long line of presidents who have not been completely transparent in sharing their medical information.

“There’s a pretty strong tradition of these things being obscured,” said John Barry, an adjunct faculty member at the Tulane University School of Public Health and Tropical Medicine. And no federal law requires a president to provide this information.

One of the most notable examples is President Woodrow Wilson, said Barry.

Wilson likely caught the so-called Spanish influenza in 1919, which was kept secret. Later that year, he had a severe stroke that disabled him, the gravity of which was also hidden from the public.

President John F. Kennedy used painkillers and other medications while in office, which wasn’t made public until years after his death.

And when President Ronald Reagan was shot in 1981, he was much closer to death than his White House spokesperson described to the public. There were also questions about Reagan’s mental acuity while in his final years in office. He was diagnosed with Alzheimer’s disease five years after his final term.

Why would White Houses want to obscure health information of presidents?

“Every White House wants the public to think the president is healthy, strong and capable of leading the country,” said Barry. “That’s consistent across parties and presidencies.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Fighting for Patient Protections While Attacking ACA — Hard to Have It Both Ways

Throughout the 2020 election cycle, candidates’ positions on health care have been particularly important for voters with underlying and often expensive medical needs — in short, those with preexisting conditions.

It’s no surprise, then, that protections for people who have chronic health problems like diabetes and cancer have become a focal point for candidates nationwide — among them, Matt Rosendale, the Republican contender for Montana’s only U.S. House seat.

On Sept. 22, Rosendale’s campaign hit airwaves and online streaming services with an ad featuring a Whitefish resident named Sandee, whose son was diagnosed with a life-threatening disease. Sandee told the story of how Rosendale came to her family’s aid, concluding that “Matt fights for everyone with a preexisting condition.”

As is often the case with health care policy, however, the truth is far from simple. Rosendale and many other Republican congressional candidates face the challenge of convincing voters they support these safeguards even as they oppose the Affordable Care Act, which codifies those safeguards.

Polls show broad public support for keeping the ACA’s preexisting condition protections.

We decided to investigate.

Rosendale is up against Democrat Kathleen Williams for the congressional seat now occupied by Republican Rep. Greg Gianforte, who has entered the state’s gubernatorial race. The open seat has been controlled by the GOP for the past 12 terms, but this year’s race is expected to be close. Williams, who also ran for the seat in 2018, has made health care her top campaign issue.

We contacted the Rosendale campaign to find out the basis for his ad’s claim. Campaign spokesperson Shelby DeMars listed a range of health policies backed by the candidate that would help people with preexisting conditions directly or indirectly by holding down health care costs. She specifically pointed to Rosendale’s work on the state’s reinsurance program as Montana’s state auditor and insurance commissioner, a post he was elected to in 2016.

“Matt Rosendale is a champion for those with pre-existing conditions and he has the record to prove it,” DeMars said via email. “It is because of the Reinsurance program he implemented that Montanans with pre-existing conditions can access the affordable healthcare coverage they need.”

Examining Reinsurance

In a nutshell, Montana’s reinsurance program is designed to help insurers cover costly medical claims with a mix of federal pass-through dollars and funding generated by a premium tax on all major medical policies in the state. Gov. Steve Bullock announced the formation of a bipartisan group tasked with developing reinsurance program legislation in fall 2018, and the state’s legislature approved the plan in 2019, allowing Rosendale to apply for and receive the necessary waiver under the Affordable Care Act.

Subsequent news accounts indicated the idea worked. In-state insurers credited the program with lowering premiums by 8% to 14% for 2020. As Montana Health Co-op CEO Richard Miltenberger told MTN News shortly after the 2019 legislative session, “It allows the insurance companies to have rate stabilization for those really big claims, the ones that are the earthquakes in health insurance.” He went on to say that this stability “brings the cost down for the consumer.” More to the point, the American Medical Association has also stated that reinsurance not only serves to subsidize high-cost patients but “protects patients with pre-existing conditions.”

But there’s a rub.

The reinsurance program that Rosendale touts wouldn’t exist without a state innovation waiver created by the ACA, which Rosendale says he’ll work to repeal. That effort will doubtless continue to fuel pitched battles in Congress, and how the U.S. Supreme Court may rule on a pending ACA challenge remains a point of speculation. One thing is clear, though: If the entire ACA is thrown out, the reinsurance program goes with it, along with Montana’s Medicaid expansion and the ban on insurers from excluding people with health problems from affordable coverage.

When asked about the resulting elimination of the reinsurance program, DeMars reiterated that Rosendale’s work as auditor has created a system that will ensure protections for preexisting conditions “regardless of what happens to the ACA.” She did not elaborate or explain what protections would remain if the ACA were repealed.

The Short-Term Plan Component

In defending his stance on preexisting conditions, Rosendale continues to be haunted by another health care policy specter from his political past. During his unsuccessful challenge against Democratic U.S. Sen. Jon Tester in 2018, Rosendale faced criticism for promoting short-term, limited-duration health insurance plans. Unlike plans offered on the individual marketplace, these short-term plans are exempt from the ACA’s ban on excluding people with preexisting conditions. And, under a 2018 regulatory change pushed by the Trump administration, the length of these short-term plans has been extended from three months to 12, with the potential to renew for up to three years.

As state auditor, Rosendale included those plans in his March 2020 roundup of year-round options for immediate coverage. They often exclude coverage for a variety of higher-cost benefits. In Montana, for example, a review by KFF found that of four short-term plans available in Billings in 2018, none offered coverage for maternity care, mental health, substance abuse or prescription drug services. (KHN is an editorially independent program of KFF.)

Historically, short-term plans were designed to help individuals fill gaps in health coverage. According to Dania Palanker, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms, the role short-term plans play on today’s health insurance landscape is to attract younger, healthier individuals seeking low-cost options to cover catastrophic events. That splits insurers into two pools — those who are less likely to incur medical expenses, and those who are more likely to incur them. Costs on the individual market go up as a result, leaving people with preexisting conditions no other option than to pay higher premiums. Short-term plans are, Palanker said, “actively hurting people with preexisting conditions.”

“Promoting short-term plans and stumping on supporting protections for preexisting conditions are mutually exclusive,” she continued.

Asked whether the cost-lowering effect of a reinsurance program would be enough to offset the effects of short-term plans, Palanker said the only way such an offset would be enough is if the program encompassed short-term plans. She hasn’t seen that happen anywhere.

Our Ruling

A campaign ad says Rosendale “fights for everyone with a preexisting condition.” While it is true that health insurance premiums have dropped during Rosendale’s tenure as state auditor, the choice to establish Montana’s reinsurance program ultimately fell to decision-makers in the state’s legislature and the governor’s office. Since his ad’s claim simply states that he “fights” for people with preexisting conditions, his testimony in support of that program and role in securing the state waiver do seem to fit the bill.

In the long-term, however, Rosendale’s positions begin to run counter to the claim. His support for short-term, limited-duration plans poses a considerable threat to keeping health insurance affordable for all, and absent a solid plan from Congress to ensure that state reinsurance programs survive, his stated goal of repealing the ACA would actually serve to unravel the very protection he’s built his case on.

We rate this statement as Mostly False.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Health Care and the 2020 Presidential Election

This side-by-side comparison examines President Trump’s record and former Vice President Biden’s positions across a wide range of key health issues, including the response to the pandemic, the Affordable Care Act marketplace, Medicaid, Medicare, drug prices, reproductive health, mental health and opioids, immigration and health coverage, and health care costs.

KHN on the Air This Week

KHN senior correspondent Sarah Jane Tribble appeared on Newsy’s “Morning Rush” on Thursday to discuss rural hospital closures and KHN’s brand-new “Where It Hurts” podcast.

KHN chief Washington correspondent Julie Rovner appeared on Newsy’s “Newsy Tonight” program on Wednesday to fact-check the health claims made by President Donald Trump and former Vice President Joe Biden during Tuesday’s debate.

Rovner also appeared on WGN’s “Midday News” on Sept. 25 to discuss the impact of the death of Justice Ruth Bader Ginsburg on the Affordable Care Act.

KHN senior correspondent Phil Galewitz discussed Pinellas County’s important role in the presidential election in the swing state of Florida with WUSF’s “Florida Matters” on Tuesday.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Republican Convention, Day 4: Fireworks … and Shining a Light on Trump’s Claims

President Donald Trump accepted the Republican Party’s nomination for president in a 70-minute speech from the South Lawn of the White House on Thursday night.

Speaking to a friendly crowd that didn’t appear to be observing social distancing conventions, and with few participants wearing masks, he touched on a range of topics, including many related to the COVID pandemic and health care in general.

Throughout, the partisan crowd applauded and chanted “Four more years!” And, even as the nation’s COVID-19 death toll exceeded 180,000, Trump was upbeat. “In recent months, our nation and the entire planet has been struck by a new and powerful invisible enemy,” he said. “Like those brave Americans before us, we are meeting this challenge.”

At the end of the event, there were fireworks.

Our partners at PolitiFact did an in-depth fact check on Trump’s entire acceptance speech. Here are the highlights related to the administration’s COVID-19 response and other health policy issues:

“We developed, from scratch, the largest and most advanced testing system in the world.” 

This is partially right, but it needs context.

It’s accurate that the U.S. developed its COVID-19 testing system from scratch, because the government didn’t accept the World Health Organization’s testing recipe. But whether the system is the “largest” or “most advanced” is subject to debate.

The U.S. has tested more individuals than any other country. But experts told us a more meaningful metric would be the percentage of positive tests out of all tests, indicating that not only sick people were getting tested. Another useful metric would be the percentage of the population that has been tested. The U.S. is one of the most populous countries but has tested a lower percentage of its population than other countries.

The U.S. was also slower than other countries in rolling out tests and amping up testing capacity. Even now, many states are experiencing delays in reporting test results to positive individuals.

As for “the most advanced,” Trump may be referring to new testing investments and systems, like Abbott’s recently announced $5, 15-minute rapid antigen test, which the company says will be about the size of a credit card, needs no instrumentation and comes with a phone app through which people can view their results. But Trump’s comment makes it sound as if these testing systems are already in place when they haven’t been distributed to the public.

“The United States has among the lowest [COVID-19] case fatality rates of any major country in the world. The European Union’s case fatality rate is nearly three times higher than ours.”

The case fatality rate measures the known number of cases against the known number of deaths. The European Union has a rate that’s about 2½ times greater than the United States.

But the source of that data, Oxford University’s Our World in Data project, reports that “during an outbreak of a pandemic, the case fatality rate is a poor measure of the mortality risk of the disease.”

