YEAR-END REPORT - 2020 Published 21-Dec-2020 HPTS Issue Brief 12-21-20.1 Health Policy Tracking Service - Issue Briefs Access to Health Insurance Access to Health Insurance This Issue Brief was written by a contributing writer. 12/21/2020 Introduction The Senate and the House of Representatives passed a bill addressing issues relating to insurance coverage during the COVID-19 pandemic facing the United States. Nine states have reopened enrollment for their health insurance exchanges in response to the coronavirus pandemic. Residents without health insurance coverage will be able to sign up for plans through the exchanges. While the three COVID-19 stimulus bills passed by Congress provided additional funding for hospitals and coverage of testing for coronavirus through Medicaid for uninsured people, the legislation did not specifically allocate money for treatment of the virus. President Trump indicated that hospitals would be reimbursed for treating uninsured people for coronavirus through the $100 billion in funding provided under the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Some insurance companies, including Blue Cross and Blue Shield, decided to temporarily waive cost-sharing for the treatment of COVID-19. Health and Human Services Secretary Alex Azar announced the federal government's plan to use CARES Act funding to cover the cost of COVID-19 treatment for uninsured patients. The Michigan Department of Insurance and Financial Services (DIFS) announced that most of the insurance companies in the state had agreed to cover the costs of testing and treatment for COVID-19 without cost-sharing for their beneficiaries. Over 58,000 people signed up for health insurance plans through California's health insurance exchange, Covered California, since March 20, the beginning of the special enrollment period in response to the COVID-19 pandemic. The U.S. Chamber of Commerce, the American Hospital Association and America's Health Insurance Plans (AHIP), and nearly 30 other organizations joined in a coalition to ask Congress to protect Americans' health care coverage in its response to the COVID-19 health emergency. According to a new Gallup poll, one out of every seven (14%) of adults in the United States indicated that they would avoid healthcare treatment for the symptoms consistent with COVID-19 for themselves or a member of their household because of concerns over the cost of treatment and their ability to pay. Pennsylvania Governor Tom Wolf announced that the federal government will reimburse the cost of testing and treatment of COVID-19 for people without health insurance coverage. Companies have been developing tests for SARS-CoV-2, the virus that causes COVID-19, that can be performed at home. However, one barrier to the wide use of the at-home tests is uncertainty about insurance coverage of the cost of the tests. According to data from Georgia, the state is seeing an increase in enrollment in Medicaid and the Children's Health Insurance Program (CHIP) due to the coronavirus pandemic. The Utah Department of Health (UDOH) announced that it had received approval from the Centers for Medicare and Medicaid Services (CMS) to expand Medicaid in the state. The number of Massachusetts residents paying fines for not having health insurance has gone down, but those who are still paying fines have seen an increase in the amount of those fines. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -1- West Virginia Attorney General Patrick Morrisey is supporting continuing with the state's involvement in a lawsuit challenging the constitutionality of the Affordable Care Act while also supporting new legislation regarding protections for people with pre-existing conditions. U.S. Sen. Joe Manchin called for the state to withdraw its support from the lawsuit and cautioned against the pending legislation. According to a recent study, a program designed to give vulnerable patients extra support failed to decrease readmissions to the hospital. Maine legislators are set to consider legislation aimed at reducing the cost of health care and expanding access to insurance coverage. A recent state report released by Colorado showed that high prices at hospitals are behind the increasing cost of health care in the state. The Centers for Medicare and Medicaid Services (CMS) announced that the Trump administration would allow block grants for the Medicaid program, a funding system that will likely tighten access to health insurance coverage under the program. According to a recent report from the Health Care Cost Institute, spending and costs for employer-sponsored health insurance plans continued to increase in 2018. A recent study in JAMA Network Open revealed that the cost of health insurance is a significant concern for middle-aged and older adults in the United States. The Massachusetts Senate unanimously passed legislation that would increase access to mental health care in the state. The Georgia Senate passed a bill that would promote price transparency for medical procedures. The Oregon House passed several bills aimed at improving access to health insurance as well as affordability. The Trump administration urged the Supreme Court to repeal the Affordable Care Act (ACA). The Trump administration indicated that “the entire ACA act must fall.” Congressman Steven Horsford (D-NV) introduced a bill aimed at strengthening the Affordable Care Act (ACA) and adding more protections for health care consumers in the United States. Oklahoma voters chose to expand eligibility for Medicaid in the state. Oklahoma is the first state to expand access to the government- sponsored health insurance program during the coronavirus pandemic. U.S. Senators Bill Cassidy, M.D. (R-LA), Tina Smith (D-MN), Dan Sullivan (R-AK) and Doug Jones (D-AL) introduced legislation that would direct the Department of Health and Human Services (HHS) to inventory telehealth programs throughout the United States with the aim of improving access to health care particularly during health emergencies. The U.S. House of Representatives passed a bill aimed at protecting and expanding the Affordable Care Act. It was nearly a party-line vote at 234-179. Twenty-three attorneys general including Minnesota Attorney General Keith Ellison filed a lawsuit to block a new Trump Administration rule that will allow health care providers and insurance companies to discriminate against several classes of people, such as LGBTQ+ individuals, people with limited English language proficiency, and women. A new study from the Urban Institute revealed that over 10 million people are predicted to lose employer-provided health insurance due to job loss related to the COVID-19 