Algunos llegan tan enfermos que van directo a cuidados intensivos. Muchos no sobreviven.
“Vivimos una pesadilla constante”, dijo Prendkowski mientras trataba a pacientes con coronavirus en el Hospital Mount Sinai, fundado a principios del siglo XX para atender a los inmigrantes más pobres. “Ojalá salgamos pronto de esto”.
La enfermera cree que algunas muertes, y mucho sufrimiento, podrían haberse evitado si estas personas hubieran tenido un tratamiento regular para todo tipo de condiciones crónicas —asma, diabetes, enfermedades del corazón— que pueden empeorar COVID-19.
Y ahora se siente esperanzada.
En medio del brote del mortal virus que ha afectado de manera desproporcionada a las comunidades hispanas, Illinois se convirtió recientemente en el primer estado de la nación en extender el seguro médico público a todos los adultos mayores no ciudadanos de bajos ingresos, incluso si son indocumentados.
Defensores de los inmigrantes esperan que inspire a otros estados a hacer lo mismo. De hecho, legisladores demócratas de California están presionando para expandir su Medicaid a todos los inmigrantes indocumentados del estado.
“Hacer esto durante la pandemia muestra nuestro compromiso con la expansión y ampliación del acceso a la atención de salud. Es un gran primer paso”, señaló Graciela Guzmán, directora de campaña de Healthy Illinois, que promueve la cobertura universal en el estado.
Muchos inmigrantes indocumentados sin cobertura de salud no van al médico. Ese fue el caso de Victoria Hernández, una limpiadora de casas de 68 años que vive en West Chicago, Illinois. La mujer, nativa de la Ciudad de México dijo que, cuando no tenía seguro, simplemente no iba al médico.
Soportaba cualquier dolencia hasta que encontró un programa de caridad que la ayudó a tratar su prediabetes. Dijo que tiene la intención de inscribirse en el nuevo plan estatal una vez que tenga más información.
“Estoy muy agradecida por el nuevo programa”, explicó a través de un traductor que trabaja para DuPage Health Coalition, una organización sin fines de lucro que coordina la atención de caridad para personas sin seguro médico como Hernández en el condado de DuPage, el segundo más poblado del estado. “Sé que ayudará a mucha gente como yo. Sé que tendrá buenos resultados, muy, muy buenos resultados”.
Primero, Healthy Illinois intentó ampliar los beneficios de Medicaid a todos los inmigrantes de bajos ingresos, pero los legisladores decidieron empezar con un programa más pequeño, que cubre a adultos mayores de 65 años o más que son indocumentados, o que han sido residentes permanentes, tienen tarjeta verde, por menos de cinco años (este grupo no califica para seguro de salud auspiciado por el gobierno).
Los participantes deben tener ingresos que estén en o por debajo del nivel de pobreza federal, que es de $12,670 para un individuo o $17,240 para una pareja. Cubre servicios como visitas al hospital y al médico, medicamentos recetados, y atención dental y oftalmológica (aunque no estancias en centros de enfermería), sin costo para el paciente.
La nueva norma continúa la tendencia de expandir la cobertura de salud del gobierno a los inmigrantes sin papeles.
El año pasado, California fue el primero en ofrecer cobertura pública a los adultos indocumentados, cuando amplió la elegibilidad para su programa Medi-Cal a todos los residentes de bajos ingresos menores de 26 años.
Según la ley federal, las personas indocumentadas generalmente no son elegibles para Medicare, Medicaid que no es de emergencia y el mercado de seguros de salud de la Ley de Cuidado de Salud a Bajo Precio (ACA). Los estados que ofrecen cobertura a esta población lo hacen usando sólo fondos estatales.
Se estima que en Illinois viven 3,986 adultos mayores indocumentados, según un estudio del Centro Médico de la Universidad de Rush y el grupo de demógrafos de Chicago Rob Paral & Associates; y se espera que el número aumente a 55,144 para 2030. El informe también encontró que el 16% de los inmigrantes de Illinois de 55 años o más viven en la situación de pobreza, en comparación con el 11% de la población nacida en el país.
Dado que la administración saliente de Trump ha promovido duras medidas migratorias, sectores del activismo pro inmigrante temen que haya miedo a inscribirse en el nuevo programa porque podría afectar la capacidad de obtener la residencia o la ciudadanía en el fututo, y trabajan para asegurarles que no lo hará.
“Illinois cuenta con un legado de ser un estado que acepta al recién llegado y de proteger la privacidad de los inmigrantes”, señaló Andrea Kovach, abogada que trabaja en equidad en la salud en el Shriver Center for Poverty Law en Chicago.
Se espera que la normativa cubra inicialmente de 4,200 a 4,600 inmigrantes mayores, a un costo aproximado de entre $46 millones a $50 millones al año, según John Hoffman, vocero del Departamento de Salud y Servicios Familiares de Illinois.
Algunos representantes estatales republicanos criticaron la expansión de la cobertura, diciendo que era imprudente hacerlo en un momento en que las finanzas de Illinois sufren por la pandemia. En una declaración condenando el presupuesto estatal de este año, el Partido Republicano de Illinois lo denominó “atención de la salud gratuito para los inmigrantes ilegales”.
Pero los defensores de la nueva política sostienen que muchos inmigrantes sin papeles pagan impuestos sin ser elegibles para programas como Medicare y Medicaid, y que gastar por adelantado en cuidados preventivos ahorra dinero, a largo plazo, al reducir el número de personas que esperan para buscar tratamiento hasta que es una emergencia.
Para Delia Ramírez, representante estatal de Illinois, ampliar la cobertura de salud a todos los adultos mayores de bajos ingresos es personal. A la demócrata de Chicago la inspira su tío, un inmigrante de 64 años que no tiene seguro.
Dijo que intentó que la legislación cubriera a las personas de 55 años o más, ya que la gran mayoría de los indocumentados no son personas mayores (señaló que muchos de los inmigrantes mayores —2,7 millones, según estimaciones del gobierno— obtuvieron el estatus legal con la ley de amnistía federal de 1986).
Un mayor número de inmigrantes más jóvenes también pueden estar sin seguro. En los Centros de Salud Esperanza, uno de los mayores proveedores de atención médica para inmigrantes de Chicago, el 31% de los pacientes de 65 años o más carece de cobertura, en comparación con el 47% de los de 60 a 64 años, según Jeffey McInnes, que supervisa el acceso de los pacientes a las clínicas.
Ramírez dijo que su tío la llamó después de ver las noticias sobre la nueva legislación en la televisión en español. Contó que su tío ha vivido en el país por cuatro décadas y ha trabajado para que sus cuatro hijos fueran a la universidad. También padece asma, diabetes e hipertensión, lo que lo hace de alto riesgo para COVID-19.