A better way to measure the threat of the virus, experts say, is to look at the number of deaths per 100,000 residents. Viewed that way, the U.S. has the 10th-highest death rate in the world.

“We will produce a vaccine before the end of the year, or maybe even sooner.”

It’s far from guaranteed that a coronavirus vaccine will be ready before the end of the year.

While researchers are making rapid strides, it’s not yet known precisely when the vaccine will be available to the public, which is what’s most important. Six vaccines are in the third phase of testing, which involves thousands of patients. Like earlier phases, this one looks at the safety of a vaccine but also examines its effectiveness and collects more data on side effects. Results of the third phase will be submitted to the Food and Drug Administration for approval.

The government website Operation Warp Speed seems less optimistic than Trump, announcing it “aims to deliver 300 million doses of a safe, effective vaccine for COVID-19 by January 2021.”

And federal health officials and other experts have generally predicted a vaccine will be available in early 2021. Federal committees are working on recommendations for vaccine distribution, including which groups should get it first. “From everything we’ve seen now — in the animal data, as well as the human data — we feel cautiously optimistic that we will have a vaccine by the end of this year and as we go into 2021,” said Dr. Anthony Fauci, the nation’s top infectious diseases expert. “I don’t think it’s dreaming.”

“Last month, I took on Big Pharma. You think that is easy? I signed orders that would massively lower the cost of your prescription drugs.”

Quite misleading. Trump signed four executive orders on July 24 aimed at lowering prescription drug prices. But those orders haven’t taken effect yet — the text of one hasn’t even been made publicly available — and experts told us that, if implemented, the measures would be unlikely to result in significant drug price reductions for the majority of Americans.

“We will always and very strongly protect patients with preexisting conditions, and that is a pledge from the entire Republican Party.”

Trump’s pledge is undermined by his efforts to overturn the Affordable Care Act, the only law that guarantees people with preexisting conditions both receive health coverage and do not have to pay more for it than others do. In 2017, Trump supported congressional efforts to repeal the ACA. The Trump administration is now backing GOP-led efforts to overturn the ACA through a court case. And Trump has also expanded short-term health plans that don’t have to comply with the ACA.

“Joe Biden recently raised his hand on the debate stage and promised he was going to give it away, your health care dollars to illegal immigrants, which is going to bring a massive number of immigrants into our country.”

This is misleading. During a June 2019 Democratic primary debate, candidates were asked: “Raise your hand if your government plan would provide coverage for undocumented immigrants.” All candidates on stage, including Biden, raised their hands. They were not asked if that coverage would be free or subsidized.

Biden supports extending health care access to all immigrants, regardless of immigration status. A task force recommended that he allow immigrants who are in the country illegally to buy health insurance, without federal subsidies.

“Joe Biden claims he has empathy for the vulnerable, yet the party he leads supports the extreme late-term abortion of defenseless babies right up to the moment of birth.”

This mischaracterizes the Democratic Party’s stance on abortion and Biden’s position.

Biden has said he would codify the Supreme Court’s ruling in Roe v. Wade and related precedents. This would generally limit abortions to the first 20 to 24 weeks of gestation. States are allowed under court rulings to ban abortion after the point at which a fetus can sustain life, usually considered to be between 24 and 28 weeks from the mother’s last menstrual period — and 43 states do. But the rulings require states to make exceptions “to preserve the life or health of the mother.” Late-term abortions are very rare, about 1%.

The Democratic Party platform holds that “every woman should have access to quality reproductive health care services, including safe and legal abortion — regardless of where she lives, how much money she makes, or how she is insured.” It does not address late-term abortion.

PolitiFact’s Daniel Funke, Jon Greenberg, Louis Jacobson, Noah Y. Kim, Bill McCarthy, Samantha Putterman, Amy Sherman, Miriam Valverde and KHN reporter Victoria Knight contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Opposition to Obamacare Becomes Political Liability for GOP Incumbents

In the 2014 elections, Republicans rode a wave of anti-Affordable Care Act sentiment to pick up nine Senate seats, the largest gain for either party since 1980. Newly elected Republicans such as Cory Gardner in Colorado and Steve Daines in Montana had hammered their Democratic opponents over the health care law during the campaign and promised to repeal it.

Six years later, those senators are up for reelection. Not only is the law still around, but it’s gaining in popularity. What was once a winning strategy has become a political liability.

Public sentiment about the ACA, also known as Obamacare, has shifted considerably during the Trump administration after Republicans tried but failed to repeal it. Now, in the midst of the COVID-19 pandemic and the ensuing economic crisis, which has led to the loss of jobs and health insurance for millions of people, health care again looks poised to be a key issue for voters this election.

With competitive races in Colorado, Montana, Arizona, North Carolina and Iowa pitting Republican incumbents who voted to repeal the ACA against Democratic challengers promising to protect it, attitudes surrounding the health law could help determine control of the Senate. Republicans hold a slim three-vote majority in the Senate but are defending 23 seats in the Nov. 3 election. Only one Democratic Senate seat — in Alabama, where incumbent Doug Jones is up against former Auburn University football coach Tommy Tuberville — is considered in play for Republicans.

“The fall election will significantly revolve around people’s belief about what [candidates] will do for their health coverage,” said Dr. Daniel Derksen, a professor of public health at the University of Arizona.

The Affordable Care Act has been a wedge issue since it was signed into law in 2010. Because it then took four years to enact, its opponents talked for years about how bad the not-yet-created marketplace for insurance would be, said Joe Hanel, spokesperson for the Colorado Health Institute, a nonpartisan nonprofit focused on health policy analysis. And they continued to attack the law as it took full effect in 2014.

Gardner, for example, ran numerous campaign ads that year criticizing the ACA and, in particular, President Barack Obama’s assertion that “if you like your health care plan, you’ll be able to keep your health care plan.”

But now, Hanel said, the ACA’s policies have become much more popular in Colorado as the costs of health exchange plans have dropped. Thus, political messaging has changed, too.

“This time it’s the opposite,” Hanel said. “The people bringing up the Affordable Care Act are the Democrats.”

Despite Gardner’s multiple votes to repeal the ACA, he has largely avoided talking about the measure during the 2020 campaign. He even removed his pro-repeal position from his campaign website.

Democratic attack ads in July blasted Gardner for repeatedly dodging questions in an interview with Colorado Public Radio about his stance on a lawsuit challenging the ACA.

His opponent, Democrat John Hickenlooper, fully embraced the law when he was Colorado governor, using the measure to expand Medicaid eligibility to more low-income people and to create a state health insurance exchange. Now, he’s campaigning on that record, with promises to expand health care access even further.

Polling Data

Polling conducted by KFF for the past 10 years shows a shift in public opinion has occurred nationwide. (KHN is an editorially independent program of KFF, the Kaiser Family Foundation.)

“Since Trump won the election in 2016, we now have consistently found that a larger share of the public holds favorable views” of the health law, said Ashley Kirzinger, associate director of public opinion and survey research for the foundation. “This really solidified in 2017 after the failed repeal in the Senate.”

The foundation’s polling found that, in July 2014, 55% of voters opposed the law, while 36% favored it. By July 2020, that had flipped, with 51% favoring the law and 38% opposing it. A shift was seen across all political groups, though 74% of Republicans still viewed it unfavorably in the latest poll.

Public support for individual provisions of the ACA — such as protections for people with preexisting conditions or allowing young adults to stay on their parents’ health plans until age 26 — have proved even more popular than the law as a whole. And the provision that consistently polled unfavorably — the mandate that those without insurance must pay a fine — was eliminated in 2017.

“We’re 10 years along and the sky hasn’t caved in,” said Sabrina Corlette, a health policy professor at Georgetown University.

Political Messaging

Following the passage of the ACA, Democrats didn’t reference the law in their campaigns, said Erika Franklin Fowler, a government professor at Wesleyan University and the director of the Wesleyan Media Project, which tracks political advertising.

“They ran on any other issue they could find,” Fowler said.

Republicans, she said, kept promising to “repeal and replace” but weren’t able to do so.

Then, in the 2018 election, Democrats seized on the shift in public opinion, touting the effects of the law and criticizing Republicans for their attempts to overturn it.

“In the decade I have been tracking political advertising, there wasn’t a single-issue topic that was as prominent as health care was in 2018,” she said.

As the global health crisis rages, health care concerns again dominate political ads in the 2020 races, Fowler said, although most ads haven’t explicitly focused on the ACA. Many highlight Republicans’ support for the lawsuit challenging preexisting condition protections or specific provisions of the ACA that their votes would have overturned. Republicans say they, too, will protect people with preexisting conditions but otherwise have largely avoided talking about the ACA.

“Cory Gardner has been running a lot on his environmental bills and conservation funding,” Fowler said. “It’s not difficult to figure out why he’s doing that. It’s easier for him to tout that in a state like Colorado than it is to talk about health care.”

Similar dynamics are playing out in other key Senate races. In Arizona, Republican Sen. Martha McSally was one of the more vocal advocates of repealing the ACA while she served in the House of Representatives. She publicly acknowledged those votes may have hurt her 2018 Senate bid.

“I did vote to repeal and replace Obamacare,” McSally said on conservative pundit Sean Hannity’s radio show during the 2018 campaign. “I’m getting my ass kicked for it right now.”

She indeed lost but was appointed to fill the seat of Sen. Jon Kyl after he resigned at the end of 2018. Now McSally is in a tight race with Democratic challenger Mark Kelly, an astronaut and the husband of former Rep. Gabby Giffords.

“Kelly doesn’t have a track record of voting one way or another, but certainly in his campaign this is one of his top speaking points: what he would do to expand coverage and reassure people that coverage won’t be taken away,” said Derksen, the University of Arizona professor.

The ACA has proved a stumbling block for Republican Sens. Thom Tillis of North Carolina and Joni Ernst of Iowa. In Maine, GOP Sen. Susan Collins cast a key vote that prevented the repeal of the law but cast other votes that weakened it. She now also appears vulnerable — but more for her vote to confirm Brett Kavanaugh’s nomination to the Supreme Court and for not doing more to oppose President Donald Trump.

In Montana, Daines, who voted to repeal the ACA, is trying to hold on to his seat against Democratic Gov. Steve Bullock, who used the law to expand the state’s Medicaid enrollment in 2015. At its peak, nearly 1 in 10 Montanans were covered through the expansion.

As more Montanans now face the high cost of paying for health care on their own amid pandemic-related job losses, Montana State University political science professor David Parker said he expects Democrats to talk about Daines’ votes to repeal cost-saving provisions of the ACA.