pandemic during 2020. Kentucky River Foothills Development Council, Inc. (KRFDC) is helping Kentucky residents and small businesses access to health insurance coverage through the Kentucky Health Benefit Exchange program. According to a recent survey, two out of every five adults in the United States do not have stable health insurance coverage. A recent study showed that rural areas in the United States have higher prices for health insurance plans and fewer options than other areas of the country. U.S. Senators Dick Durbin (D-IL) and Catherine Cortez Masto (D-NV) joined 13 Senate Democrats to introduce the Worker Health Coverage Protection Act. Cigna Corp, a global health service company, announced that it is increasing access to health coverage by offering more plans through the Affordable Care Act (ACA) marketplace individual health insurance exchange. A recent study showed that eliminating surprise billing could significantly reduce the cost of health insurance premiums. The Kaiser Family Foundation reported that the annual family premiums for employer-sponsored health insurance plans increased 4% this year to an average cost of $21,342 per year. The American Medical Association released an annual analysis of competition and choice in health insurance markets showing decreases in markets where health insurance is the scarcest. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -2- The Centers for Medicare & Medicaid Services (CMS) released a report showing that the average premium costs for health insurance plans available through healthcare.gov decreased by 2% for 2021 plans. The Centers for Medicare & Medicaid Services (CMS) released information about the White House plan to give all Americans access to the COVID-19 vaccine at no cost when it becomes available. Open enrollment for individual health insurance plans available through the Affordable Care Act exchanges began November 1 in New York and across the United States. Utah Chooses Medicaid Expansion The Utah Department of Health (UDOH) announced that it had received approval from the Centers for Medicare and Medicaid Services (CMS) to expand Medicaid in the state. The full Medicaid expansion will extend Medicaid eligibility to adult Utah residents with annual incomes up to 138% of the federal poverty level. An individual can qualify with yearly income up to $16,753 and families of four can be eligible earning up to $34,638 per year. The cost of the expansion will be shared by the federal government and the state. The federal government will cover 90% of the cost and Utah will cover ten percent of the expansion. Newly eligible individuals were able to enroll for coverage beginning on January 1. The expansion will extend Medicaid eligibility to up to 120,000 adults living in Utah when combined with a smaller expansion of the program implemented in April. “CMS's decision is evidence states can craft viable, unique solutions to deliver critical health care services to their residents,” said Utah Governor Gary R. Herbert. “I want to thank CMS Administrator Seema Verma, along with her dedicated staff, who worked quickly and diligently to approve this request and allow us to expand within the parameters set by our state law.” “Under Governor Herbert's exemplary leadership, his state diligently pursued innovative and sustainable solutions to improve the lives of all Utahns,” said CMS Administrator Seema Verma. “Local leaders understand how to best design programs that align with their local needs and goals, and I am committed to helping states achieve their goals. I thank the Governor for his strong commitment to delivering impactful results to his state, and look forward to our continued work with Utah as we consider further enhancements to their health care programs.” Some of the adults newly eligible for Medicaid will be required to participate in self-sufficiency standards in order to enroll in the program. Enrollees will be exempt from the self-sufficiency requirement if they meet one of 13 exemption criteria, including: • age 60 or older • pregnant • caring for young children • working at least 30 hours per week • student People who are not exempt from the self-sufficiency requirement will have to complete an online job assessment, online training programs, and 48 job searches within the first three months of eligibility. If enrollees fail to complete the requirements, their health care benefits will be terminated. If enrollees are eligible for an employer-sponsored health plan, they must enroll in that plan. Medicaid will cover the cost of the monthly premium and out-of-pocket expenses for that plan. The Utah waiver request to the federal government included additional components of the Medicaid expansion program. These components related to premiums and surcharges for those over 100% of the federal poverty level, housing supports, and penalties for intentional program violations. The federal government is currently reviewing the waiver requests for these components of the program. The Utah legislature directed UDOH to submit the expansion request through Senate Bill 96, sponsored by Sen. Allen Christen and Rep. Jim Dunnigan. “Over the last couple of years, we have explored and implemented several expansion options,” said Rep. Dunnigan. “This approval is very important for our state budget so we can begin receiving the higher federal match for these services. We look forward to working with CMS to obtain approval of the remaining components of our request so this expansion has the additional supports and cost controls we envisioned.” © 2021 Thomson Reuters. No claim to original U.S. Government Works. -3- Enrollees for coverage under Medicaid expansion in Utah must be a Utah resident between the ages of 19 and 64, must be a U.S. [FN2] citizen or legal resident, and must meet income requirements. Fewer Massachusetts Residents Paying Insurance Mandate Fines The number of Massachusetts residents paying fines for not having health insurance has gone down, but those who are still paying fines have seen an increase in the amount of those fines. In 2019, Massachusetts imposed a health insurance mandate fine on 32,106 individuals for failing to obtain health insurance coverage in 2018. In 2018, 33,693 faced a penalty. The average penalty paid in 2019 was $429, an increase of almost 20%. As a result, Massachusetts collected a larger amount in health insurance mandate penalties in 2019 than the prior year. According to the Massachusetts Department of Revenue, the numbers of people fined will fluctuate when taxpayers submit late proof of health insurance coverage, late filers make payments, and the department takes back refunds. The federal government had a health insurance mandate that imposed a federal tax penalty for failing to obtain health insurance coverage that was imposed by the Affordable Care Act. However, the legislature eliminated that penalty with the passage of the latest federal tax law. Massachusetts, along with four other states and Washington, D.C. resumed the imposition of a state tax penalty for failing to obtain health insurance this year or will implement the change in 2020. Massachusetts rested its healthcare legislation of 2006 on an individual mandate. That law went on to become an example for the drafting and passage of the federal Affordable Care Act. According to experts in the healthcare industry, the insurance mandate along with subsidies to help pay for the cost of premiums for people with lower incomes has helped Massachusetts achieve a high rate of health insurance coverage among its residents. The rate of uninsured residents is the lowest in the United States. 