“Yo le dije: ‘Tío, todavía no. Pero cuando cumplas 65 años, finalmente tendrás atención médica, si es que aún no hemos conseguido legalizarte”, recordó Ramírez, emocionada, durante una reciente entrevista telefónica.
“Así que es un recordatorio para mí de que, en primer lugar, fue una gran victoria para nosotros y ha significado la vida o una segunda oportunidad de vida para muchas personas”, dijo. “Pero también significa que todavía tenemos un largo camino por recorrer para hacer de la atención de salud un verdadero derecho humano en el estado, y en la nación”.
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“We’re in a bad dream all the time,” she said during a recent day treating coronavirus patients at Mount Sinai Hospital, which was founded in the early 20th century to care for the city’s poorest immigrants. “I can’t wait to wake up from this.”
Prendkowski believes some of the death and suffering could have been avoided if more of these people had regular treatment for the types of chronic conditions — asthma, diabetes, heart disease — that can worsen covid. She now sees a new reason for hope.
Amid a deadly virus outbreak that has disproportionately stricken Latino communities, Illinois recently became the first state to provide public health insurance to all low-income noncitizen seniors, even if they’re in the country illegally. Advocates for immigrants expect it will inspire other states to do the same, building on efforts to cover undocumented children and young adults. Currently, Democratic legislators in California are pushing to expand coverage to all low-income undocumented immigrants there.
“The fact that we’re going to do this during the pandemic really shows our commitment to expansion and broadening health care access. It’s an amazing first step in the door,” said Graciela Guzmán, campaign director for Healthy Illinois, a group that advocates for universal coverage.
Undocumented immigrants without health insurance often skip care. That was the case for Victoria Hernandez, 68, a house cleaner who lives in West Chicago, a suburb. The Mexico City native said she had avoided going to the doctor because she didn’t have coverage. Eventually, she found a charity program to help her get treatment, including for her prediabetes. She said she intends to enroll in the new state plan.
“I’m very thankful for the new program,” she said through a translator who works for the DuPage Health Coalition, a nonprofit that coordinates charity care for the uninsured in DuPage County, the state’s second-most populous. “I know it will help a lot of people like me.”
Healthy Illinois pushed state lawmakers to offer health benefits to all low-income immigrants. But the legislature opted instead for a smaller program that covers people 65 and older who are undocumented or have been legal permanent residents, also known as green card holders, for less than five years. (These groups don’t typically qualify for government health insurance.) Participants must have an income at or below the federal poverty level, which is $12,670 for an individual or $17,240 for a couple. It covers services like hospital and doctor visits, prescription drugs, and dental and vision care (though not stays in nursing facilities), at no cost to the patient.
The new policy continues a trend of expanding government health coverage to undocumented immigrants.
Illinois was the first state to cover children’s care — a handful of states and the District of Columbia have since followed suit — and organ transplants for unauthorized immigrants. In 2019, California became the first to offer public coverage to adults in the country illegally when it opened eligibility for its Medi-Cal program to all low-income residents under age 26.
Under federal law, undocumented people are generally not eligible for Medicare, nonemergency Medicaid and the Affordable Care Act’s health insurance marketplace. The states that do cover this population get around that by using only state funds.
An estimated 3,986 undocumented seniors live in Illinois, according to a study by Rush University Medical Center and the Chicago demographer group Rob Paral & Associates — but that number is expected to grow to 55,144 by 2030. The report also found that 16% of Illinois immigrants 55 or older live in poverty, compared with 11% of the native-born population.
Given the outgoing Trump administration’s crackdown on immigration, some advocates worry that people will be afraid to enroll in the insurance because it could affect their ability to obtain residency or citizenship. Andrea Kovach, senior attorney for health care justice at the Shriver Center on Poverty Law in Chicago, said she and others are working to assure immigrants they don’t need to worry. Because the new program is state-funded, federal guidance suggests it is not subject to the “public charge” rule designed to keep out immigrants who might end up on public assistance.
“Illinois has a legacy of being a very welcoming state and protecting immigrants’ privacy,” Kovach said.
The Illinois policy is initially expected to cover 4,200 to 4,600 immigrant seniors, at an approximate cost of $46 million to $50 million a year, according to John Hoffman, a spokesperson for the Illinois Department of Healthcare and Family Services. Most of them would likely be undocumented.
Some Republicans criticized the coverage expansion, saying it was reckless at a time when Illinois’ finances are being shredded by the pandemic. The Illinois Republican Party deemed it “free healthcare for illegal immigrants.”
But proponents contend that many unauthorized immigrants pay taxes without being eligible for programs like Medicare and Medicaid, and that spending on preventive care saves money in the long run by cutting down on more expensive treatment for emergencies.
State Rep. Delia Ramirez, a Chicago Democrat who helped shepherd the legislation, advocated for a more expansive plan. She was inspired by her uncle, a 64-year-old immigrant who has asthma, diabetes and high blood pressure but no insurance. He has been working in the country for four decades.
She wanted the policy to apply to people 55 and older, since the vast majority of those who are undocumented are not seniors (she noted that a lot of older immigrants — 2.7 million, according to government estimates — obtained legal status under the 1986 federal amnesty law).
The real impact of this plan will likely be felt in years to come. At Esperanza Health Centers, one of Chicago’s largest providers of health care to immigrants, 31% of patients 65 and older lack coverage, compared with 47% of those 60 to 64, according to Jeffrey McInnes, who oversees patient access there.
Ramirez said her uncle called her after seeing news of the legislation on Spanish-language TV.
“And I said to him, ‘Tío, not yet. But when you turn 65, you’ll finally have health care, if we still can’t help you legalize,’” Ramirez recalled, choking up during a recent phone interview.
“So it is a reminder to me that, one, it was a major victory for us and it has meant life or a second chance at life for many people,” she said. “But it is also a reminder to me that we still have a long way to go in making health care truly a human right in the state and, furthermore, the nation.”
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Settles was also uninsured and had just been sent home from an emergency room for the second time, and he was worried about medical bills. An investigation into his death found that, like many uninsured COVID-19 patients, he had never been told that cost shouldn’t be a concern.
Back at the end of June, Settles and his wife, Angela, were both feeling ill with fevers and body aches. Then Darius took a turn — bad enough that he asked his wife to call an ambulance.
“My husband is having issues breathing and he’s weak, so we’re probably going to need a paramedic over here to rush him to the hospital,” she told the operator, according to the 911 recordings obtained by WPLN News.
