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November 16, 2020

Reforms in the wake of COVID-19

 

Coronavirus protection during the quarantine

COVID-19 has sparked multiple proposals to reform the health care system. Some of the proposals have been made before, but the urgency of the proposals increased with the scope of the pandemic and its impact on the economy.

More than 30 million people in the United States lost their jobs during the pandemic. Many also lost their health insurance or the ability to pay for it.

Expanding Medicare and the ACA

Joe Biden would expand subsidies for coverage under the Affordable Care Act (ACA). He also advocates "a new Medicare-like public option, with the federal government providing enhanced premium subsidies."

Under current law, subsidies under the ACA are available for families with an income up to 400 percent of the poverty level ($104,800 for a family of four). Biden and many other Democrats would increase that threshold of eligibility by a factor of two or more.

The more liberal wing of the Democratic party does not want health insurance tied to employment, arguing that the pandemic illustrates the dangers of having employment as a condition of obtaining insurance. Several senators, including Elizabeth Warren, Bernie Sanders and Cory Booker, would make Medicare available to anyone, at least during the period of the pandemic.

Subsidies under COBRA

Another proposal for expanding coverage is for the federal government to provide subsidies, including 100 percent subsidies, of insurance under COBRA (the Consolidated Omnibus Budget Reconciliation Act). That law allows people who have lost coverage through their employers to continue their current insurance.

Normally, a person who has lost a job pays for the continued coverage, but in the wake of COVID-19, the government would pay the premiums during the public health emergency. Receipt of subsidies under COBRA would not count as income for the purpose of determining a person’s eligibility for unemployment benefits.

Expansion of public health

Between 2008 and 2017, more than 56,000 jobs have been eliminated in local health departments, according to a survey by de Beaumont Foundation, which focuses on public health issues. That figure represents approximately one-quarter of the local health department workforce.

Oxiris Barbot, M.D., former New York City health commissioner, commented in the Health Affairs Blog: "The public health system cannot just be turned on and off in between crises. …It shouldn’t take mass casualties for the federal government to commit to safeguarding the public’s health."

The public health infrastructure needs substantial improvement including developing early warning systems capable of detecting microclusters through testing, symptom reports and tracing contracts. Collection of data on race and ethnicity is imperative, said Barbot.

Greater role for telehealth

Prior to the pandemic, telehealth was a peripheral part of the health care system. Now it is more central, and it is likely to stay that way.

To encourage the use of telehealth and promote patient safety in the initial phases of the pandemic, reimbursement rates for telehealth more than doubled, and the number of services covered increased. Some health policy analysts referred to the rates as being in "parity" with office visits, often meaning the rates for a telehealth visit and an office visit were the same.

More recently, the term "equitable" has been used. Under an equitable approach, rates for telehealth reimbursement would be higher than they were before the pandemic, but generally not as high as for an office visit. The rationale for the equitable approach is that telehealth visits usually are shorter than office visits and don’t involve procedures or exams that would be done during an office visit.

Telehealth facilitates what have been termed "eReferrals" or "eConsults" for obtaining advice from specialists. In the past, referrals or consults often took weeks or months. With use of telehealth, input from specialists can be obtained more quickly - perhaps in hours or days.

To facilitate access to telehealth, state and federal licensing laws are likely to be revised to make it easier to practice telehealth across state lines. In addition, privacy regulations under HIPAA (Health Insurance Portability and Accountability Act) also will be more flexible.

Earlier this year, the Office for Civil Rights at the U.S. Department of Health and Human Services issued a notification that it "will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules … in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency."

For example, it is permissible for providers and patients to use video chat applications on their phones or desktop computers to assess medical conditions, regardless of whether the condition relates to COVID-19.

The notice also said: "Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications."

Relationship to broader reforms

Health care reform in response to COVID-19 is part of a broader push for social reforms. The challenges of this year were not only on health issues, but also on issues of race and economic justice.

It has become increasingly apparent that health outcomes are determined not just by medical care, but also by employment, housing, access to food, and a person’s sense of safety and well being.

Jonathan Metzl, M.D., and his colleagues, in a "Viewpoint" article in JAMA (June 4, 2020) said the pandemic "highlights the extent to which no one is safe until everyone is safe."

Jeff Atkinson is a professor for the Illinois Judicial Conference and has taught health care law at DePaul University College of Law in Chicago.



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