“People are losing jobs, and their jobs bring health care with them,” Parker said. “I don’t think it’s a good space for Daines to be right now.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Pence Praises Trump’s ‘Seamless’ COVID Response, Leaves Out His State Feuds

Vice President Mike Pence portrayed his boss, President Donald Trump, as a leader who has reached out across the aisle to help during the coronavirus pandemic.

“President Trump marshaled the full resources of the federal government and directed us to forge a seamless partnership with governors across America in both parties,” Pence said during his speech Wednesday night at the Republican National Convention.

Clearly, the federal government has provided supplies and funding to states led by both parties in response to the pandemic, and Pence himself has held regular conference calls with governors in both parties. But Pence was speaking about the actions of Trump, not his own.

Pence’s comments ignored Trump’s multiple feuds, frequently with Democratic governors, about state-federal responsibilities and the pandemic response.

A Trump campaign spokesperson sent us a list of dozens of teleconferences and meetings that Trump or Pence had with governors, including Democrats such as New York’s Andrew Cuomo and Michigan’s Gretchen Whitmer. In March, Trump sent a letter to governors thanking them for “stepping up to help America confront this unprecedented global pandemic.” The campaign pointed to actions by administration officials to brief governors about making available supplies, such as testing swabsutilizing the National Guard, and reopening state economies.

Trump Argued With Governors Over COVID-19 Supplies, Tests

Early in the pandemic, Trump traded barbs with governors, especially over where the responsibility lay in securing medical supplies for the states.

After declaring a national emergency over the health crisis on March 13, Trump directed governors to order their own ventilators, respirators and supplies, saying the federal government is “not a shipping clerk.” Governors in both parties shot back that Trump’s stance, and the lack of coordination from Washington, left states bidding against one another and the federal government for access to critical equipment.

Cuomo said it was akin to competing on eBay with all the other states plus the Federal Emergency Management Agency.

Whitmer and Maryland Gov. Larry Hogan, a Republican and then chair of the National Governors Association, were among those pleading for better coordination from FEMA to ensure that supplies were distributed based on need.

“The lack of any centralized coordination is creating a counterproductive competition between states and the federal government to secure limited supplies, driving up prices and exacerbating existing shortages,” they wrote in a joint March 30 op-ed in The Washington Post.

couple of days earlier, Trump said during a White House briefing that governors should be “appreciative” toward him and the federal government.

Speaking of Pence, Trump said: “He calls all the governors. I tell him — I mean, I’m a different type of person — I say, ‘Mike, don’t call the governor of Washington. You’re wasting your time with him. Don’t call the woman in Michigan.’” On Twitter, Trump said Whitmer was “way in over her head, she doesn’t have a clue.”

In April, Trump said that testing “is a local thing” and that states should turn to commercial labs for help. After he was blasted by governors from both parties, Trump said the federal government would step up efforts to get testing supplies.

Governors also called on Trump early on to enact the Defense Production Act, a law that gives the president authority to expedite the supply of materials for national defense, in order to ramp up production of personal protective equipment and COVID-19 testing supplies. While the president did eventually invoke the act to produce ventilators and medical equipment, he delayed efforts to do so and did it sparingly. Washington Gov. Jay Inslee and Arkansas Gov. Asa Hutchinson called for him to broaden its use.

Trump’s justification for slow-rolling the act was that he didn’t want the government to intervene in the private sector.

“You know, we’re a country not based on nationalizing our business,” Trump said at a coronavirus task force press briefing on March 22. “Call a person over in Venezuela, ask them how did nationalization of their businesses work out? Not too well.”

In April, Trump said that Georgia Gov. Brian Kemp, a Republican, had reopened Georgia “too soon.” In May, he criticized Pennsylvania Gov. Tom Wolf, a Democrat, for keeping parts of his state closed that Trump said were “barely affected.”

Trump said in mid-April that it was up to him — not the governors — to decide when to reopen states on lockdown.

Some Governors Bypassed the Federal Government to Work Together

Frustrated with the responses from the Trump administration, some governors teamed up with one another to get needed supplies.

In May, a coalition of governors from seven Northeastern states, including New York, Connecticut, New Jersey, Rhode Island, Pennsylvania and Delaware, joined together to buy personal protective equipment and ventilators and create a unified reopening strategy.

As late as July, some governors were calling on the feds for help and not getting what they needed. There were shortages of testing supplies, as well as personal protective gear. Washington state asked for 4.2 million N95 respirators. It received a bit under 500,000. It asked for about 300,000 gowns. It got about 160,000.

On Aug. 18, a bipartisan group of governors — five Democrats and five Republicans — announced they would be partnering with the Rockefeller Foundation to create a national testing strategy in the absence of federal action. The 10 states are Louisiana, Maryland, Massachusetts, Michigan, Ohio, North Carolina, Utah, Arkansas, Rhode Island and Virginia. Their goal is to buy and deploy 5 million COVID-19 antigen tests.

Feuds Between Trump Administration and States Continue

The Trump administration sought to pressure states to reopen schools for in-person instruction. In July, Trump threatened to cut off funding if schools didn’t reopen.

This summer, the Trump administration reduced the federal share of National Guard assistance to the states to help with pandemic response, despite pleas from governors in both parties. An Aug. 3 memo said that the federal government would no longer continue to pay for 100% of the tab for most states and that it would be reduced to 75% as of Aug. 21.

And when the CDC unveiled new testing guidelines that downplayed the need to test people who don’t show symptoms — about 40% of those infected — Cuomo and California Gov. Gavin Newsom said that they wouldn’t follow it. Asymptomatic people are thought to be significant spreaders of the virus. Both governors at times praised certain responses by the Trump administration to help their states respond to the pandemic.

Our Ruling

Pence said, “President Trump marshaled the full resources of our federal government from the outset. He directed us to forge a seamless partnership with governors across America in both political parties.”

Trump and top administration officials have communicated with governors of both parties for months in meetings, phone calls and written communication. But Pence’s comment ignores that Trump has feuded with governors over state-federal responsibilities, supplies and policies for shutting down or reopening. Trump also has suggested a lesser role for the federal government and said that the handling of COVID-19 should be left to the states.

We rate this claim Mostly False.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Republican Convention, Day 3: Revisionist History

In accepting the Republican Party nomination Wednesday night, Vice President Mike Pence accurately recounted the history of Baltimore’s Fort McHenry, and how a failed British bombardment in 1814 helped inspire Francis Scott Key to write “The Star-Spangled Banner.”

Pence’s claims about the Trump administration as well as his attacks on Democratic presidential nominee Joe Biden, on the other hand, were sometimes misleading, incomplete or wrong.

As the number of Americans who have lost their lives to COVID-19 neared 180,000, he spent part of his speech recasting the Trump administration’s handling of the coronavirus response, offering sympathy to “the families who have lost loved ones and have family members still struggling with serious illness” and saluting the “doctors, nurses, first responders, factory workers, truckers and everyday Americans, who put the health and safety of their neighbors first.” He optimistically reported that the U.S. is “on track to have the world’s first safe, effective coronavirus vaccine by the end of this year.” His live audience was mostly unmasked.

Our partners at PolitiFact did a wide-ranging fact check on Pence’s complete speech. Here are the highlights related to the administration’s COVID-19 response:

“President Trump marshaled the full resources of our federal government [to deal with the coronavirus] from the outset. He directed us to forge a seamless partnership with governors across America in both political parties.”

Revisionist history. After declaring a national emergency over the health crisis on March 13, Trump directed governors to order their own ventilators, respirators and supplies, saying the federal government is “not a shipping clerk.” Governors say the disjointed response left states bidding against one another and the federal government for access to critical equipment.

New York Gov. Andrew Cuomo said it was akin to competing on eBay with all the other states plus the Federal Emergency Management Agency. Maryland Gov. Larry Hogan, a Republican, pleaded for better coordination to ensure that supplies were distributed based on need.

As late as July, some governors were calling on the feds for help and not getting what they needed. There were shortages of testing supplies, as well as personal protection gear. Washington state asked for 4.2 million N95 face masks. It received a bit under 500,000. It asked for about 300,000 surgical gowns. It got about 160,000.

“Before the first case of the coronavirus spread within the United States, the president took unprecedented action and suspended all travel from China.” 

Pence’s timeline is wrong, and Trump didn’t ban “all” travel from China; there were exemptions.

Here’s the correct timeline:

  • Jan. 21: The Centers for Disease Control and Prevention confirmed the first U.S. case of the new coronavirus, a patient in Washington state who had traveled from Wuhan, China.
  • Jan. 30: The CDC confirmed the first instance of person-to-person spread of the new coronavirus in the United States. It involved a couple in Illinois, one spouse who had traveled to Wuhan and one who had not traveled.
  • Jan. 31: The Trump administration announced a ban on travelers from China, exempting a number of categories of people, including U.S. citizens and lawful permanent residents. It took effect Feb. 2. Trump’s proclamation acknowledged that the virus “has spread between two people in the United States, representing the first instance of person-to-person transmission of the virus within the United States.”

According to The New York Times, about 40,000 people traveled from China to the United States in the two months after Trump announced travel restrictions, and 60% of people on direct flights from China were not U.S. citizens.

“As we speak, we’re developing a growing number of treatments, known as therapeutics, including convalescent plasma, that are saving lives all across the country.”

This requires context. Days before Pence’s speech, the Food and Drug Administration authorized the use of convalescent plasma for the treatment of hospitalized COVID-19 patients. This treatment involves isolating COVID-19 antibodies from the plasma of people who have recently recovered from the virus and injecting the antibodies into patients in the early stages of the illness.

Although the Trump administration has said this treatment shows encouraging early findings, the data they shared was based on a Mayo Clinic preliminary analysis that has not been peer-reviewed. Clinicians and researchers have urged caution, maintaining that more research is necessary before a survival benefit is proven. They also question the timing of the authorization — which came on the eve of the Republican convention.

Before Pence Took the Mic

Throughout the evening, speakers referred to the novel coronavirus as “the China virus” or something the “Chinese communist regime unleashed on the world.” Kellyanne Conway, a former special adviser to the president, commended Trump for “taking unprecedented action to combat this nation’s drug crisis.” Our PolitiFact partners fact-checked a range of these statements. Here’s one related to health policy:

“I can tell you that this president stands by Americans with preexisting conditions.” — Kayleigh McEnany, press secretary

McEnany was sharing her personal story of having a preventive mastectomy to minimize her risk for breast cancer, which was prevalent in her family. Trump called to see how she felt after her surgery and, she said, has since continued to be a source of support.