Darius Settles was stabilized and tested for the coronavirus at the hospital, according to his medical records. The doctor sent him home with antibiotics and instructions to come back if things got worse.
Three days later, they did. And now he also knew he had COVID-19; his test results were in.
But Settles was between full-time jobs, playing the organ at a church as he launched a career as a suit designer. So he had no health insurance.
His wife, who works for Tennessee State University, said he was worried about costs as he went back to the hospital a second time; she tried to reassure him
“He said, ‘I bet this hospital bill is going to be high.’ And I said, ‘Babe, it’s going to be OK.’ And we left it alone, just like that,” she said.
When he returned to TriStar Southern Hills Medical Center, owned by the for-profit hospital chain HCA, physicians tested his blood oxygen levels, which are usually a first sign that a COVID-19 patient is in trouble. They had dropped to 88%. An X-ray of his lungs “appears worse,” the physician wrote in the record.
But the doctor also noted that after a few hours in the emergency room his oxygen saturations had improved and he was breathing on room air. The records show they discussed why he might not want to be admitted to the hospital since he was otherwise young and healthy and didn’t note any risk factors for complications.
And when Angela Settles called to check in, he seemed to be OK with leaving despite his persistent struggle to breathe.
He was a COVID-19 patient so, “I could not go up there to see him,” she said. “He was saying that I might as well go home.”
Angela Settles was surprised since her husband was the one who wanted to go to the hospital in the first place.
At first, she thought the hospital just didn’t want to admit a man without insurance who would have trouble paying a big bill. But TriStar Southern Hills admits hundreds of patients a year without insurance — more than 500 in 2019, according to a spokesperson.
And in this case, the federal government would have paid the bill. But no one said that when it might have made a difference to Darius Settles.
The Message Never Makes It to Patients
TriStar, like most major health systems, participates in a program through the Centers for Medicare & Medicaid Services in which uninsured patients with COVID-19 have their bills covered. It was set up through the pandemic relief legislation known as the CARES Act.
But TriStar doesn’t tell its patients that upfront. Neither do other hospitals or national health systems contacted by WPLN News. There’s no requirement to, which is one of the program’s shortcomings, said Jennifer Tolbert of KFF, who studies uninsured patients. (KHN is an editorially independent program of KFF.)
“This is obviously a great concern to most uninsured patients,” Tolbert said. Her research finds that people without insurance often avoid care because of the bill or the threat of the bill, even though they might qualify for any number of programs if they asked enough questions.
Tolbert said the problem with the COVID-19 uninsured program is that even doctors don’t always know how it works or that the program exists.
“At the point when the patient shows up at the hospital or at another provider site, it’s at that point when those questions need to be answered,” she said. “And it’s not always clear that that is happening.”
Among clinicians, there’s a reluctance to raise the issue of cost in any way and run afoul of federal laws. Emergency rooms must at least stabilize everyone, regardless of their ability to pay, under a federal law known as the Emergency Medical Treatment and Labor Act, or EMTALA. Asking questions about insurance coverage is often referred to as a “wallet biopsy,” and can result in fines for hospitals or even being temporarily banned from receiving Medicare payments.
Physicians also don’t want to make a guarantee, knowing a patient still could end up having to fight a bill.
“I don’t want to absolutely promise anything,” said Dr. Ryan Stanton, an ER physician in Lexington, Kentucky, and a board member of the American College of Emergency Physicians.
“There should not be a false sense that it will be an absolute smooth path when we’re dealing with government services and complexities of the health care system,” he said.
‘Could I Have Done More?’
Darius Settles knew he was in bad shape. But he didn’t attempt to make a third trip to the hospital. Instead of 911, he called his father, pastor David Settles, and asked his father to come pray for him.
When the elder Settles replied that he was always praying for his son, Darius said, “No, I really need you to pray for me. I need you to get the oil, lay hands on me and pray,” David Settles recalls, and so he went, despite concerns about getting COVID-19 himself.
He sat by his son’s side. Darius’ wife made some peppermint tea, and when they put it to his lips, Darius didn’t sip. They thought he had fallen asleep. But he was unconscious.
At that point, they called 911 again and the operator instructed them to get Darius to the floor and perform chest compressions until paramedics arrived.
For 11 minutes, Angela Settles pumped her husband’s chest, occasionally asking the dispatcher “what’s taking so long,” the 911 recordings show. Even after help showed up, Darius never revived.
Pastor Settles was back in the pulpit just a few weeks later, preaching on suffering and grief after the death of his son, “whom I watched as the breath left his body,” he told his congregation. “The Lord gives, and the Lord takes away.”
Darius Settles left behind his own son, who was 6. And his widow’s head is still spinning. She said she can’t shake a sense of personal guilt.
“Could I have done more?” Angela Settles asked. “That’s hard, and I know that he would not want me to feel like that.”
She wondered, too, if the hospital could have done more for him. And even after failing to disclose its policy for uninsured COVID-19 patients, it did send her a bill for part of her husband’s care. Asked why, a TriStar spokesperson said it was sent in error and does not have to be paid.
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“What’s been fascinating is that carriers in general are not projecting much impact from the pandemic for their 2021 premium rates,” said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University in Washington, D.C.
Although final rates have yet to be analyzed in all states, those who study the market say the premium increases they have seen to date will be in the low single digits — and decreases are not uncommon.
That’s good news for the more than 10 million Americans who purchase their own ACA health insurance through federal and state marketplaces. The federal market, which serves 36 states, opens for 2021 enrollment Nov. 1, with sign-up season ending Dec. 15. Some of the 14 states and the District of Columbia that operate their own markets have longer enrollment periods.
The flip side of flat or declining premiums is that some consumers who qualify for subsidies to help them purchase coverage may also see a reduction in that aid.
Here are a few things to know about 2021 coverage:
It might cost about the same this year — or even less.
Despite the ongoing debate about the ACA — compounded by a Supreme Court challenge brought by 20 Republican states and supported by the Trump administration — enrollment and premium prices are not forecast to shift much.
“It’s the third year in a row with premiums staying pretty stable,” said Louise Norris, an insurance broker in Colorado who follows rates nationwide and writes about insurance trends. “We’ve seen modest rate changes and influx of new insurers.”
That relative stability followed ups and downs, with the last big increases coming in 2018, partly in response to the Trump administration cutting some payments to insurers.
Those increases priced out some enrollees, particularly people who don’t qualify for subsidies, which are tied both to income and the cost of premiums. ACA enrollment has fallen since its peak in 2016.