'We believe it's proven to be a very effective part of the Commonwealth's effort to make sure residents have access to universal and affordable health insurance coverage,' indicated Audrey Morse Gasteier, chief of policy and strategy at the Massachusetts Health Connector. The health insurance mandate in Massachusetts has made the insurance pool larger in the state, noted Morse Gasteier, which has made the healthcare coverage market stronger and more stable. The penalties, which total over $11 million paid in 2019, will go toward subsidies to help cover the cost of premiums for Massachusetts residents with low and moderate incomes. Many people in the state who pay a penalty would qualify for the subsidies that help cover the cost of insurance. According to a Kaiser Family Foundation report, at least 10,000 Massachusetts residents who are currently uninsured are eligible for free health insurance coverage. Massachusetts officials estimate that even more than 10,000 would likely qualify. Morse Gasteier indicated that over half of the approximately 250,000 Massachusetts residents without coverage could acquire free coverage of coverage at a low cost due to the state's generous subsidies. She pointed to various reasons that people do not apply for coverage. 'They may not believe that they need health insurance coverage, but in many respects, we think it's just a lack of information about how affordable Massachusetts health coverage can be,' she indicated. The final cost of the premium to the consumer depends on income level and the plan the consumer chooses. Premiums can cost less for low- to moderate-income Massachusetts residents than the cost of the tax penalty for the insurance mandate. [FN3] However, some residents have trouble affording co-pays, co-insurance, and deductibles for those plans. Maine to Consider Health Care Legislation Maine legislators are set to consider legislation aimed at reducing the cost of health care and expanding access to insurance coverage. One bill would create a new state-run health insurance exchange in Maine. Another would expand dental care coverage to children participating in Medicaid. A bill would address the high cost of prescription medications. Other pending legislation is aimed at assisting small businesses that provide health insurance coverage to employees. According to Senate President Troy Jackson, D-Allagash, one of his top priorities is a bill that would create a state-run health insurance consumer protection advocacy office. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -4- “Information is power,” Jackson stated. “And anyone that feels like they can pull the wool over your eyes by just spouting off a bunch of stuff, these individual people who have no idea, these insurance people just tell them no. You know ? deny, deny, deny and they can get nine out of 10 people to go away.” Jackson indicated that such an agency would advocate for health care consumers in Maine facing the corporate health insurance industry. In 2019, the Maine government passed legislation approving funding for the voter-approved expansion of Medicaid. Approximately 80,000 Maine residents will become eligible for coverage through Medicaid expansion. About 40,000 new people [FN4] enrolled in the program after the expansion. State officials expect that enrollment will continue to increase. Study: Extra Support for Patients Fails to Prevent Hospital Readmissions According to a recent study, a program designed to give vulnerable patients extra support failed to decrease readmissions to the hospital. The program in Camden, N.J. paired frequently hospitalized patients with nurses and social workers. The program's goal: reduce the expensive cycle of hospital readmissions for this patient population. According to researchers, the program had no effect on readmissions. Patients with the extra support were equally as likely to be readmitted to a hospital within 180 days as patients without the extra support. Dr. Jeffrey Brenner and the Camden Coalition of Healthcare Providers, the organization he founded two decades ago, were hopeful that the program would work, lowering healthcare costs overall. 'It's my life's work. So, of course, you're upset and sad,' indicated Brenner. Brenner is now working with UnitedHealthcare on a similar program. Brenner partially created the model of care, which was profiled in a popular article published in 2011 in The New Yorker. Dozens of similar programs have been created and millions of dollars of donations have gone toward supporting them. 'This is the messy thing about science,' indicated Brenner, a recipient of the MacArthur Foundation ‘Genius Grant’ for his work surrounding the programs. ‘Sometimes things work the way you want them to work and sometimes they don't.’ Hospital and insurance executives hoped that the programs would decrease expensive recurring hospital readmissions for patients whose lives were complicated by social issues such as poverty and addiction. For those patients, chronic medical conditions can lead to hospital readmissions. Brenner's idea was to give these patients access to care workers who would connect them with needed social and medical services. He predicted that the model would lead to improved medical care and lower costs. 