However, the support he provided her has not translated into supporting legal protections for people who have preexisting conditions from being excluded from health plans or charged higher rates. In fact, we rated a claim by Trump in which he said he was the person who saved preexisting conditions as Pants on Fire. He got a False rating for saying he would protect those with preexisting conditions.

The Affordable Care Act, which was signed into law by President Barack Obama in 2010, put in place these protections. Trump has supported overturning the ACA. In 2017, Trump supported congressional efforts to repeal the ACA. The Trump administration is now backing the efforts to overturn the ACA via a court case. He has also expanded short-term health plans that don’t have to comply with the ACA.

Jon Greenberg, Louis Jacobson, Samantha Putterman, Amy Sherman, Paul Specht, Miriam Valverde and KHN reporter Victoria Knight contributed to this report. All photos courtesy of the Associated Press.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What the Health?’ Replay: What’s at Stake When High Court Hears ACA Case

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The “What the Health?” panelists are taking a break for two weeks. But since the Supreme Court recently scheduled arguments in the case challenging the constitutionality of the Affordable Care Act, it seemed like a good opportunity to replay an episode from March, when the law turned 10.

As the “What the Health?” panelists point out in this episode, that’s a milestone that many considered unlikely. The past decade for the health law has been filled with controversy and several near-death experiences. But the law also brought health coverage to millions of Americans and laid the groundwork for a shift to a health system that pays for quality rather than quantity.

Yet the future of the law remains in doubt. Many progressive Democrats would like to scrap it in favor of a “Medicare for All” system that would be fully financed by the federal government. Republicans would still like to repeal or substantially alter it. And GOP officials have brought the case asking the Supreme Court to invalidate the entire law. Those arguments will be heard on Nov. 10.

This special episode, which first aired March 19, also includes a discussion between “What the Health?” host Julie Rovner and Kathleen Sebelius, who was secretary of Health and Human Services during the development, passage and implementation of the health law. KHN published a transcript of that interview.

Rovner, Joanne Kenen of Politico and Mary Agnes Carey of KHN, who have all covered the law from the start, discuss the ACA’s past, present and future.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Republican Convention, Day 2: Pomp, the Pandemic and Planned Parenthood

The Republican National Convention offered Americans a picture Tuesday night of a compassionate White House in action. But not a lot was said about the biggest health crisis in a century that has killed more than 170,000 people in this country.

First lady Melania Trump wrapped up the evening with a speech from her redesigned Rose Garden, acknowledging to audience members — almost all without masks — that, “since March, our lives have changed drastically.” She also said her husband’s administration has been relentless in its effort to find a vaccine or treatment for COVID-19. “Donald will not rest until he has done all he can to take care of everyone impacted by this terrible pandemic,” she said.

Before ending her address, she alluded to her husband’s brash reputation. “Total honesty is what we as citizens deserve from our president,” she said. “Whether you like it or not, you always know what he’s thinking.”

Her speech didn’t leave much work for fact checkers, but other remarks from the president’s adult children, as well as the evening’s other speakers, did.

Our PolitiFact partners provided a detailed rundown on statements from Tuesday night. Here are some health care highlights:

The pandemic “was awful. Health and economic impacts were tragic. Hardship and heartbreak were everywhere. But presidential leadership came swiftly and effectively, with an extraordinary rescue for health and safety to successfully fight the coronavirus.” — Larry Kudlow, director of the National Economic Council

To hear chief White House economic adviser Larry Kudlow say it, the pandemic is in the rearview mirror. There are states, such as Texas and Florida, where a deadly surge has eased. Nationally, however, the death toll continues to climb.

Data from the COVID Tracking Project shows deaths topping 170,000. And the recent rise in deaths is only slightly less compared with the early months of the pandemic.

The Institute for Health Metrics and Evaluation at the University of Washington estimates that the number of COVID deaths will exceed 300,000 by Dec. 1. That would be nearly double the deaths so far.

Kudlow offered an optimistic picture of the economic recovery and the growth to come, telling Americans to expect 20% growth in a “V-shaped recovery” in the second half of the year.

But much hinges on the course of the virus. Current trends show an ongoing threat to the prosperity Kudlow described.

“And if you believe in expanding quality and affordable health care, only President Trump, my father, signed Right to Try into law, the favored nations clause, and other actions to lower drug prices and keep Americans from getting ripped off.” — Tiffany Trump

This is somewhat misleading. The Right to Try law that Trump signed in 2018 allows individuals with life-threatening conditions who have tried all approved treatment options and cannot participate in clinical trials to access unapproved treatments. It did not, however, lower drug prices.

Trump also signed an executive order on July 24, which he has referenced as the “favored nations clause,” that has not been put into action. Nor has the text of this executive order been made public, so the details of how it would be executed are unclear. The idea of the “favored nations” proposal is that the U.S. would pay similar prices as European countries do for some Medicare Part B physician-administered drugs. This proposal has been strongly opposed by drugmakers, and experts told us they were skeptical that it would be implemented.

While Trump has long talked about lowering drug prices as one of his top health care goals, he has made little progress in doing so, outside of issuing several executive orders that have yet to be enacted.

“Margaret Sanger was a racist who believed in eugenics. Her goal when founding Planned Parenthood was to eradicate minorities.” — Abby Johnson, former Planned Parenthood worker

This statement is misleading. Sanger has been routinely criticized for supporting eugenics — the belief of improving the population by controlled breeding for desirable characteristics. But historians and scholars who have studied Sanger’s life say her opinions concerned public health and were not specific to race.

The basic concept that humanity could be improved by selective breeding was a firmly held belief by many in the years before World War II. Winston Churchill, Herbert Hoover, Theodore Roosevelt, George Bernard Shaw and H.G. Wells all supported the eugenics movement. The philosophy fell out of favor after Nazis adopted eugenics to support exterminating non-Aryan races.

Still, Planned Parenthood recently announced it would remove Sanger’s name from its Manhattan Health Center because of her eugenics beliefs, and there is some disagreement about her views and whether they should be reevaluated amid protests against systemic racism and a pandemic that has disproportionately affected minorities.

Sanger was a birth control activist, which means she wanted women to be able to avoid unwanted pregnancies. The historical record shows she worked for women of all classes and races to have that choice.

Those who call Sanger a racist often cite her work on what was called the Negro Project, an effort that started in 1939 that brought birth control services (but not abortion) to Black communities in the South. Black leaders such as W.E.B. Du Bois and Mary McLeod Bethune, founder of the National Council of Negro Women, were members of its advisory council.

PolitiFact’s Louis Jacobson, Amy Sherman, Samantha Putterman, Jon Greenberg, Miriam Valverde and KHN reporter Victoria Knight contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Trump Again Claims He’s Bringing Down Drug Prices, But Details of How Are Skimpy

President Donald Trump has long considered lowering the high cost of prescription drugs to be one of his signature issues, and it is likely to be a talking point he relies on throughout the upcoming campaign.

During his afternoon speech Monday ― delivered on the first day of the Repubublican National Convention after delegates had unanimously renominated him to seek reelection ― he returned to this theme.

“Now, I’m really doing it,” he said, referring to a series of four executive orders he issued in July. These orders touched on a range of issues, including insulin prices and drug importation. He focused on two specifically.

“But the fact is that we signed a favored nations clause and a rebate clause, and your numbers are going to come down 60, 70%,” he said.

However, those executive orders are far from being implemented, and multiple experts told us it’s unlikely the measures would pass along drug-pricing discounts to a majority of Americans. And the text of one, the favored nation executive order, has not yet been made public ― making it hard to know how exactly the initiative would work.

“Details are a bit murky,” Matthew Fiedler, a health care fellow with the Brookings Institution, wrote in an email.

We checked in with the White House to find out more details about the favored nation order and when the text might be released. However, we did not get a response. Still, we decided to dig in.

What We Know

The favored nation executive order was supposed to match U.S. prices for a certain class of drugs with the lower amount paid in certain European countries, which negotiate drug prices. It reportedly would have applied only to drugs covered by Medicare Part B ― those that patients receive at their doctors’ offices, such as infused cancer drugs ― but not those purchased at the pharmacy counter. Drug companies criticized the executive order, and the Trump administration offered to consider an alternative plan if the firms offered it by Aug. 24. So far, the industry has not made a counter offer.

A spokesperson for PhRMA, the lobbying group that represents major drugmakers, said in a statement that “the most favored nation executive order is an irresponsible and unworkable policy that will give foreign politicians a say in how America provides access to treatments and cures for seniors and people struggling with devastating diseases.” The group did not confirm on the record whether an alternative drug-pricing plan had been discussed with the White House.

The Trump administration floated a similar idea in 2018, which met with swift criticism from some of its usual supporters, such as Americans for Tax Reform, a right-leaning advocacy group that opposes tax increases. The criticism was marked by TV ads warning that this approach to drug costs was a step toward socialism. We found that claim to be Mostly False. The Centers for Medicare & Medicaid Services estimated at that time the resulting savings from such a plan would be 30%, but it was never enacted.

Multiple experts questioned Trump’s claims about how much costs would come down as a result of the more recent proposal.

That’s in part because the full text of the executive order has not been published, and so classifying the president’s statement as true “requires a leap of faith,” said Benedic Ippolito, a resident scholar who studies health care costs at the American Enterprise Institute.

Ippolito allowed that because some drug prices in other countries are far below those in the U.S., a reduction of 60% or 70% could be plausible for an individual product. But, in order for that to happen, the policy would have to be implemented.

Seeing this 60% to 70% decrease “relies on the idea that this policy ever happens. And I think there is reason to be very skeptical there,” Ippolito wrote in an email.

Rachel Sachs, an associate professor of law at Washington University in St. Louis, who has analyzed the drug-pricing executive orders, agreed there’s no solid foundation to support those percentages.

“I don’t know about the 60 or 70%,” she said. “I don’t know what he’s talking about.”

Another executive order attempted to address the rebates paid to pharmacy benefit managers within Medicare by directing that these payments instead be used as discounts for beneficiaries within the Part D program, the plans that pay for prescription medications.

However, experts pointed out that those discounts usually go toward lowering insurance premiums for seniors. Without applying the discount there, premiums would likely go up. And, in order to keep premiums down, the federal government would need to spend more on subsidies.

Analyses from the Congressional Budget Office and other groups predicted that Trump’s rebate proposal would lower drug prices for some seniors, but would also increase federal spending and increase seniors’ premiums.