Charles Gaba, a web developer who has since late 2013 tracked enrollment data in the ACA on his ACASignups.net website, follows premium changes based on filings with state regulators. Each summer, insurers must file their proposed rates for the following year with states, which have varying oversight powers.
Gaba said the average requested increase next year nationwide is 2.1%. When he looked at 18 states for which regulators have approved insurers’ requested rates, the percentage is lower, at 0.4%.
Another study, by KFF, of preliminary premiums filed this summer had similar findings: Premium changes in 2021 would be modest, only a few percentage points up or down. (KHN is an editorially independent program of KFF.)
It’s still worth it to shop around.
Actuaries and other experts say premiums vary by state or region — even by insurer — for a number of reasons, including the number and relative market power of insurers or hospitals in an area, which affects the ability of insurers to negotiate rates with providers.
Because subsidies are tied to each region’s benchmark plan, and those premium costs may have gone down, subsidies also could decrease. (Benchmark plans are the second-lowest-priced silver plan in a region.)
Switching to the benchmark plan can help consumers maintain how much they spend in premiums.
Enrollees should update their financial information, particularly this year when many are affected by work reduction or job losses. “They might be eligible for a bigger” subsidy, said Myra Simon, executive director of commercial policies for America’s Health Insurance Plans, the industry lobbying group.
Enrollees can update their information online, or call their federal or state marketplace for assistance. Insurance brokers, too, can aid people in signing up for ACA plans. When shopping, consumers should check whether the doctors and hospitals they want to use are included in the plan’s network.
Premiums are just one part of the equation. Consumers should also look closely at annual deductibles, because the trade-off of going with a lower-cost premium may well be higher annual deductibles that must be met before much of the coverage kicks in.
“We encourage people to consider all their options,” said Simon.
What’s behind the variation.
Enrollees in some states next year will see premium decreases, according to Gaba’s website: Maine, for example, shows a 13% drop in weighted average premium prices, while Maryland’s is down almost 12%. At the same time, Indiana’s average is up 10%. And Kentucky is up 5%.
In Florida, regulators say insurance premiums will rise about 3%, while the state exchange in California is reporting just over a half-percent increase, its lowest average increase since opening in 2014. Officials in California cite factors that include an influx of healthier enrollees and a reduction in fees that insurers pay.
Other factors affecting rates include how much state regulators step in to alter initial rate filings, along with a provision of the ACA that requires insurers to spend at least 80% of revenue on direct medical care. If insurers don’t meet that standard, they must issue rebates to policyholders. Many insurers were already on the hook to return money in 2020 for previous years.
Most insurers did not cite additional COVID treatment or testing costs as factors in their requested rate increase, Gaba said. Even those that did, however, mainly found them unnecessary because of reduced expenditures resulting from patients delaying elective care during the spring and summer.
Indeed, many insurers in the second quarter posted record profits.
“Some of them thought, ‘We’re going to make more than we thought this year in profits, so let’s not be aggressive with pricing next year,’” said Donna Novak, a member of the American Academy of Actuaries’ Individual and Small Group Markets Committee.
A smaller factor may be the repeal of a fee paid by insurers on premiums. Part of the ACA, the fee was permanently eliminated by the Trump administration effective for 2021.
Your choice of insurers may have widened.
More insurers, including UnitedHealth Group, either stepped back into that individual market or expanded into new counties.
“Insurers are seeing a profit or potential for it,” said John Dodd, an insurance broker in Columbus and past president of the Ohio Association of Health Underwriters.
Rates are down in general across his state for ACA plans, he said, and he expects agents to be busier than ever, simply because there are more plan offerings and choices to make and people want help.
Insurers, he said, like the way the ACA is working.
“People on TV who say it’s not working, they don’t know what they’re talking about,” said Dodd. “It’s working well [for insurers] and every year it gets better.”
New stuff in some states, including a public option.
Residents of New Jersey and Pennsylvania will buy coverage from new state-based marketplaces for 2021, after those states pulled out of the federal healthcare.gov, which now covers 36 states.
In 19 Washington state counties, insurers are offering “public option plans,” which have all the standard benefits, including lower deductibles, and must meet additional quality standards.
As envisioned, the public option plans aimed to be less expensive, with the legislation tying payment rates to Medicare. Insurers offering a public option must stick to an aggregate cap of paying doctors, hospitals and other medical providers an average of 160% of what Medicare would pay for the same services.
When the premium rates came in, however, the five insurers offering the plans had varying prices. Not all parts of the state have the option, but where they do, two of the public option insurers have premiums that are either lower than other plans in the area or are the lowest-cost plan the insurer offers.
But three are more expensive.
The state’s marketplace staff said the higher prices may reflect a number of things, from difficulty getting the program started during COVID-19 to a lack of incentives to get providers to participate.
It could also just be normal first-year jitters.
“It’s Year One. As with any market entry strategy, people are pretty conservative,” said Michael Marchand, chief marketing officer of the Washington Health Benefit Exchange.
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The Affordable Care Act, facing its first test during a deep recession, is providing a refuge for some — but by no means all — people who have lost health coverage as the economy has been battered by the coronavirus pandemic.
New studies, from both federal and private research groups, generally indicate that when the country marked precipitous job losses from March to May — with more than 25 million people forced out of work — the loss of health insurance was less dramatic.
That’s partly because large numbers of mostly low-income workers who lost employment during the crisis were in jobs that already did not provide health insurance. It helped that many employers chose to leave furloughed and temporarily laid-off workers on the company insurance plan.
And others who lost health benefits along with their job immediately sought alternatives, such as coverage through a spouse’s or parent’s job, Medicaid or plans offered on the state-based ACA marketplaces.
From June to September, however, things weren’t as rosy. Even as the unemployment rate declined from 14.7% in April to 8.4% in August, many temporary job losses became permanent, some people who found a new job didn’t get one that came with health insurance, and others just couldn’t afford coverage.
The upshot, studies indicate, is that even with the new options and expanded safety net created by the ACA, by the end of summer a record number of people were poised to become newly uninsured.
What’s more, those losses could deepen in the months ahead, and into 2021, if the economy doesn’t improve and Congress offers no further assistance, health policy experts and insurers say.
“It’s a very fluid situation,” said Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, a New York-based health research group. “The ACA provides an important cushion, but we don’t know how much of one yet, since this is first real test of the law as a safety net in a serious recession.”
Collins also noted that accurately tracking health insurance coverage and shifts is difficult in the best of times; amid an economic meltdown, it becomes even more precarious.
Coverage Was Already on the Decline
Some 20 million people gained coverage between 2010 and 2016 under the ACA’s expansion of Medicaid and its insurance marketplaces for people without employer-based coverage. A gradually booming economy after the 2008-2009 recession also helped. The percentage of the population without health insurance declined from about 15% in 2010 to 8.8% in 2016.
