Thinking Fast (Medium) and Slow About COVID-19
The rapidly unfolding health and economic disasters the COVID-19 pandemic has triggered can only be dealt with effectively via a robust public response at both the federal and state levels. Unfortunately, the Trump administration missed the opportunity to intervene early, offering a litany of misleading statements in lieu of effective action. In addition, the Trump administration is continuing to pursue policies – such as seeking judicial repeal of the ACA and restricting states’ ability to finance Medicaid – that could make things even worse.
Fortunately, while these threats loom, governors, Congress and the administration have agreed to a series of legislative and administrative actions – including a declaration of national emergency, adoption of social-distancing measures in a number of states, and passage of three bills to support the health care system and provide economic support to a faltering economy. The first bill provided emergency supplemental funding, the second provided additional funding and programming flexibilities to enhance our health care system’s response, and the third primarily seeks to stimulate the economy.
However, much more needs to be done to support the health care system and mitigate the necessary financial contraction that comes along with the public health measures needed to slow the spread of the virus (aka, “social distancing”). This means more needs to be done to:
- protect people who have lost income in the economic downturn;
- address the unmet needs of people with special circumstances such as people living in various institutional settings and people relying on community-based services that may have been disrupted by social distancing; and
- address disproportionate barriers to coverage and care for groups such as immigrants, people of color, low-income people and rural populations. This also includes people stuck in health plans with high levels of cost sharing.
Speaker Pelosi has already signaled that work has begun on a fourth package. With that in mind, let’s look at the recently passed stimulus bill to better understand what still needs to be done.
A study in contrasts
There is a dramatic difference between the proposal Senate Republications initially crafted and the one House Democrats put forward. The House proposed a robust package of health care and economic supports while the Senate bill offered less support to health care providers and tilted heavily toward financial support for big businesses. There were few, if any, safeguards to ensure the support would actually benefit workers. The final legislation, the CARES Act, contains many important provisions but hews much more closely to the Senate proposal.
The good news
There are some strong and important provisions in the final compromise legislation that move us toward the goals of bolstering the economy and increasing equitable and affordable access to coverage and care. These include investments in our hospital systems and frontline health care workforce, expansion of unemployment insurance, and state and local aid. While this revenue is important and works to partially address holes in state and local budgets resulting from the pandemic and social distancing directives – it’s simply a patch.
The not so good news
While these investments are badly needed, the final bill still spends inefficiently and without sufficient safeguards to prevent corporate profiteering while at the same time leaving many critical needs unaddressed.
Three Next Steps
It is critically important that future congressional efforts address the holes in the CARES Act, that states act aggressively, and that the advocacy community crafts a response to the crisis that goes beyond a short-term patch to address structural weaknesses that have exacerbated the health and economic challenges we face.
1. Address the weaknesses in the CARES Act
Filling the holes in the CARES Act requires Congress to do the following:
Strengthen Medicaid. The next bill should do more to ensure people can qualify for Medicaid and that Medicaid fully covers the cost of treatment. This means addressing barriers to coverage and care for immigrants, easing enrollment and paying 100% of the cost of Medicaid expansion in states that have not yet expanded the program to the legally permissible limit.
Strengthen private coverage. Covering the cost of testing and, eventually, a vaccine is not enough. Exposure to high out-of-pocket costs will deter people from seeking timely treatment. And crippling medical debt those requiring intensive treatment will incur also will be a drag on the economy (and on the finances of the health care system since much of this debt will be uncollectible).
Provide additional economic security for people who have lost wages or incurred large bills. In addition to the cash assistance CARES provides, a number of consumer protection measures are needed such as prohibiting hospitals from sending people to collection, barring eviction, foreclosure or utility shutoff, additional food assistance, and potentially, more cash support.
Protect specific populations. People living in close proximity to one another, such as people in nursing homes or people who are incarcerated, are at great risk not only of becoming infected but also of transmitting the disease. People who depend on home and community-based services and those who live in under-resourced areas such as on tribal lands are also at high risk. We need a seamless response to this crisis, which means addressing the special needs of these and other populations.
2. Implement key public health and health care measures at the state level
While the federal government set some important policy parameters and is providing resources, states will have many choices about how they respond. The most effective response would be for states to act aggressively to remove barriers to care, support the health care system and discourage the virus from spreading. They should implement presumptive/retroactive eligibility for Medicaid, vigorous enrollment assistance and a grace period for renewals. They should also leverage telehealth to ensure access to care and support a strained health workforce by securing needed medical supplies and equipment. There are also opportunities for cross-sector coordination and communication to protect families and consumers from food and housing insecurity and medical debt.
3. Thinking Long Term
The interlocking health care and economic crises we are now experiencing have shone a harsh spotlight on the inadequacies of US health care system and our system of social and economic supports.
It will require more than a short-term patch to get us through the current emergency. We need to learn the lessons of this crisis and put in place policies and programs that will make the country more resilient as well as more equitable. High on the list is the need for a universal coverage system not dependent on employment. Cost-sharing must be modest enough to not create barriers to care and inflict financial distress. It should be targeted to improving value.
We also need a much more robust system of social and economic supports that can respond more seamlessly to any future crises. Instead of relying on the uncertainties of federal legislative process, we should institute automatic triggers that would let additional support kick in for states and individuals without having to wait for Congress.
Like the Great Depression, the current crisis lays the predicate for an overhaul of US health and social welfare systems. However, the New Deal and subsequent measures were a function of political leadership. They did not inevitably flow from the circumstances. It very much remains to be seen whether political leadership in US is willing and able to rise to this moment. Health care advocates need to come together with advocates for other social/economic supports to demand that they do.