There is also a stipulation in the text of the order, which says the order cannot be implemented if it leads to increased government spending or higher premiums for beneficiaries. Thus, it’s unclear how such a proposal would be implemented.

“The executive order on the rebate is internally contradictory, which makes you wonder how they can do this,” said Sachs.

Why It Matters

Trump is likely to continue saying he has reduced drug prices, not only during the Republican National Convention but for the remainder of the 2020 campaign.

Trump likes to present proposals in the works as having been implemented, and we’ve fact-checked him twice before on similar drug-pricing statements.

In May 2019, he claimed he brought down drug prices for the first time in 51 years, which we found to be Mostly False. And in early August of that year, we fact-checked a claim about another of his drug-pricing executive orders that inflated his efforts to reduce insulin prices, which we also found to be Mostly False.

This time, Trump referenced two different drug-pricing executive orders. While it is true that he signed both of them (though the text of only one is publicly available), experts have expressed skepticism about whether these proposals will be implemented, as well as whether they would lower drug prices significantly for Americans.

And this isn’t the first time Trump has made this promise to the American people.

“He promised to lower drug prices as part of his campaign in 2016 and has done absolutely nothing of substance about drug prices at all while he’s been in office,” Aaron Kesselheim, a professor of medicine at Harvard, wrote in an email.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Republican Convention, Day 1: A Campaign-Style Trump Speech and More

Before the prime-time GOP showcase began, President Donald Trump took to the podium Monday afternoon and delivered an approximately one-hour campaign-style speech to delegates after he was officially renominated by the Republican Party as its candidate for president.

His comments were wide-ranging, and our partners at PolitiFact found many to be either wrong, misleading, premature or in need of clarification. Here is the complete rundown from that speech and a wrap-up story detailing the rest of the evening. (PolitiFact also fact-checked former Vice President Joe Biden’s acceptance speech during the Democratic National Convention.)

Monday’s evening broadcast was full of platitudes. Amy Ford, a West Virginia nurse, applauded Trump’s steps during the pandemic to expand telemedicine, saying these policies are “essential” and will “continue to aid many that are unable to find transportation or a way to the doctor for regular checkups. This is especially true in rural America.” Dr. G.E. Ghali, a Louisiana oral surgeon and chancellor of a medical research center, spoke as both a clinician and a patient about how the administration’s efforts to provide emergency-use authorization for emerging treatments saved lives.

Video vignettes heralded Trump’s leadership during the coronavirus, focusing on things like Operation Warp Speed, the administration’s initiative to speed vaccine development, rather than the statistics: nearly 6 million Americans who have contracted COVID-19 or the more than 177,000 who have died. Trump also spoke with a group of first responders — including nurses, postal workers and a police officer from Colorado who said she had contracted COVID-19 in late March and has since recovered. “That means we don’t have to be afraid of you at all, right?” Trump said to her. “Once you’re recovered, we have the whole thing with plasma happening. That means your blood is very valuable, you know that, right?”

What follows are some of Trump’s statements from his afternoon speech geared to health policy issues:

Trump has repeatedly claimed that President Barack Obama left him with an empty national stockpile of emergency supplies. But this is an exaggeration.

The stockpile had a shortage of N95 masks, which were depleted as a result of the H1N1 outbreak in 2009 and not substantially replenished during the Obama or Trump administrations.

ProPublica found that the budget battles during Obama’s tenure after the Republicans won the 2010 election also hurt the stockpile’s budget.

Budget figures going back to 2009 show overall funding for the stockpile dropped to its lowest level in 2013, to about $477 million. Allocations have grown steadily since then to a 2020 budget of $705 million.

“We eliminated Obamacare’s horrible and very unfair individual mandate, which basically knocked out Obamacare. We knocked out Obamacare.”

Saying Republicans “knocked out Obamacare” is a stretch. Trump did sign legislation to eliminate the requirement that Americans have health insurance or pay a tax penalty, but eliminating this requirement did not get rid of Obamacare, or the Affordable Care Act, as it is officially known.

The administration supports a lawsuit by a group of Republican state attorneys general that argues that the ACA should be ruled unconstitutional. The lawsuit’s argument focuses on the Supreme Court’s previous ruling that the ACA was constitutional because it was based on a tax, which Congress has the authority to levy. With the tax penalty now eliminated, the lawsuit argues, the law should be scrapped entirely. The Supreme Court has agreed to hear the case.

In the meantime, much of the health law’s key provisions remain in force. In 2020, at least 11.4 million Americans have purchased insurance through the online marketplaces created under the act. More than 10 million others have signed up for Medicaid under the expanded eligibility requirements passed as part of the law. And people who have private insurance have benefited from new rules enacted by the law, from the ability to keep young adults on a parent’s policy to an end to out-of-pocket payments for certain preventive measures.

“So we protected your preexisting conditions, very strongly protected.”

We rated a similar claim as Pants on Fire. Protections for preexisting conditions under Obamacare remain on the books, but it’s not for lack of trying by the Trump administration.

For starters, the administration backs the lawsuit that would eliminate protections for preexisting conditions by getting rid of Obamacare.

In addition, the administration has not put forth any plan that might keep those guarantees in place. Every replacement health bill the administration has endorsed has offered protections less generous than those offered by the ACA.

Finally, the administration has issued a rule loosening restrictions on the length of so-called short-term health plans. While such plans could be more affordable for individuals in the market for insurance, they are not required to provide preexisting condition protections.

PolitiFact’s Louis Jacobson, Amy Sherman, Samantha Putterman and Miriam Valverde contributed to this story.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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COVID-19, Mental Health, and the 2020 Election: A Review of Candidate Platforms

This brief examines where the candidates stand on four key aspects of the nation’s mental health and substance abuse challenges: the opioid epidemic, suicide rates, mental health parity, and mental health workforce. On each issue, the brief summarizes the policy positions of President Trump and former Vice President Joe Biden.

Democratic Convention, Night 4: ‘Facts Over Fiction’ in Biden’s Speech

In a near-empty arena on the river in his hometown of Wilmington, Delaware, former Vice President Joe Biden accepted the Democratic nomination for president, promising hope over fear, fairness over privilege, love over hate.

And, he said, “Facts over fiction.”

Let’s see about that.

Our partners at PolitiFact examined a range of claims made by Biden, fact-checking or putting them in context. Here are excerpts related to health policy and the COVID-19 pandemic:

“Five million Americans infected with COVID-19.”

It’s a little higher than that. According to data from Johns Hopkins University, the number of positive tests as of Aug. 20 was 5,573,517.

“More than 170,000 Americans have died.”

This is accurate. Johns Hopkins data counted 174,248 U.S. deaths through Aug. 20.

“More than 50 million people have filed for unemployment this year.”

This, too, is accurate. Since March 21, 57.4 million Americans have filed initial unemployment claims.

“By far the worst performance of any nation on Earth.”

The United States leads the world in the number of COVID-19 cases and deaths. Using other metrics that account for population, the U.S. isn’t the absolute worst, but it still lags behind many other countries. For instance, the United States has the fifth-highest death rate per 100,000 people.

The virus is known to have infected a higher percentage of the population in the U.S. than in many other places. The U.S. has one of the highest rates globally of people who have tested positive — 16,430 per million residents, which is lower than Chile’s, but higher than that of any other large country.

“More than 10 million people are going to lose their health insurance this year.”

This number may be an underestimate. In a July report, the Urban Institute estimated that from April through December 2020, 10.1 million people will lose health insurance tied to a job that they lost during the pandemic. This analysis was done by looking at employment loss projections data from U.S. Labor Department reports.

But that number is lower than another estimate. KFF estimates that nearly 27 million people could lose their employer-sponsored health insurance and become uninsured due to the COVID-19 pandemic. (KHN is an editorially independent program of KFF, the Kaiser Family Foundation). This 27 million figure includes both those who lost employer-sponsored insurance as well as dependents who may have been covered on the same plan. The estimate was based on assessing data from Labor Department unemployment claims and determining whether workers were eligible for ACA insurance.

“The assault on the Affordable Care Act will continue until it’s destroyed, taking insurance away from 20 million people, including more than 15 million people on Medicaid. And getting rid of the protections that President Obama worked so hard to get passed.”

Biden was referring to the coverage losses that would result if a Trump administration-backed lawsuit to overturn the Affordable Care Act is successful. And health policy experts and press reports cite numbers close to what Biden listed.

Close to 20 million people gained health insurance after the Affordable Care Act was enacted, either through the Medicaid expansion or as a result of its marketplace subsidies for individuals below 400% of poverty. So, it follows that if the ACA were overturned, their health coverage would be at risk.

Additionally, an Urban Institute estimate matches Biden’s 15 million figure regarding how many people would lose Medicaid coverage if the ACA were struck down. That would be a result of the federal government no longer helping states pay for Medicaid expansion.

There are other estimates that take into account the effects of the COVID-19 pandemic. The left-leaning Center for American Progress estimates that 3 million additional people (beyond the already estimated 20 million) could lose health insurance coverage because of COVID-19 and be eligible for other government programs, such as Medicaid.

And because the ACA ensures that those with preexisting conditions must be covered by health insurance, that “protection,” as Biden called it, would no longer be in place if the law were overturned, because President Donald Trump has not issued a health care plan that would offer a similar guarantee.

“And after all this time the president still does not have a plan” for the COVID-19 pandemic.

It’s unclear exactly what type of plan Biden is referring to in this general statement. It is true that, thus far, no national testing or contact tracing plan has been issued. Nor has the White House issued a national blueprint to address the COVID-19 pandemic, despite Trump saying he would do so in July.

“We are in the process of developing a strategy that’s going to be very, very powerful. We’ve developed as we go along,” Trump said July 21.

However, the White House has said that Trump does have a plan. Several plans, in fact, seem to have emerged.

Part of one Trump administration plan included restricting travel from areas that have been affected by the virus in March. This initially targeted only China, but then extended to Iran, Italy, South Korea and other European countries. The White House also said Trump worked to expand testing capacity by developing a public and private partnership that would bring more coronavirus testing to parking lots of big-name chain stores. (There were only a few in operation when we checked in April.)

Trump has also touted a plan to develop a COVID-19 vaccine as quickly as possible, called Operation Warp Speed. The goal of Operation Warp Speed is to deliver 300 million doses of a COVID-19 vaccine by January 2021. A federal plan for vaccine distribution is not yet ready.