But then, even as the economy continued to grow after 2016, coverage began to decline when the Trump administration and some Republican-led states took steps that undermined the law’s main aim: to expand coverage.
In 2018, 1.9 million people joined the ranks of the uninsured, and the Census Bureau reported earlier this month that an additional 1 million Americans lost coverage in 2019.
The accelerating decline is helping fuel anxiety over the fate of the ACA in the wake of the death of Supreme Court Justice Ruth Bader Ginsburg. The high court is scheduled to hear a case in November brought by Republican state officials, and supported by the Trump administration, that seeks to nullify the entire law.
In July, researchers at the Urban Institute, a Washington, D.C., think tank, forecast that around 10 million workers and their dependents would lose employer coverage in 2020. But they estimated that two-thirds of them will have found new coverage by year’s end — leaving about 3.3 million uninsured.
A more recent Urban Institute report, released Sept. 18, and using 2020 data from the Census Bureau, calculated that of the roughly 3 million people under age 65 who had lost job-based insurance between May and July, 1.4 million found coverage elsewhere — most through Medicaid — and 1.9 million became newly uninsured. Notably, 2.2 million of those who lost their coverage were between 18 and 39 years old; 1.6 million were Hispanic.
Another recent study, using different methods, reported higher numbers for the same period. The analysis released by the Economic Policy Institute last month determined that between April and July 6.2 million people lost employer coverage. The authors didn’t calculate how many found alternative coverage via Medicaid or the ACA, however.
Other findings support the notion that the health insurance loss trend shifted by mid summer. KFF, for example, published an analysis Sept. 11 showing that most companies that offered coverage to begin with chose to continue insuring furloughed and temporarily laid-off workers between March and the end of June. But as the virus continued to batter the economy, employers moved to permanently shed those jobs. (KHN is an editorially independent program of KFF.)
“The issue now is that the temporary layoffs have greatly decreased and permanent job losses, including jobs that came with health coverage, are increasing,” said Cynthia Cox, a KFF vice president and director for the Program on the ACA.
Many low-income workers who lose their jobs and don’t have coverage through a spouse or parent turn to Medicaid, the federal-state health program for low-income people. The Centers for Medicare & Medicaid Services reported last week that enrollment in Medicaid and the Children’s Health Insurance Program grew by 4 million between February and June, a nearly 6% increase since the beginning of the coronavirus crisis.
The Impact of the Marketplaces
Gains and losses of coverage in the ACA marketplace are not yet clear, experts say. The Trump administration issued a report in June indicating that 487,000 people had, between January and June, enrolled in an ACA plan via the federal website, healthcare.gov. But that report failed to say how many people dropped an ACA plan in that period — for example, because they could no longer afford the premiums.
A study by Avalere, a health research and consulting firm in Washington, D.C., has estimated that enrollment in the ACA marketplaces since March could have swelled by around 1 million. That includes new enrollees in the 13 ACA marketplaces that states, plus the District of Columbia, operate. Many of those states held a “special enrollment period” when the pandemic hit. Healthcare.gov, run by the Trump administration, did not offer a special enrollment period.
About 11 million were enrolled in an ACA plan in February. Open enrollment for coverage that would start on Jan. 1, 2021, begins Nov. 1.
Jessica Banthin, a senior health policy researcher at the Urban Institute and until 2019 deputy director for health at the Congressional Budget Office, said it’s anyone’s guess how many people who lost their job-based coverage this year will choose this option. She said numerous factors will influence people’s health insurance decisions this fall, and into 2021.
Chief among them is gauging whether they might soon get a new job, or get back an old job, that offers insurance. That may hold some people back from enrolling in an ACA plan this fall, Banthin said. Plus, buying insurance may be too expensive, especially for families more concerned with paying for housing, food and child care while going without a paycheck.
“Health insurance may not be their immediate concern,” Banthin said. “Many people’s lives have been disrupted as never before. There’s a lot of trauma out there.”
Collins of the Commonwealth Fund said that, even before the pandemic, a growing proportion of families were vulnerable to loss of coverage and care.
In a survey of more than 4,000 adults early this year, Collins and colleagues found a “persistent vulnerability among working-age adults in their ability to afford coverage and health care that could worsen if the economic downturn continues.”
In large part, that’s because 1 in 5 respondents who had coverage were “underinsured.” Underinsurance reflects the extent to which coverage leaves people at risk of high out-of-pocket costs — a situation exacerbated by widespread job loss.
“Now is absolutely not be the time for the ACA to be further undermined, let alone killed outright,” said Stan Dorn, director of the National Center for Coverage Innovation at Families USA.
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In a wide-ranging executive order, President Donald Trump this month outlined some of the efforts he has made to affect health care since taking office.
One involved uninsured people and the current pandemic. The administration, Trump said, set up a program to provide them “access to necessary COVID-19-related testing and treatment.”
We asked the White House for more specifics about the program Trump mentioned but did not get a reply.
Nonetheless, experts said he is likely referring to reimbursement assistance to help pay the COVID testing and treatment costs of uninsured patients, which is available through the Provider Relief Fund.
This fund was established by Congress in the Coronavirus Aid, Relief and Economic Security Act to bolster eligible health care providers for lost revenue or expenses related to the pandemic.
The Trump administration said this spring it would tap into the fund to reimburse providers who test and treat uninsured COVID patients; hence, the executive order’s reference to “coverage access.” Here’s how it works: The assistance doesn’t go directly to patients. Instead, health care providers can apply for reimbursement of costs associated with testing or treating uninsured people for COVID-19. Patients must be uninsured and their primary diagnosis must be COVID-19. The program does not check immigration status in determining eligibility.
Our experts acknowledged that the fund overall has helped providers by making money available, especially important since many physicians, hospitals and other health care facilities are struggling with reduced income as elective surgeries and visits have nose-dived during the pandemic. The relief fund pays providers at standard Medicare rates for testing or treating uninsured COVID patients.
Still, many patients, and some providers, don’t know about the funding to reimburse for uninsured costs. And even providers who are aware of it don’t necessarily know how to use it. Hospitals and other providers are not required to publicize it. Additionally, eligibility restrictions can make it hard for some patients to qualify to have their bills paid.
“It’s absolutely not broad protection or a guarantee of coverage,” said Karen Pollitz, a senior fellow with KFF. “People are uninsured. They remain uninsured. If they don’t know how to ask for this or the provider can’t figure out how to use it, [their bills] are uncollectable.” (KHN is an editorially independent program of KFF.)