'Lots of organizations make claims that their programs work and they've never been rigorously tested,' Brenner noted. Brenner invited researchers to study his programs. Massachusetts Institute of Technology economist Amy Finkelstein started a randomized controlled trial of the model in 2014. Researchers followed the progress of the 800 patients the Coalition enrolled over four years. All patients had recent hospital admissions and faced social issues. Half of the patients received no extra support after leaving the hospital. The other half received approximately three months of assistance from the coalition aimed at social and medical issues. Researchers found that the 400 patients receiving the social and medical assistance were equally as likely as the other patients to be [FN5] readmitted to the hospital. Almost two-thirds of all the patients returned to the hospital within 180 days. West Virginia Considers Preexisting Conditions Legislation West Virginia Attorney General Patrick Morrisey is supporting continuing with the state's involvement in a lawsuit challenging the constitutionality of the Affordable Care Act while also supporting new legislation regarding protections for people with pre-existing conditions. U.S. Sen. Joe Manchin called for the state to withdraw its support from the lawsuit and cautioned against the pending legislation. Manchin sent a letter to state legislators encouraging them to withdraw support for the lawsuit that challenges the federal healthcare law. He also cautioned them with proceeding on the state legislation. Eighteen Republican state attorneys general, including Morrisey, joined the lawsuit asserting that the Affordable Care Act is unconstitutional. In December, a federal appeals court struck down the individual mandate provision of the law, sending the issue back to federal district court to determine if the law can exist without the mandate. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -5- Morrisey, Senate Majority Leader Mitch Carmichael, R-Jackson, and other legislators introduced the state legislation, the West Virginia Healthcare Continuity Act. The bill focuses on protecting access to health insurance for people with pre-existing conditions if the Affordable Care Act is struck down. According to Manchin, a complete repeal of the ACA would be detrimental to rural health clinics in West Virginia. He estimated that it could lead to a loss of 16,000 jobs in the state and the loss of $1.08 billion in federal funding for Medicaid in West Virginia. Manchin argued against the pending state bill because it does not contemplate alternative funding for requiring access for people with pre-existing conditions. “The state doesn't have the budget. If anything, they're in a deficit going in the wrong direction, and now they're talking about throwing away $1 billion of federal funding coming into the state. It makes no sense whatsoever,” Manchin indicated. The elimination of the ACA would also risk the access to coverage of the over 150,000 West Virginia residents who became eligible for Medicaid after the state expanded the program. The ACA allowed states to expand eligibility with federal funding. Medicaid includes coverage for general and behavioral health services and coverage for substance use disorder treatment. Manchin supports fixing the Affordable Care Act rather than striking it down completely. He introduced the Premium Reduction Act of 2019 along with Sen. Susan Collins, R-Maine. This bill would expand state-based reinsurance programs that put taxpayer dollars toward helping insurance companies pay for the most expensive recipients of medical care. That legislation is aimed at decreasing the price of health insurance plans while keeping ACA protections and federal subsidies. Morrisey disagreed with Manchin's assessment, indicating that the impact of overturning all or part of the ACA is unknowable since courts have not yet decided if any of the provisions will remain. He argued that the state legislation is necessary, asserting, “We want to make sure that West Virginia is getting out in front of these [FN6] issues, because we want to protect people with pre-existing conditions.” White House Approves Medicaid Block Grants The Centers for Medicare and Medicaid Services (CMS) announced that the Trump administration would allow block grants for the Medicaid program, a funding system that will likely tighten access to health insurance coverage under the program. Under the new demonstration program, Healthy Adult Opportunity, states will receive a capped amount of federal money to support Medicaid programs. State participation in the program is not mandatory. The program will affect only Medicaid beneficiaries who are younger than 65 and do not have a disability. Currently, the federal government provides matching funds to state Medicaid programs based on a state's per capita income. Federal contributions are not capped. Medicaid recipients receive whatever health care services they need regardless of expense. The new program allows states to choose a capped-funding system. States could create programs that are exempt from some Medicaid requirements. For example, Medicaid currently covers all prescriptions, but under the new system, states could exclude some drugs from coverage. CMS administrator Seema Verma defended the approach from potential criticism, asserting that it will keep Medicaid financially viable in the future by allowing states to set a budget for the program. 'The Healthy Adult Opportunity represents an innovative and historic approach to surmounting Medicaid's structural challenges,' she indicated. The block grant structure has been considered by conservative-leaning legislators from the creation of the Medicaid program. However, Congress and the White House have previously decided against this system, preferring to leave funding for the program open. 'When enrollment goes up or during an economic downturn or the cost of prescription drugs go up, it costs the states more money to finance their programs, but the federal government matches those dollars to states,' stated Robin Rudowitz, vice president of the Kaiser Family Foundation and co-director of the foundation's program on Medicaid and the uninsured. States will have to proactively ask CMS for a waiver and receive approval prior to implementing a block grant system. Verma announced that the usually lengthy process will be streamlined with a template application. It is likely that the plan will take months to be implemented in any state. The legality of the move remains in question. Verma's initiative to allow states to request waivers for “work requirements” for Medicaid eligibility was met with legal action. The courts blocked the move and the decision is facing appeal. Arkansas is the only state to implement a work requirement. Research showed that thousands of people in the state lost access to health insurance due to the work requirements. According to Rudowitz, work requirements face the legal argument that they do not ‘promote the objectives of the Medicaid program, which is primarily to provide affordable health coverage to low income people.’ © 2021 Thomson Reuters. No claim to original U.S. Government Works. -6- Oklahoma Gov. Kevin Stitt indicated that the block grant system was ‘a game-changer.’ He expressed interest in applying for the waiver. Oklahoma has not expanded Medicaid under the ACA. Stitt is using the block grant plan as an alternative to the upcoming ballot issue that would expand Medicaid. Stitt called the block grant waiver an innovation that would help contain costs. He said it would allow the state to charge premiums for Medicaid coverage and add work requirements for adults. Jamila Michener, an assistant professor of government at Cornell University said that Republican governors like Stitt would use the block grant program as leverage to prevent full Medicaid expansion. 'They can't outright support Medicaid expansion or support Obamacare,' she indicated. ‘Work requirements were a way for them to kind of help save face, to expand Medicaid, but still be able to make it appear as though they were remaining true to their conservative bona fides.’ She noted that this new plan attempts to go around the litigation of the work requirements to reach a similar political goal. Previous attempts to implement Medicaid block grants were in the form of bills proposed in Congress. The legislation would have transitioned all states to block grant funding at the same time. This rule allows states to choose whether to sign up for the funding structure. Some officials, such as Washington Gov. Jay Inslee, have expressed a dislike for the proposal. Other critics, like Eagan Kemp, health care policy advocate with the liberal advocacy group Public Citizen, called the program ‘a Medicaid block grant by another name.’ Edwin Park of the Georgetown University Center for Children and Families indicated that the plan would not benefit states. '[They're] placing a fiscal straitjacket on themselves that will only lead to eventual cuts to their programs and harmful effects to their budgets,' Park asserted. Park argued that targeting Medicaid was politically risky for the Trump administration. The program is widely liked. ‘Medicaid is more popular than it has ever been because people understand that if it's not their immediate family, their kids, it's their parents, it's neighbors [FN7] and others who rely on the program,’ Park said. Colorado: Hospitals Causing Health Care Costs to Increase A recent state report released by Colorado showed that high prices at hospitals are behind the increasing cost of health care in the state. Health care costs are increasing more rapidly in Colorado than in other places in the United States. Gov. Jared Polis and his administration are at odds with hospitals over rising health care costs. The administration asserted that the cost of hospital care is largely driving the increases in health care costs overall. They pointed to hospital operating expenses in the state in 2018, which were 14 percent higher than elsewhere in the nation. According to Lt. Governor Diane Primavera, health care in the United States costs twice as much as it does in other developed nations but the United States has the lowest life expectancy of all developed countries. 'So the question is. If all the money we spend on healthcare isn't making us healthier, then where is all the money going?' Primavera stated. Hospital leaders disagreed with the assessment. They blamed several factors, including the high cost of living in Colorado and a competitive job market for hospital price increases. Researchers found that hospital profits increased by over 280 percent between 2009 and 2018. Per-patient profits topped $1,500, an increase of more than triple from ten years earlier. The Colorado Department of Health Care Policy and Financing conducted the study, also finding that uncompensated care for hospitals in the state was at an all-time low. The Affordable Care Act as well as a fee on hospitals helped to reduce the number of uninsured people in the state by half. The data also showed that costs to hospitals for charity care and bad debt decreased by over $385 million per year since the state expanded Medicaid eligibility under the ACA. According to researchers, “strategic hospital decisions” are causing the increased costs. Hospitals are shifting costs to patients with private insurance plans, leading to billions of dollars of profits for hospital systems. The report also showed that increased funding from public programs focused on reducing the cost of private insurance premiums and [FN8] out-of-pocket costs for consumers are not leading to savings for consumers and employers. Older Adults Concerned About Health Insurance Costs © 2021 Thomson Reuters. No claim to original U.S. Government Works. -7- A recent study in JAMA Network Open revealed that the cost of health insurance is a significant concern for middle-aged and older adults in the United States. Adults have worries about the cost of health insurance coverage after retirements. They are also concerned that federal policies might change regarding health insurance coverage for older adults. Over twenty-five percent of people in their 50s and early 60s are not certain if they will be able to afford health insurance coverage in the next year. Nearly half of adults in that age group are concerned about affording health insurance coverage in retirement. Two-thirds of older adults worry about possible changes in federal health insurance policies for people in their age group and older. Almost one in every five respondents to the survey who are currently employed revealed that they kept a job in the past year to continue access to employer-sponsored health insurance coverage. Approximately 15% of employed older adults indicated that they delayed retirement or considered delaying retirement due to the cost of health insurance coverage. Researchers collected data from the National Poll on Healthy Aging, conducted in late 2018. Data was collected during the normal open enrollment period for insurance plans offered by many employers. It was also close to the beginning of open enrollment for Medicare and for plans available through the state and federal exchanges. 'Seeking regular medical care is critically important for adults in their 50s and 60s, to prevent and treat health conditions,' indicated lead author Renuka Tipirneni, M.D., M.Sc. ‘We found that many adults in this age group are unfortunately worried about affording health insurance and avoiding care because of costs.’ Tipirneni is an assistant professor of internal medicine at the University of Michigan and a member of the U-M Institute for Healthcare Policy and Innovation, that conducts the poll. She treats patients at the General Medicine clinics at Michigan Medicine, U-M's academic medical center. At the time of the data collection, the Affordable Care Act had stood up to challenges in Congress but was still facing a challenge in federal court. That case is currently pending in the Supreme Court. 'It is clear from our poll that health care remains a top issue for middle-aged adults and that many of them find the recent uncertainty surrounding federal healthcare policies troubling,' noted senior author Aaron Scherer, Ph.D., an associate in internal medicine at the University of Iowa and former postdoctoral fellow at U-M. ‘Policymakers should work to ensure the stability and affordability of health insurance for vulnerable adults on the verge of retirement.’ Researchers found that concern over cost also affects how older adults who do not yet qualify for Medicare coverage utilize health care. Over 18 percent of people in this group declined to seek medical care or did not fill a prescription in the past year due to cost concerns. People with fair or poor health were four times more likely to decline to seek medical care than their healthy counterparts. People who had purchased an individual health insurance plan, such as the plans available to consumers through the exchanges, were three times more likely to decline seeking medical care. Researchers collected data from 1,024 adults. The study was sponsored by AARP and Michigan Medicine, U-M's academic medical center. The authors pointed to the results of the study as support for policy proposals that would expand Medicare eligibility to younger age [FN9] groups or offer a publicly funded plan through the federal health insurance exchange. Report: Costs for Employer-Sponsored Health Insurance Continue to Rise According to a recent report from the Health Care Cost Institute, spending and costs for employer-sponsored health insurance plans continued to increase in 2018. The annual Health Care Cost and Utilization Report revealed that spending per person for employer-sponsored insurance (ESI) increased to $5,892 per person in 2018. The data came from 2.5 billion medical claims. Spending trends affect about 160 million individuals in the United States who are covered by employer-sponsored health insurance plans. The growth rate of spending was larger than in 2017. Researchers pointed to continued price growth for health care and increases in utilization. 'Prices, spending, and out-of-pocket costs continue to rise for the 160 million Americans with employer-sponsored health insurance,' stated Niall Brennan, president and CEO of HCCI. ‘Higher prices for medical services continue to drive most spending increases, but in 2018 we also saw an uptick in utilization for the first time in several years. If these price and utilization trends continue, we expect spending growth to stay on an upward trajectory in the coming years.’ Utilization of health insurance coverage has increased, however, increasing prices of health care were the main reason spending growth increased over the 5-year period of the study. Researchers considered inflation and concluded that spending increased by $610 per person between 2014 and 2018. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -8- 'Higher prices for medical services were responsible for about three-quarters of overall spending increases between 2014 and 2018, after inflation,' indicated Jean Fuglesten Biniek, report co-author and senior researcher at HCCI. Utilization changes added to spending growth after inflation, but at a smaller rate. About one-fifth of the spending growth was attributable to utilization increases. Most of the increases in utilization occurred during only one year. In 2018, the increase in utilization affected costs more than a similar increase would have affected costs during an earlier year due to the rate of price growth between 2014 and 2017. Researchers looked at four groups of health care services and dozens of sub-categories. The largest 2018 spending increases (5.5%) of the major categories was for outpatient visits and procedures. Researchers also found the following notable trends: Inpatient services. • Spending per patient increased for inpatient admissions by 11.4% between 2014 and 2018. • Average prices increased between 2014 and 2018 for each sub-category of inpatient admissions. Utilization of these services varied. From 2014 to 2017, there were almost 4% annual increases. In 2018, there was a 2.0% price increase. Outpatient services. • Both cost and utilization increases contributed to a 16% increase in spending from 2014 to 2018. • From 2014 to 2018, spending on ER visits increased 32%. Costs for observation treatment increased 29%. Professional services. • Costs increased by 16%. Growth rate of spending increased from 2014 to 2018. Office visits and administered medications were the largest categories of spending. • Spending on psychiatry increased 43% from 2014 to 2018, caused by significant increases in utilization. Prescription drugs. • 88% of prescriptions were generic medication. • Generic prescriptions cost consumers less than one-fifth of out-of-pocket costs that brand-name drugs cost. • Out-of-pocket spending increased during 2014 and 2018. According to John Hargraves, senior researcher and co-author of the report, ‘People with job-based insurance saw their out-of-pocket costs rise 14.5%, or $114, between 2014 and 2018.’ [FN10] Out-of-pocket costs included copays, coinsurance, and deductibles. It did not include the cost of insurance premiums. Oregon Legislation to Improve Access to Insurance Pending The Oregon House passed several bills aimed at improving access to health insurance as well as affordability. House Bill 4110 focuses on extending the state's minimum grace period for payments of health insurance premiums. It would help Oregon residents who miss open enrollment or face cancellation of coverage of existing health insurance plans because of late payments or misunderstanding of deadlines. “We heard about the tangible ways that this legislation will help everyday Oregonians,” indicated Rep. Paul Holvey (D-Eugene), the chief sponsor of House Bill 4110. “One woman missed the short grace period by two days due to poor health and was kicked off her health insurance. Another resident paid a charge of $3 past due one day late and lost his coverage. This policy will better support these Oregonians and keep more people enrolled in health care.” Under House Bill 4102, the state would require reporting on prior authorization. Providers and health insurers use this process when deciding whether to cover pharmaceuticals, medical procedures or medical devices. The legislation would improve transparency in reporting as well as simplify procedures for navigating the healthcare system. “In my work as a primary care provider, there are too many times I experience unnecessary administrative burdens in providing medical services, which has led to complications and hospitalizations,” stated Rep. Rachel Prusak (D-West Linn), the chief sponsor of House Bill 4102. “On top of seeing patients, many healthcare clinicians across the state experience stress because they are also faced with extra calls, notes, and faxes just to get the procedures, medications, and devices that they know their patients need.” The House approved bill 4081 as well, a bill aimed at decreasing administrative regulations and burdens for physician assistants. It addresses the practice agreements between physician assistants and physicians. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -9- “This legislation is about reducing barriers and increasing access to care for Oregonians in every corner of our state,” stated Rep. Tiffiny Mitchell (D-Astoria), the chief sponsor of House Bill 4081. “Physician assistants are at the front line of health care for many Oregonians, especially rural Oregonians. I am proud to stand with them in cutting unnecessary red tape.” The House also passed House Bill 4161. It supports Regional Health Equity Coalitions (RHEC). These organization work regionally with a focus on local health disparities in communities. “The RHECs are doing great work to serve historically underserved communities in the counties where they are operational, but there is still a significant portion of Oregon lacking one of these organizations,” stated Rep. Teresa Alonso Leon (D-Woodburn). “This legislation is about building capacity and meeting the health care needs of those of our fellow community members who might not otherwise be reached.” Rep. Marty Wilde (D-Eugene) spoke in favor of the pending legislation, noting that it builds on the work that Oregon has made toward expanding access to health insurance and increasing affordability. “Every Oregon resident deserves access to high-quality, affordable health care,” Wilde said. “I am proud that we continue to make progress every session, improving our health care system, and ensuring working Oregonians have the support they need.” [FN11] The Oregon Senate will consider the bills next. Georgia Pending Legislation for Price Transparency The Georgia Senate passed a bill that would promote price transparency for medical procedures. The bill would help patients compare prices for medical procedures and obtain estimates of their out-of-pocket costs. It would also help consumers rate the quality of physicians. The vote was 51-1 in favor of the legislation, the “Georgia Right to Shop Act.” The House will next consider the bill. Under the legislation, health insurers would have to disclose which physicians in their network have accepted payments for a medical procedure within the previous year. They would have to allow consumers to access quality metrics for in-network providers on their websites. Insurers' websites would also have to include tools to access out-of-pocket costs for a health service. According to state Sen. Ben Watson, a Republican from Savannah and a sponsor of the legislation, it “provides sunshine or transparency.” The cost of the same medical procedure can vary widely for different physicians. Patients in Georgia cannot currently determine the cost comparisons. Advocates for the legislation assert that it will help patients become better consumers. Allan Hayes, a representative for the group, America's Health Insurance Plans, indicated to the legislature at a hearing that insurers are in favor of transparency throughout the health care industry. The Trump administration released rules aimed at medical price transparency last year. Those rules regarded the prices hospitals would charge patients without insurance. [FN12] Hospitals and insurers opposed those rules as undermining their negotiation process for determining costs for procedures. Massachusetts Legislation for Improving Access to Mental Health Care The Massachusetts Senate unanimously passed legislation that would increase access to mental health care in the state. The bill is focused on guaranteeing that patients have equal access to mental health care as they do to physical health care. The legislation would give the state new enforcement mechanisms, call for the expansion of the practitioner workforce, and set a rate floor to pay mental health clinicians equal to the pay primary care providers receive for similar services. 'This is a really big first step. I'd call it landmark. This is so many years, decades in the making,' Senate President Karen Spilka indicated. ‘This bill will lay the foundation. It's the first step in hopefully many steps we will be taking over the next few sessions to start correcting and fixing what has been a broken system for so many people.’ The bill would create new oversight and enforcement tools for the Division of Insurance to require insurance companies to treat mental health coverage equally. Insurers would have new compliance reporting requirements and face penalties for violations. The bill would prevent insurers from requiring prior authorization for acute psychiatric inpatient care for patients. That care would be equal to emergency treatment for physical issues. The bill would also create a commission to study medical necessity criteria to protect patients who require vital mental health services. 'What we try to do in this bill which may be unique among states, is to do this in such a comprehensive way,' indicated Sen. Julian Cyr, co-chair of the Joint Committee on Mental Health, Substance Use and Recovery and the sponsor of the legislation. ‘We're laying the foundation for things we can do immediately that are going to make a really big difference around access, and then what we're going to be able to come to next.’ © 2021 Thomson Reuters. No claim to original U.S. Government Works. -10- The House will now consider the bill. Senate Minority Leader Bruce Tarr spoke in favor of the bill, calling it a bipartisan effort for change ‘overdue by decades.’ Under a 2000 state law and a 2008 federal law, insurers are required to provide comparable mental health benefits to health insurance consumers. However, advocates and legislators argued that insurers have never completely met those standards. According to Sen. Cindy Friedman, who co-chairs the Health Care Financing Committee, the vague nature of the current laws allows insurers to claim they are complying without actually providing equal access to mental health care. 