Throughout the COVID-19 pandemic, Trump has emphasized he wanted state leaders to take control of virus response within their states. But critics say these efforts do not represent a coordinated strategy.

“We’ll have a national mandate to wear a mask, not as a burden, but to protect each other.”

A nationwide mask mandate is easier said than done, given current law.

The Congressional Research Service found that the Centers for Disease Control and Prevention could use the Public Health Service Act (Sec. 361) to issue regulations mandating the use of masks. But a mandate would likely run into legal problems with the Constitution and other laws, including the Religious Freedom Restoration Act of 1993, which requires courts to grant certain religious exemptions.

Meanwhile, the Supreme Court’s interpretation of the 10th Amendment prevents the federal government from controlling or requiring states to carry out federal directives. Congress could incentivize states to enact mask mandates, as long as the incentives aren’t considered significant enough to coerce or force states into enacting the mandate, the CRS report said.

A number of courts have affirmed state and local authority to impose social distancing measures and temporary business closures. Opponents of masks say that the requirement violates their First Amendment rights. At least one federal court has already rejected this claim and said the requirement regulates conduct, not speech.

Daniel Funke,  Louis Jacobson, Victoria Knight, Bill McCarthy, Samantha Putterman, Amy Sherman and Miriam Valverde contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Democratic Convention, Night 3: Making the Party Lines Clear

The third night of the Democratic National Convention was all about one thing: Sen. Kamala Harris of California becoming the first Black and Indian American woman to accept a major political party’s vice presidential nomination.

But key Democratic criticisms — many rooted in health care issues and the COVID-19 pandemic — were repeated throughout the evening.

Hillary Clinton took an early swipe at President Donald Trump’s coronavirus response, describing how he has fallen short despite coming in “with so much set up for him,” such as “plans for managing crises — including a pandemic.”

House Speaker Nancy Pelosi reupped another criticism of Trump and his fellow Republicans: “Instead of crushing the virus, they’re trying to crush the Affordable Care Act and its preexisting conditions benefit,” she said.

During her acceptance speech, Harris issued her harsh rebuke: “Donald Trump’s failure of leadership has cost lives and livelihoods.”

Our partners at PolitiFact did a thorough rundown on many of the evening’s claims. Here’s one of our favorites:

“And while this virus touches us all, we’ve got to be honest: It is not an equal opportunity offender. Black, Latino and Indigenous people are suffering and dying disproportionately.” — Democratic vice presidential nominee Kamala Harris 

This is true, based on available data.

The Centers for Disease Control and Prevention has broken down some COVID data by race and ethnicity; however, not all cases reported include demographic information. Of the cases that do, Hispanic/Latino people have represented 31% of cases and 16.9% of deaths. Black people account for 19.8% of cases and 22.3% of deaths. And American Indians and Alaska Natives make up 1.2% of cases and 0.8% of deaths.

This data isn’t balanced against what proportion of the population fits into each group. Other sources have attempted to provide such context.

The COVID Racial Data Tracker has asked every state to report complete data by race and ethnicity. These data sets are then analyzed against Census Bureau demographic statistics. According to the tracker’s website, Black people nationwide are dying from COVID-19 at 2.4 times the rate of white people. In May, NPR analyzed data from the COVID Racial Data Tracker and reported that in 42 states and Washington, D.C., Hispanics and Latinos make up a greater share of COVID-19 confirmed cases than their share of the population. White deaths from COVID-19 were found to be lower than their share of the population in 37 states and Washington, D.C.

In addition, The New York Times has analyzed CDC data by race and ethnicity. According to its July analysis, the Times found that Latinos and African Americans in the U.S. are three times as likely to become infected with COVID-19 as white people. And Blacks and Latinos are also twice as likely to die from COVID-19 as white people.

The New York Times also analyzed limited data from state and local health agencies on COVID-19’s impact on the Native American community in July. In its analysis, the rate of known cases in eight counties with the largest populations of Native Americans is nearly double the national average. There were also smaller counties with large Native American populations that had high COVID-19 case rates.

— Victoria Knight, Kaiser Health News

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What The Health?’: Democrats in Array (For Now)

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Democrats have shown a remarkably united front, including on health care, in their socially distant, made-for-TV convention this week. That’s likely due, at least in part, to the physical separation of party members who disagree on issues — this year they cannot chatter on live television — and to the party truly being united in its desire to defeat President Donald Trump in November.

Meanwhile, the coronavirus pandemic continues to complicate efforts around the country to get students back to school, from preschool to college. And the Trump administration’s effort to eliminate anti-discrimination protections in health care for transgender people is put on hold by a federal judge.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Paige Winfield Cunningham of The Washington Post and Shefali Luthra of The 19th.

Among the takeaways from this week’s podcast:

  • Democrats’ online convention has helped make the party seem unified. But on health policy, divisions remain even though Vice President Joe Biden has agreed to broaden some of his plans, such as lowering the eligibility age for Medicare and agreeing to have federal regulators run a public option plan he is advocating. Progressives in the party still hope to move the debate next year back to establishing a “Medicare for All” system.
  • The heated Democratic primary campaign put a good deal of focus on health policy, including whether to support a Medicare for All system and efforts to make health care more affordable. But the convention rhetoric on health hasn’t focused much attention on that and instead has played up issues surrounding the Trump administration’s response to the coronavirus pandemic.
  • The emphasis on COVID-19 in recent months has also pushed out much of the debate on the issues of high drug prices and surprise bills.
  • As the question of a mail slowdown has enveloped the country, concerns are being raised about mail delivery of prescription drugs, especially for seniors and veterans. Despite anecdotal reports of missed deliveries, most drug industry experts say problems haven’t been widespread.
  • The controversies about reopening schools — both K through 12 and colleges — point to difficulties with the country’s COVID testing program. It is too hard and too expensive for schools to be able to test enough students to guarantee that the virus isn’t spreading.
  • Schools may want to reconsider which age groups they target for returning to the classroom. Since there is little evidence that younger kids spread the virus widely and since they may need the in-classroom experience more, it could make sense to bring them back to school sooner than older students. Plus, older students generally can better handle online classes.
  • Federal health officials have recently warned that the pandemic is having an impact on mental health for many people, raising levels of depression and anxiety. The physical isolation and the economic stresses are fueling much of that.
  • The Trump administration’s rule overturning an Obama administration rule on transgender protections in the Affordable Care Act has been put on hold by a federal judge. But the Obama-era rule had also been put on hold by another judge. So the question is in limbo until higher courts — perhaps the Supreme Court — take up the case.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The Washington Post’s “Can Dogs Detect the Novel Coronavirus? The Nose Knows,” by Frances Stead Sellers

Margot Sanger-Katz: The Atlantic’s “The Plan That Could Give Us Our Lives Back,” by Robinson Meyer and Alexis C. Madrigal

Paige Winfield Cunningham: Stat News’ “Seven Months Later, What We Know About Covid-19 – And the Pressing Questions That Remain,” by Andrew Joseph, Helen Branswell and Elizabeth Cooney.

Shefali Luthra: KHN’s “Back to the Future: Trump’s History of Promising a Health Plan That Never Comes,” by Victoria Knight

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Democratic Convention, Night 2: Defending the ACA and Attacking Trump on Pandemic

The second night of the 2020 Democratic National Convention featured a 17-person keynote speech, past presidents, a roll call vote that doubled as a virtual tour of the United States and an emphasis on health care and national security issues.

Ady Barkan, a health care activist paralyzed by ALS, appeared in a video — speaking with a computer-generated voice in support of Joe Biden. “Nearly 100 million Americans do not have sufficient health insurance,” he said. Barkan emerged on the national scene as a backer of “Medicare for All,” an approach Biden does not support.

Jill Biden, the wife of the now official Democratic presidential candidate, closed out the evening with a speech from a Delaware classroom, highlighting the school’s silence and these difficult times.

Our partners at PolitiFact checked a range of those statements. Here are highlights dealing with coronavirus case numbers and the Trump administration’s position on the Affordable Care Act.

“Now, it’s unthinkable that Donald Trump is trying to take that health care away. In the middle of a pandemic, he is still trying to get rid of the Affordable Care Act.” — Narrator of a health care video segment

We checked a similar statement by former President Barack Obama and found it to be True.

The attack line refers to Texas v. Azar, a court case pending before the Supreme Court in which the Trump administration has joined with a group of Republican governors in an effort to overturn the Affordable Care Act, or ACA. The ACA is Obama’s signature health care law that expanded access to health insurance to millions of Americans and took effect in 2010.

It is estimated that 27 million Americans could become uninsured during the COVID-19 pandemic due to job losses and other factors. But the Trump administration has continued its legal challenge.

On Tuesday night, Biden addressed several patients who relied on ACA coverage, including Laura Packard, with stage 4 Hodgkin lymphoma. She said, “Ever since I was diagnosed, every night I would go to bed concerned about what news I would get in the morning. And even still, even today, they’re still trying to take away our health care, even during a pandemic.”

Another woman later said in a video segment focused on health care that “I chose to become a Joe Biden delegate as I watched with our nation as President Donald Trump sought to dismantle the Affordable Care Act.”

For Trump’s part, he ran for president in 2016 on the promise he would repeal and replace the ACA. He supported a 2017 congressional effort to repeal the legislation that narrowly failed to pass. Since then, Trump has continuously promised to produce a Republican health care bill, which would replace the ACA and protect people with preexisting conditions. He has so far failed to deliver.

— Victoria Knight, Kaiser Health News

Meanwhile, former President Bill Clinton took on the Trump administration’s handling of the coronavirus pandemic, calling attention to case-count numbers to show how the U.S. is doing compared with other nations:

“We have just 4% of the world’s population — 25% of the world’s cases.” — Former President Bill Clinton

This statistic is correct. The Johns Hopkins database of COVID-19 cases shows about 22 million global cases as of Wednesday morning, including almost 5.5 million cases in the U.S. That works out to about 25% of the world’s cases. The U.S. represents about 4% of the world’s population.

As we explained in a fact check of President Donald Trump’s false statement that “our numbers are better than almost all countries,” there are other ways to compare cases globally. Those measures include case fatality rate, death rate per 100,000, per capita cases and the positivity rate.

Measured against the size of the population, the United States has the 10th-highest death rate in the world. It’s doing better than the United Kingdom, Spain, Italy, Sweden and Chile, but worse than France, Canada and Germany, to pick a few examples.

Factoring in population size, the United States has one of the highest rates globally of people who have tested positive — 16,430 per million residents, which is lower than Chile’s, but higher than that of any other large country.