What Exactly Is ‘Coverage Access’?
Even before the pandemic, uninsured patients had a hard time finding medical care, often delaying needed medical services until a crisis sent them to the hospital. Federal law ensures that no one needing emergency care is turned away and must be treated until stabilized.
The relief fund program came amid calls from health insurers, Democrats and others for the Trump administration to reopen enrollment in the Affordable Care Act through the federal marketplace, which operates in 38 states.
Usually, the insurance sign-up period occurs each November. When the virus began causing concern in the U.S. in the spring, some of the 12 states (and the District of Columbia) that run their own marketplaces moved to reopen because of the pandemic, so uninsured residents could sign up.
But the Trump administration decided not to reopen the federal marketplace. Uninsured people who want to enroll either have to wait to sign up starting in November for coverage next year or see if they qualify for special enrollment because they have experienced one of several “qualifying life events.” One such event is job loss that ends health coverage.
That potentially left hospitals and other medical providers holding the bag for the uninsured who fall sick with COVID.
Enter the relief fund.
The Health Resources and Services Administration said the fund so far has handed out a little more than $1 billion for uninsured patient reimbursement, a substantial amount but well short of publicized estimates of what it will ultimately cost hospitals and medical providers to test and treat uninsured COVID patients.
“We are appreciative” that Congress and the administration “did provide some coverage for the uninsured,” said Molly Smith, vice president for coverage and state issues at the American Hospital Association. “But we don’t think it’s the best approach for covering the uninsured.” Hospitals would have preferred something that “would have expanded comprehensive coverage.”
Parts of the program work well, she said, but “there are some pretty substantial flaws.”
Why ‘Access’ Becomes a Slippery Term
Failing either test could make a patient ineligible. In that case, the hospital or medical provider can either seek payment from the patient — or eat the cost.
To qualify for coverage, the patient cannot have any kind of health insurance coverage, according to guidelines published online by HRSA.
Even having very limited coverage — such as a program in Medicaid that covers only family planning services such as birth control — would disqualify a patient, said Smith. Another disqualification would be the purchase of one of the limited coverage plans touted by the administration that don’t cover all the same services an ACA plan would include.
The second hurdle: COVID-19 must be the primary diagnosis.
“If someone with a heart attack comes in and it turns out COVID is also involved — or could have even been the trigger,” the provider might not be eligible for reimbursement, said Jack Hoadley, a research professor emeritus at Georgetown University.
Another common example, Smith said, is a patient with COVID-19 who develops sepsis, a life-threatening blood infection. Under long-standing coding and billing rules, sepsis would be the primary diagnosis, making any coronavirus-related patient care ineligible under the provider relief program.
The Trump administration did implement a program to reimburse medical providers for testing and treatment of some uninsured patients, tapping into funding allocated by Congress.
Whether — and to what extent — the measure improved “coverage access” to care is hard to determine. The fund has paid out more than $1 billion so far.
The administration chose this route, which experts said was an incomplete fix, over following some states’ lead in allowing a special enrollment period on the federal marketplace, which would have enabled people without health insurance to buy more comprehensive coverage. Meanwhile, the program has not been publicized and has confusing eligibility rules — both of which have led to speculation that it is not being used as widely as possible.
The administration’s program appears to provide narrow financial assistance for COVID-related health care costs. But patients who fall through the cracks may find themselves facing substantial bills.
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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.
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Pennsylvania is rolling out its new “Pennie” this fall: a state-run insurance exchange that officials say will save residents collectively millions of dollars on next year’s health plan premiums.
Since the Affordable Care Act’s marketplaces opened for enrollment in fall 2013, Pennsylvania, like most states, has used the federal www.healthcare.gov website for people buying coverage on their own.
But in a move defying the usual political polarization, state lawmakers from both parties last year agreed the cost of using the federal marketplace had grown too high and the state could do it for much less. They set up the Pennsylvania insurance exchange (nicknamed “Pennie”), designed to pass on expected savings to policyholders. Although the final rates for 2021 are not yet set, insurers have requested about a 3% average drop in premiums.
Pennsylvania is one of six states shifting in the next several years from the federal insurance exchange to run their own online marketplaces, which determine eligibility, assist with enrollment and connect buyers with insurance companies. They will join 12 states and the District of Columbia with self-contained exchanges.
The transitions come amid mounting evidence that state marketplaces attract more consumers, especially young adults, and hold down prices better than the federal exchange. They’ve also been gaining appeal since the Trump administration has cut the enrollment period on healthcare.gov and slashed funds for advertising and helping consumers.
State policymakers say they can run their own exchanges more cheaply and efficiently, and can better respond to residents’ and insurers’ needs.
“It comes down to getting more bang for your buck,” said Rachel Schwab, a researcher at Georgetown University’s Center on Health Insurance Reforms in Washington, D.C.
The importance of state-run exchanges was highlighted this year as all but one of them held special enrollment periods to sign up hundreds of thousands of people hurt financially by COVID-caused economic turmoil. The federal exchange, run by the Trump administration, refused to do so, although anyone who has lost workplace insurance is able to buy coverage anytime on either the state or federal exchange.
Like Pennsylvania, New Jersey expects to have its state-run exchange operational for the start of open enrollment on Nov. 1.
In fall 2021, New Mexico plans to launch its own marketplace and Kentucky is scheduled to fully revive its state-run exchange, which was dismantled by its Republican governor in 2015. Maine has also announced it will move to set up its own exchange, possibly in fall 2021.
Virginia’s legislature passed an exchange bill this year and hopes to start it in 2022 or 2023.
Nationwide, about 11 million people get coverage through the state and federal exchanges, with more than 80% receiving federal subsidies to lower their insurance costs.
“Almost across the board, states with their own exchanges have achieved higher enrollment rates than their federal peers, along with lower premiums and better consumer education and protection,” according to a study published this month in the Journal of Health Politics, Policy and Law.
Controlling ‘Their Own Destiny’
Since 2014, states using the federal marketplaces have had a rise in premiums of 87% while state exchanges saw 47% growth, the study found.
In one key metric, from 2016 to 2019 the number of young enrollees in state exchanges rose 11.5%, while states using the federal marketplace recorded an 11.3% drop, a study by the National Academy for State Health Policy found.
Attracting younger enrollees, who tend to be healthy, is vital to helping the marketplaces spread the insurance risk to help keep premiums down, experts say.
When the Affordable Care Act was debated, Republicans and some Democrats in Congress were cautious about a one-size-fits-all approach to insurance and accusations about a federal takeover of health care. So the law’s advocates gave states more control over selling private health coverage. The law’s framers included a provision that allowed states to use millions in federal dollars to launch their own insurance exchanges.
Initially, 49 states took the money. But in 2011, conservative groups convinced Republican-controlled states that forgoing state-run exchanges would help undermine Obamacare.
As a result, most GOP-controlled states defaulted to the federal marketplace.
In the ensuing years, several states that had started their own marketplaces, such as Oregon, Nevada and Hawaii, reverted to the federal exchange because of technological problems. Nevada relaunched its exchange last fall.
“States want to control their own destiny, and the instability of healthcare.gov in the Trump administration has frustrated states,” said Joel Ario, managing director for the consulting firm Manatt Health Solutions and a former Obama administration official, who helped set up the exchanges. States running their own platform can use data to target enrollment efforts, he said.
An Effort to Hold Down Premium Increases
Marlene Caride, New Jersey commissioner of Banking and Insurance, said that “the beauty of [a state-based exchange] is we can tailor it to New Jersey residents and have the ability to help [them] when they are in dire need.”
About 210,000 New Jersey residents enrolled in marketplace health plans for this year.
New Jersey has been spending $50 million a year in user fees for the federal exchange. After startup costs, the state estimates, it will cost about $7.6 million a year to run its own exchange enrollment platform and $7 million a year for a customer service center.
Open enrollment on the New Jersey exchange — called Get Covered NJ — will run from Nov. 1 to Jan. 31.
New Jersey plans to provide additional government subsidies for lower-income enrollees. Those would supplement federal subsidies.
Kentucky officials said insurers there were paying $15 million a year in user fees for healthcare.gov, a cost passed on to policyholders. When the state switches to its own operation, it plans to collect $5 million in its first year to cover the startup costs to revive its Kynect exchange and another $1 million to $2 million in annual administrative costs. So insurers will pay lower fees and those savings will help cut premium costs, said Eric Friedlander, secretary of the Kentucky Cabinet for Health and Family Services.
States using the federal marketplace this year paid either a 2.5% or 3% surcharge to the federal government on premiums collected.
In Pennsylvania, where about 330,000 residents buy coverage through an exchange plan, those fees accounted for $90 million a year. State officials estimate they can run their own exchange for about $40 million and will use the savings for a reinsurance program that pays insurers to help cover the cost of extremely expensive health care needed by some customers. Removing those costs from the insurers’ responsibility allows them to drop premiums by 5% to 10%, the state projects.
“When we talk about bringing something back to state control, that is a real narrative that can appeal to both sides of the aisle,” said Jessica Altman, the state’s insurance commissioner. “There is nothing political about making health insurance more affordable.” (Altman is the daughter of Drew Altman, CEO of KFF. KHN is an editorially independent program of KFF.)
Without the savings from running its own exchange, Pennsylvania would not have been able to come up with the more than $40 million needed for the reinsurance program, state officials said.
In addition, Pennsylvania has extended its enrollment period to run an extra month, until Jan. 15 (federal marketplace enrollment ends Dec. 15). Pennie also plans to spend three to four times the $400,000 that the federal government allocated to the state for navigators to help with enrollment, said Zachary Sherman, who heads Pennie.
“We think increased outreach and marketing will bring in a healthier population and broaden enrollment,” he said.
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Steve Alvarez started feeling sick around Father’s Day weekend this year. His symptoms started as mild, but developed into a fever, chills and shortness of breath he couldn’t shake.
“Just when I started to get to feeling better and I would have a couple of good days,” Alvarez said. “I felt like I’d backtrack and I was just really run down. This thing lingered and lingered.”
Alvarez, a Tejano musician who lives in the San Antonio area, said he eventually got a free COVID-19 test provided by the city of San Antonio. A week later, he found out he tested positive for the coronavirus.
Steve Alvarez stands with his wife, Regina. Alvarez is a Tejano musician who had no health insurance when he was diagnosed with COVID-19. Money has been tight because the pandemic dried up his musical gigs.(Credit: Vic G’s Photography)
Alvarez and his wife — who also became infected — never ended up in the hospital, and they feel fine now. But, he said, there were some scary days — he knows a lot of people who got sick with COVID-19. A friend around his age — mid- to late 40s — has been in an ICU and on a ventilator for weeks now.
But it was not just their health that worried Alvarez. Financial fears loomed large, too.
“We thought if something happens and this starts getting much worse, we need to start thinking about how we are going to deal with it, how we are going to pay for it,” he said. “It was just abject terror as to what was going to happen and what we were going to do.”
Money is tight because the pandemic shut down most of his musical gigs. Alvarez also lost his health insurance a year ago when he was laid off from his day job in construction safety. While he was sick with the coronavirus he paid for remote doctor visits, some prescriptions and over-the-counter medicine all out-of-pocket, he said.
“I use discount cards for those prescriptions as much as possible,” Alvarez said. “If something is not generic, that’s just absolutely too expensive, I have to consider doing without it.”
Texas’ uninsured rate has been climbing along with its unemployment rate as COVID cases also surge in the state. Before the pandemic, Texas already had the highest rate and largest number of people without insurance among all states. And 20% of all uninsured children in the U.S. live in Texas.
The uninsurance problem has only gotten worse in Texas in 2020. According to recent data from Families USA, a consumer health advocacy group that supported the Affordable Care Act, 29% of Texas adults under 65 don’t have health insurance so far this year.
The group found that about 659,000 people in the state became uninsured between February and May as job losses soared. Texas is one of 13 states that has not expanded Medicaid under the ACA.
“Texans who lose their health insurance that is tied to jobs simply have fewer options for new insurance because we do not have Medicaid expansion,” said Elena Marks, the president and chief executive officer of the Episcopal Health Foundation in Houston.
Republican leaders in Texas have long refused to expand health coverage to more low-income adults through Medicaid, despite the state’s having had the highest uninsured rate in the country for years.
Marks said the pandemic has made the state’s existing health insurance crisis much worse.
“Everything that’s happening now was happening before — it’s just on a path of acceleration,” she said, because there are “so many more people who are sick and who are getting very sick and the costs are very expensive.”
And this is hurting patients. Stacey Pogue, a senior policy analyst at a think tank in Austin called Every Texan, said uninsured Texans could face steep costs for COVID treatment and testing.
Although some Texans are able to find free COVID-19 testing, others have had to pay as much as a few hundred dollars. Pogue said for people who are already financially strained, that’s prohibitively expensive.
“We need to do everything we can to make sure people are not afraid to get tested because of cost, or are not afraid to get treatment because of cost,” she said. “And states like Texas with such a huge uninsured population, that’s a huge barrier to our public health response.”