With a positivity rate of about 7%, the United States ranks in the middle of the pack, ranking better than countries such as Mexico and Argentina, but worse than just about every country in Europe, as well as Canada and Australia.

— Amy Sherman and Jon Greenberg

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Democratic Convention, Night 1: Hitting Trump Team on Pandemic Preparedness

On the first night of the Democrats’ 2020 national convention, one thing was clear. This time would be different. No crowds, buttons, placards or party swag. The coronavirus pandemic was an ever-present theme.

Still, there was a virtual National Anthem and everyday people offering their thoughts on the upcoming election and the state of the nation. A young woman whose father, a Donald Trump voter, died of COVID-19, was among them. A list of marquee speakers including Sen. Bernie Sanders and former first lady Michelle Obama spoke directly into the camera.

Our partners at PolitiFact noted that “nothing jumped out as Pants on Fire false” during the course of the evening. Some claims, they went on to say, were interestingly accurate. Others could have used more context.

We focus here on two points related to the Trump administration’s pandemic preparedness.

“Vice President Biden and President Obama assembled a pandemic playbook to make sure that America was prepared and protected. The Trump administration disbanded the pandemic response team that was given to them.” — Eva Longoria Bastón

Longoria is largely correct on both points.

After the 2014 Ebola crisis, the Obama administration created a document titled “Playbook for Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents.”

The National Security Council developed the guidebook in 2016 with the goal of assisting leaders “in coordinating a complex U.S. Government response to a high-consequence emerging disease threat anywhere in the world.” It outlined questions to ask, who should be asked to get the answers and what key decisions should be made.

Politico reported on the document in March, but White House press secretary Kayleigh McEnany dismissed the playbook’s usefulness when asked about it in May.

As for the pandemic response team, the Trump White House reorganized the team that oversaw global health security issues under former national security adviser John Bolton. Tom Bossert, a homeland security adviser who recommended strong defenses against disease and biological warfare, was pushed out by Bolton in April 2018, The Washington Post reported. In May 2018, the top White House official in charge of the U.S. response to pandemics, Rear Adm. Timothy Ziemer, left the administration and was not replaced.

Neither White House official nor their teams, which were responsible for coordinating the U.S. response to pandemic outbreaks across agencies, were replaced before the coronavirus arrived.

In November 2019, a bipartisan group of lawmakers and experts brought together by the Center for Strategic and International Studies to focus on U.S. global health security formally recommended that health security leadership on the NSC be restored.

— Jon Greenberg, PolitiFact

“And our current federal government is dysfunctional and incompetent. It couldn’t fight off the virus. In fact, it didn’t even see it coming. The European virus infected the Northeast while the White House was still fixated on China.” — New York Gov. Andrew Cuomo

There is evidence that suggests Cuomo is right. The disease most likely arrived in Europe from China, but it was travel from Europe to the United States that brought the disease to New York.

Researchers from the Icahn School of Medicine at Mount Sinai traced the strains of the COVID-19 virus — which was circulating in late January and was responsible for the New York City COVID-19 outbreak — back to Europe.

The study, published in July, examined the genomic sequences of the COVID-19 virus based on samples taken from confirmed COVID cases in the Mount Sinai Health System. The cases were traced through March and represented a large number of New York City neighborhoods. Only one strain was closely related to COVID-19 strains circulating in Asia.

“These results show that SARS-CoV-2 came to the New York City area predominantly via Europe through untracked transmissions,” said Dr. Viviana Simon, professor of microbiology and infectious diseases at Mount Sinai’s Icahn School of Medicine, in a press release.

Cuomo’s charge that the Trump administration was fixated only on the spread from China has some merit as well. Beginning in mid-January, the U.S. started screening travelers arriving from Wuhan, China, where the COVID-19 outbreak started. Then on Jan. 31, President Trump banned non-U.S. citizens from traveling from China into the United States. But U.S. citizens could still travel back from China, as long as they observed a 14-day quarantine upon arrival. No such travel limits were put in place for Europe until mid-March.

— Victoria Knight, Kaiser Health News

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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GOP Senate Ad Misrepresents Mont. Governor’s Stance on Rural Hospitals, Public Option

An attack ad, which was released in mid-July, states that Montana Gov. Steve Bullock, a Democratic candidate for the Senate, supports a government-run health care program that would wreak havoc on the state’s health care infrastructure.

“Bullock’s health care plan will force rural hospitals to close. Medicare as we know it will change, replaced by a government-run program with fewer doctors and longer wait times,” says the narrator in the dark and grainy advertisement paid for by the National Republican Senatorial Committee (NRSC).

Bullock is running against first-term incumbent Republican Sen. Steve Daines in a race viewed as a toss-up. Given the COVID-19 pandemic, both candidates have been focusing on health issues.

Because this race is critical to determining whether Democrats or Republicans control the Senate, and considering that its themes are likely to be repeated in many congressional campaigns, we thought it was important to check the ad’s validity.

We first asked the NRSC for the evidence on which the ad was based. A spokesperson pointed to Bullock’s support for a “public option” health plan and provided us with a report predicting this proposal’s negative impact on rural hospitals, as well as quotes from both Republicans and Democrats about how the public option could lead to the eventual implementation of a “Medicare for All” program. (Medicare for All refers to the single-payer health system, advocated by Vermont Sen. Bernie Sanders, which would eliminate private insurance and replace it with a government-run health care system.)

We also reached out to the Bullock campaign for its response.

In a statement, Sean Manning, spokesperson for Montanans for Bullock said, “The claims in this ad are false. Montana hasn’t lost one rural hospital under Governor Bullock, and he will continue to support policies that protect rural hospitals while making affordable healthcare available to all Montanans in the Senate.” (According to the University of North Carolina Sheps Center for Health Services Research, no rural hospitals have closed in Montana since 2005.)

Hold Up ― Which Health Care Plan Is the NRSC Ad Talking About?

The ad vaguely refers to Bullock’s “health care plan” but doesn’t say outright what the candidate supports.

According to Bullock’s campaign website, he supports the creation of a public option.

A public option is generally defined as a health plan administered by the federal government that exists alongside and competes with private health insurance plans on the Affordable Care Act exchanges. Public option proposals differ by political candidate, and can take various forms, including Medicare or Medicaid buy-ins as well as a new government-run entity.

Opponents of such plans say that a public option, which would have the scale and regulatory power of the federal government to set lower reimbursement rates to providers, would have a competitive advantage and could put private insurance companies out of business. This would leave Americans with only one choice ― government-backed insurance. But that conclusion is debatable. Some health care scholars argue a public option would increase competition, leading to expanded access to health coverage, lower health care costs and lower premiums for consumers.

In the end, the outcomes from implementing this approach are difficult to predict unless a specific plan is released, said Benedic Ippolito, a health care research scholar at the American Enterprise Institute.

“Things can be radically different based on what the public option looks like,” said Ippolito. “The two big variables are, who is covered? And how does that insurer actually pay health care providers? You can imagine two public options looking totally different.”

The Payment Rate Is Key 

Now to tackle the first part of the ad, which says that “Bullock’s health care plan will force rural hospitals to close.”

This argument stems from the idea that a public option would lead to lower reimbursement rates, based on the model provided by Medicare, which pays less than private insurance. And, because many rural hospitals are already severely financially strapped, lowered payments would do them in, the argument goes.

When we asked the NRSC for the evidence to support this position, a spokesperson provided an August 2019 study conducted by Navigant, a consulting firm. The study was commissioned by the Partnership for America’s Healthcare Future, a health industry coalition including  drugmakers, insurance companies and private hospitals. The organization opposes Medicare for All and a public option.

The study modeled what would happen to rural hospitals if three separate public option approaches were implemented.

While it found that a public option could, depending on the scenario, cause a revenue reduction for rural hospitals of between 2.3% and 14%, the study reached these findings by assuming that the hospitals would be paid at Medicare rates.

Bullock’s campaign website, though, under his rural health care policy proposals, specifically states: “We need a public option that includes higher reimbursements for rural hospitals.”

We asked the Bullock campaign if it could provide us with details about what the “higher reimbursement” rate would be based on. It declined. A campaign staffer told us Bullock would support a public option that pays rural hospitals above Medicare rates. Since the reimbursement rates would be higher than Medicare’s, the assumptions in the Navigant study cannot be applied here.

“If the public option is a reasonably generous payer, that won’t be the end of rural health care,” said Ippolito. “But, you can easily imagine due to budgetary concerns, a public payer could have a lower reimbursement, which would have consequences.”

Some health policy experts argue that a public option would help rural hospitals by increasing the number of people in rural areas who have health insurance.

This would “benefit rural hospitals, since getting virtually nothing from uninsured patients is worse than getting a reasonably good rate from the public option,” said Gerard Anderson, a professor of health policy and management at Johns Hopkins University in Baltimore.

That’s a Big Jump 

Next, we’re on to the NRSC ad’s second claim: “Medicare as we know it will change, replaced by a government-run program with fewer doctors and longer wait times.”

As several experts pointed out, this sentence doesn’t make a lot of sense. Medicare is already a government-run program.

Also, the design of most public option proposals thus far keeps Medicare and the public option as two separate government programs, said Linda Blumberg, a health policy analyst at the Urban Institute, a think tank.

The NRSC clarified its position and told us it was referring to the idea that a public option would stifle competition in the insurance market, eventually leading to only government-run insurance or Medicare for All. The evidence the NRSC provided to support this claim were quotes from a selection of Republicans, Democrats, professors, and experts from conservative think tanks saying that the public option is a stepping stone to this single-payer approach.

But others suggest that’s a big leap in logic.

“I think that analysis is almost surely wrong,” said Matthew Fiedler, a fellow with the Brookings Institution. “In a world where there is a public option, the negotiating dynamics between insurers and providers would change substantially.”

This would likely create an environment in which private insurers could negotiate lower rates and providers would have to respond to that change in revenue with more efficiencies, he added. However, depending on how a public option plan is structured — specifically if providers can opt out of participating — some in-demand providers may choose to stay in private-plan networks where they could negotiate higher payments. This would keep private plans competitive.

“I don’t think it’s reasonable to argue that a public option would drive all other plans out of the market,” Fiedler said.

Again, Ippolito said it all depends on how the public option program is designed, and he allowed that if providers and hospitals were paid at Medicare rates, the public option would have a huge competitive advantage over commercial insurers because it would be paying out less for services and then could charge lower premiums, and “there’s no question in the short run, that it would be disruptive.”