And when uninsured, poor Texans have no choice but to go to the hospital, those hospitals end up with much of the cost.
John Hawkins, senior vice president for advocacy and public policy at the Texas Hospital Association, said that even before the pandemic the cost of care provided to people without insurance in Texas hospitals amounted to more than $7 billion a year.
“We’ve been able to make it work, frankly, because of the growth in the state,” he said. “But as we look at COVID going forward, it really does make the case that we have to look at addressing the coverage piece.”
Hawkins said federal relief money will be directed to health care providers in the coming months. Long term, however, he said this is unsustainable for Texas hospitals. If unaddressed, this financial burden on hospitals could lead to future cuts and possibly closures, he warned.
If state lawmakers don’t start addressing the state’s coverage issues soon, Hawkins predicted, it will become a significant issue during the state’s upcoming legislative session early next year.
Even before the pandemic, health care advocates in the state had begun organizing in an effort to make Texas’ uninsured rate a political liability for state lawmakers in November.
And for Texans currently living without insurance, not having health care coverage has been an added financial stressor.
Alvarez said he and his family are already doing everything they can to defer payments and bring in money so they don’t lose their house.
“But that bottom is going to fall out soon enough,” he said. “And that’s what I am really dreading right now. And I know that that’s not an uncommon thing that’s going on.”
This story is part of NPR’s reporting partnership with KUT and Kaiser Health News.
People who’ve been laid off or furloughed from their jobs now have significantly more time to decide whether to hang on to their employer-sponsored health insurance, according to a recent federal rule.
Under the federal law known as COBRA, people who lose their job-based coverage because of a layoff or a reduction in their hours generally have 60 days to decide whether to continue their health insurance. But under the new rule, that clock doesn’t start ticking until the end of the COVID-19 “outbreak period,” which started March 1 and continues for 60 days after the COVID-19 national emergency ends. That end date hasn’t been determined yet.
By extending the time frame to sign up for COBRA coverage, people have at least 120 days to decide whether they want to elect COBRA, and possibly longer depending on when they lost their jobs.
Take the example of someone who was laid off in April, and imagine that the national emergency ends Aug. 31. Sixty days after that date takes the person to the end of October. Then the regular 60-day COBRA election period would start after that. So, under this example, someone whose employer coverage ended at the beginning of May could have until the end of December to make a decision about whether to sign up for COBRA, with coverage retroactive to the beginning of May.
Some health policy experts question the usefulness of the change, given how expensive COBRA coverage can be for consumers, and how limited its reach: It isn’t an option for people who are uninsured or self-employed or who work for small companies.
“For ideological reasons, this administration can’t do anything to expand on the Affordable Care Act’s safety net,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. “So they’re using these other vehicles. But it’s really a fig leaf. It doesn’t do much to actually help people.”
What does this rule change mean for workers? If you have lost your job, here are some things to consider.
Playing a Waiting Game
Under the new rule, workers can keep their COBRA options open far longer than before. It’s always been the case that people could take a wait-and-see approach to signing up for COBRA during the first 60 days after losing their coverage. If they needed care during that time, they could elect COBRA, pay the back premiums and continue their coverage. But if they didn’t need care during that time, they could save a chunk of money on premiums before opting for other coverage to kick in after the 60-day period.
Now, people have even more time to wait and see. Under the rule, once the administration declares the national emergency over, laid-off workers would get 120 days to decide whether to purchase their job-based insurance — 60 days under the new rule and the regular 60 days allowed as part of the COBRA law.
“It becomes a long-term unpaid insurance policy,” said Jason Levitis, a fellow at the Center for Health Policy at the Brookings Institution. “There’s no reason to enroll until something bad happens.”
This is not without risk, consumer advocates point out. Someone who has a serious medical emergency — a car accident or a stroke — might not be able to process their COBRA paperwork before they need medical care.
Waiting too long could also affect people’s ability to sign up for other coverage. When people lose job-based coverage, it triggers a special enrollment period that allows them to sign up for new coverage on their state health insurance marketplace for up to 60 days afterward.
“You could miss your opportunity to enroll in the [insurance] exchange” created under the Affordable Care Act, said Katy Johnson, senior counsel for health policy at the American Benefits Council, an employer advocacy group.
Don’t Count on the Boss to Clue You In
Employers are not mandated to tell people promptly about their eligibility for COBRA. The same federal rule that gives workers more time to sign up for COBRA also pushes back the notification requirements for employers.
“Once an employer lays you off, they don’t have to notify you that you’re eligible for COBRA until after the emergency period,” said Karen Pollitz, a senior fellow at KFF, the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)
For many employers, especially large ones that outsource their benefits administration, notifications are routine and are continuing despite the federal change, said Alan Silver, a senior director at benefits consultant Willis Towers Watson. However, for smaller companies with fewer than 200 workers, getting the information out might be an issue, Silver said.
Costs Can Be Jaw-Dropping
Opting for COBRA is expensive because workers have to pay both their portion of the premium and their employer’s share, plus a 2% administrative fee. A 48-year-old paid $599 a month on average for individual COBRA coverage last year, according to a KFF analysis.
In addition, if people elect COBRA several months after losing their coverage, they could be on the hook for thousands of dollars in back premiums.
The upside for former employees is that sticking with their previous employer’s plan means they don’t have to start from scratch paying down a new deductible on a new plan. Nor do they have to find new doctors, as often happens when people switch health plans and provider networks change.
Ten percent of workers laid off or furloughed because of the coronavirus pandemic reported they had COBRA coverage, according to a survey conducted last spring by the Commonwealth Fund.
The COBRA extension is available only to people who worked at firms with 20 or more employees and had job-sponsored coverage before being laid off or furloughed. If the company goes out of business, there’s no health insurance to continue to buy.
Might Hospitals Step In to Pay Premiums?
Employers are typically not big fans of the program. Workers who elect COBRA are typically older and sicker than others with employer coverage, the KFF analysis found. They may have serious medical conditions that make them expensive to cover and raise employer costs.
Some policy experts are concerned that giving people more time to sign up for COBRA leaves the door open for hospitals or other providers to offer to pay sick patients’ back premiums in order to increase their own payment above what they’d receive if someone were on Medicaid or uninsured. Doing so could be a boon for some patients but raise health care costs for employers, said Christopher Condeluci, a health care lawyer who does legal and policy work around the Affordable Care Act and ERISA issues.
“Employers are worried,” said Pollitz. After getting laid off, “what if you’re uninsured and you wind up in the hospital six months in, and then the hospital social worker learns you’re eligible for COBRA and offers to pay your premium?”