As we noted earlier, the prediction of any outcome is difficult without specifics. Without details of Bullock’s public option plan, it’s misleading to characterize the outcome of the public option as surely leading to Medicare for All.

Why It Matters 

The race between Bullock and Daines is indicative of a trend occurring in campaigns across the country. Republicans often paint Democrats as left of the general public and health care has often been one of the issues the GOP highlights in that effort.

In this case, the NRSC ad links  Bullock to Medicare for All, despite his expressed support for a public option. Sean Manning, Bullock’s campaign spokesperson, said the governor does not support Medicare for All.

Jeremy Johnson, an associate professor of political science at Carroll College in Helena, Montana, said that even before COVID-19 became a major campaign issue, Daines, echoing a Trump theme, had pushed the idea that he stood for freedom versus socialism.

“One of the things [Daines] gives as a symbol of socialism is Medicare for All,” said Johnson. “Because Bullock says he favors a public option, there is a conflation of that on the Republican side to mean Medicare for All.”

But the public option and Medicare for All are not the same program and it’s misleading to lump them together.

Our Rating 

The NRSC claimed in a television ad that Steve Bullock’s support for the public option would cause rural hospitals to close.

While the NRSC did provide us with one study that offered support for its rural hospital claim, the study was industry-funded and based on broad assumptions that don’t accurately reflect positions outlined on Bullock’s website. Thus, this claim doesn’t stand up.

The second part of the ad asserts that the public option would lead to the implementation of Medicare for All. While supporters and critics debate how a public option would affect the private health insurance market and some on both sides consider it a “glide path” to a single-payer health care system, it’s too big of a jump to say it would definitely trigger this outcome.

We rate this False.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Voters Are Souring on President Trump’s Handling of Coronavirus, with Implications for November

As the country struggles to get a handle on the coronavirus pandemic and prepares for the 2020 election, this analysis finds that, while voters are increasingly negative in their evaluations of President Trump’s handling of the pandemic, he continues to garner strong support among Republican voters – even those living in areas disproportionately impacted by the virus.

KHN’s ‘What the Health?’: Kamala Harris on Health

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California Sen. Kamala Harris, the newly named running mate for presumptive Democratic presidential nominee Joe Biden, doesn’t have a lot of background in health policy. But that’s unlikely to prevent Republicans from using her on-again, off-again support for “Medicare for All” against her in the fall campaign.

Meanwhile, with talks between Congress and the Trump administration over the next round of COVID-19 relief at a standstill, President Donald Trump is trying to fill the void with executive orders. What’s unclear is whether the president has the authority to do some of what he is proposing — or whether it will work to help people in dire economic and health straits.

This week’s panelists are Julie Rovner of KHN, Kimberly Leonard of Business Insider, Joanne Kenen of Politico and Mary Agnes Carey of KHN.

Among the takeaways from this week’s podcast:

  • Although Harris isn’t closely associated with health care issues, one created problems for her last fall during her failed presidential bid. She was an original co-sponsor of the Medicare for All bill put forward by Sen. Bernie Sanders (I-Vt).
  • Trump’s executive order to suspend payroll taxes is causing consternation. It’s not clear if the order applies to both Social Security and Medicare or whether employers will follow the order. There is no indication that Congress would accept the president’s plan — and, if lawmakers don’t, workers and companies would owe the back taxes by the end of the year.
  • The tax suspension also has handed Democrats a club for the fall campaign. They are charging that the lack of revenue would endanger the Social Security and Medicare trust funds and could affect consumer benefits. Trump has replied that money from the federal government’s general fund would be used to fill the gap, but with the pandemic causing an economic upheaval, there’s no guarantee the government could afford that.
  • The president has promised he will shortly issue an executive order to protect coverage for people with medical conditions. The Affordable Care Act, which Trump has repeatedly pledged to abolish, already carries that protection, so this could be an attempt to offer Republicans a shield if the case before the Supreme Court overturns the law or some of its provisions. Previous vows by the president to offer health care plans have largely gone unfulfilled.
  • The administration is seeking to change the U.S. reliance on foreign nations, largely China and India, for prescription drugs and is moving to mandate that the government buy only U.S.-manufactured medications. Although the effort enjoys bipartisan support, it could end up increasing drug prices.
  • The recent announcement that the federal government is offering Kodak a $765 million loan to begin making chemicals that could be used in drug manufacturing triggered new scrutiny of the company. Stock trades made before the announcement, major escalation of the company’s lobbying efforts in Washington and a leak about the pending deal are all being analyzed.
  • The KHN-Guardian spotlight on the deaths of health care workers from COVID-19 points to a longer-term issue: shortages of medical professionals in key care fields.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The Wall Street Journal’s “Covid-19 Data Reporting System Gets Off to Rocky Start,” by Robbie Whelan

Joanne Kenen: The Texas Tribune and ProPublica’s “ICE Is Making Sure Migrant Kids Don’t Have COVID-19 — Then Expelling Them to ‘Prevent the Spread’ of COVID-19,” by Dara Lind and Lomi Kriel

Kimberly Leonard: The Philadelphia Inquirer’s “Coronavirus Is Changing Childbirth in the Philadelphia Region, Including Boosting Scheduled Inductions,” by Sarah Gantz

Mary Agnes Carey: The New York Times’ “Inside the Fight to Save Houston’s Most Vulnerable,” by Sheri Fink, Emily Rhyne and Erin Schaff

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Pandemic’s Bumps and Backlash Shape Montana Race Poised to Steer US Senate

MISSOULA, Mont. — Bradshaw Sumners watched throughout February as COVID-19 hot spots developed in major American cities, waiting to see when the coronavirus pandemic would manifest in Montana.

When it finally did, life for the Livingston resident and father of two changed dramatically. His daughters, 8 and 4 years old, were suddenly home from school. The restaurant group where Sumners works maintenance shut down, thrusting him onto unemployment alongside legions of workers nationwide.

Despite his life being upended, Sumners backed Gov. Steve Bullock’s decision to lock down the state, and Montana saw relatively few cases through the spring.

That response, echoed by others across the state who approved of how Bullock had handled the pandemic, was good news for the governor’s nascent campaign to unseat Republican Sen. Steve Daines in a key race for control of the U.S. Senate.

Republicans, who hold a slim three-seat majority in the Senate, considered Montana a safe seat until Bullock’s last-minute entry in March. The term-limited governor had repeatedly rejected the idea of challenging Daines, a first-term incumbent seeking reelection in a state that President Donald Trump won by 20 percentage points in 2016. Bullock reconsidered after dropping his long-shot presidential bid and being wooed by top Democrats, including former President Barack Obama and Senate Minority Leader Chuck Schumer.

The pandemic has shaped the race beyond simply focusing the public’s attention on health directives and congressional stimulus packages. Health care in general has rocketed to the forefront of both candidates’ campaigns. Television ads have touted and attacked Bullock’s push to expand Medicaid, Daines’ opposition to the Affordable Care Act and Daines’ plan for lowering prescription drug prices.

That dynamic has national implications, said Jessica Taylor, the Senate and governors editor for The Cook Political Report. A decade ago, health care — and a campaign to repeal and replace the ACA — helped Republicans wrest control of the House and then four years later the Senate. In 2018, health issues aided Democrats in taking back the House. Now the pandemic could play into a power flip in the Senate, sweeping many of the GOP’s strongest knocks against Bullock, such as his support for a ban on assault weapons, off the table in favor of a policy debate that Republicans have lost ground on.

But matters have grown more complicated for Bullock as the pandemic continues. When coronavirus cases began to rise in Montana in June, hundreds of people from across the state wrote to Bullock’s office. According to emails, released by the governor’s office under a public records request, many criticized the governor for not issuing a statewide mask mandate early enough and questioned his motives in other pandemic-related decisions.

Sumners wrote Bullock twice. He strongly disagreed when the governor in June lifted the 14-day quarantine rule for out-of-state visitors. Later, he felt Bullock was taking too long to issue the mask order, which didn’t come until July 15.

Sumners, who said he still supports Bullock, began to suspect that the governor’s political ambitions were coloring his response to the crisis. He wrote to the governor’s office and urged him to “put your politics aside” and issue the mask order.

“I think he’s been trying to play the political game a little too much, to his own benefit,” Sumners said in a recent interview.

That the early sheen of public praise lavished on governors in their battles against COVID-19 would gradually scuff and wear was a foregone conclusion. The pandemic continues to bring fresh challenges around the country, from rising case counts and testing delays to quandaries over what to mandate and what to reopen.

Rob Saldin, a political scientist at the University of Montana, said Bullock’s very presence on the ballot means his actions on the outbreak will be seen through a political lens.

That worked in his favor early on when constant media coverage of all things COVID put Bullock in a spotlight that would not otherwise have existed for a lame-duck governor. Even with the recent criticism over the timing of the face mask order, Saldin speculated that Bullock’s supporters will still back him. Whether voters continue to see Bullock as an effective and reliable leader into the fall is the real question hanging over Election Day.

“It is really kind of a ‘damned if you do, damned if you don’t’ situation he finds himself in,” Saldin said. “This is such a highly charged issue that’s impacting everybody’s lives that it just does raise the salience of this thing.”

Bullock refuses to give the notion of a campaign calculus in his pandemic response much note, saying, “None of that is politics. That’s just trying to do the job that I’m fortunate that I’ve gotten to do for eight years.”

If it took time to issue a face mask mandate, Bullock said in a phone interview, it’s because lining up support from Montana business leaders and stoking public acceptance were critical to ensuring the order would have the intended effect.

Daines appears equally reluctant to marry the pandemic to the campaign. According to the Associated Press, one unnamed Daines campaign staffer accused Bullock in early July of staging photo-ops at COVID testing sites, a charge Bullock’s team countered was baseless. So far, however, that salvo has been a one-off. Daines declined to be interviewed, but spokesperson Julia Doyle said in an email that his response to the pandemic is not political.

“It’s about ensuring Montanans have the resources to protect their health, help our small businesses, and [getting] Montanans safely back to work,” she said.

For now, Daines and Bullock as candidates are largely keeping their talk about the coronavirus confined to their own roles. Daines’ tele-town halls and in-state visits have centered on his work securing federal relief funding for Montana workers and businesses.

Bullock, meanwhile, has his attention trained on health directives and economic aid programs. He said criticism of his coronavirus policies is not affecting his plans.

“My responses and my efforts can’t be defined by the individuals that were upset that we didn’t do a masking order earlier, or can’t be defined by the individuals that were protesting around the Capitol or the [governor’s] residence,” Bullock said. “You just have to do the best you can with everything you know.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.