'There was a real lack of specificity around what the expectation and requirements were around parity,' she stated. ‘For a long time, while these laws have been on the books, it's really been about self-reporting, so insurers and people who are responsible for parity were allowed to self-report.’ Legislators pointed to a lack of access to mental health coverage. About fifty percent of mental health care providers in the state to not accept insurance coverage because of low rates and paperwork requirements. Providers that do accept insurance coverage are [FN13] sometimes backed up for weeks before patients can receive appointments. Legislation in Response to COVID-19 Pandemic The Senate and the House of Representatives passed a bill addressing issues relating to insurance coverage during the COVID-19 pandemic facing the United States. The vote in favor of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) in the Senate was 96-0. It allocates $2.2 trillion for the coronavirus pandemic. The bill covers issues relating to expanding coverage for diagnostic testing, expediting coverage of preventive services and vaccines, changes to health savings accounts (HSAs), and other healthcare provisions. The CARES Act added to health insurance provisions of the Families First Act, passed earlier. Under that law, all comprehensive private health insurance plans must cover FDA-approved diagnostic testing for coronavirus along with the cost of administering testing without cost-sharing or prior authorization requirements. Under the CARES Act, tests provided by labs on an emergency basis, state- developed tests, and tests deemed appropriate by the Department of Health and Human Services (HHS) are included. The CARES Act contains a limited provision addressing surprise bills for coronavirus testing. Out-of-network test providers will be reimbursed based on the provider's cash price for the test, which providers must list on a public website. The legislation does not prevent providers from then sending the consumer an additional bill. The legislation also addresses the coverage of testing under Medicaid and the Children's Health Insurance Program (CHIP). It eliminates the requirement that tests be FDA-approved to quality for coverage with no cost-sharing. The Families First Act allows states to use Medicaid programs to test uninsured people for coronavirus. The CARES Act gives states full federal funding to cover the cost of testing uninsured people through Medicaid. The federal funding covers testing but not treatment for coronavirus. People who have only short-term, limited duration insurance are considered uninsured for purposes of the federal funding covering the cost of testing under Medicaid. People who would qualify for Medicaid coverage if their states had agreed to expand Medicaid under the Affordable Care Act are also considered uninsured for this purpose. The CARES Act provides for access to testing for the coronavirus as well as access to a coronavirus vaccine (when developed) to be covered without cost-sharing permanently. It specifies that testing for coronavirus and a vaccine for coronavirus are essential benefits required to be covered under any ACA-compliant health insurance plan. The CARES Act does not directly address coverage affordability, which is expected to become an even more significant issue as a result of the impact of the coronavirus pandemic. Serious coverage issues are expected as record numbers of employees lose their jobs and employer-sponsored health insurance coverage. Individuals losing coverage will be able to enroll in plans through the health insurance exchanges. The CARES Act does not address bolstering the exchanges, nor does it contemplate subsidies for COBRA coverage for laid-off workers. Healthcare providers are expected to receive over $100 billion in federal funding for expenses and lost revenue from the pandemic. The CARES Act does not address the expected significant cost-sharing for individuals who will need treatment for the coronavirus. Stakeholders have asked Congress to increase federal matching funds for states that have not currently chosen Medicaid expansion, with the goal of increasing access to health insurance coverage in those states. Toward that end, some legislators have also called for a special enrollment period for the federal health insurance exchange, an increase in advertising and outreach, and the withdrawal of [FN14] the Medicaid Fiscal Accountability Regulation, actions that could be taken by the White House without congressional approval. Some States Reopen Health Insurance Exchanges Nine states have reopened enrollment for their health insurance exchanges in response to the coronavirus pandemic. Residents without health insurance coverage will be able to sign up for plans through the exchanges. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -11- The decision was in response to the concern that consumers without health insurance would avoid treatment for coronavirus infection. Open enrollment for health insurance exchanges normally occurs in the Fall. Consumers who do not purchase plans during open enrollment cannot purchase plans through the exchange at other times unless they qualify for a special enrollment period. Colorado, Connecticut, Maryland, Massachusetts, Nevada, New York, Rhode Island, and Washington have decided to reopen exchanges. They have the flexibility for this move because they do not depend on the federal government for a health insurance exchange. California's health insurance exchange enrollment was open for other reasons and will continue to accept enrollment through June. The District of Columbia's exchange was also open for enrollment for reasons unrelated to the pandemic. According to Michael Marchand, chief marketing officer for the Washington Health Benefit Exchange in Washington state, uninsured residents who avoid obtaining the test for coronavirus would be an ‘extremely weak link in the response chain and would make things much worse.’ 'The bottom line is, in a pandemic situation, your response will only be as strong as the most vulnerable link in the chain,' he stated. In late March, over 16,000 cases of COVID-19 had been diagnosed in the United States. Over 200 people had died, researchers at Johns Hopkins University reported. Almost 28 million people in the United States are uninsured. Most coverage obtained through the state-run health insurance exchanges of the states reopening enrollment will begin on April 1. The federal health insurance exchange, which serves residents of states that have chosen not to run their own exchanges, has not reopened enrollment. Thirty-two states use the federal exchange. In mid-March, 25 senators wrote a letter to the Department of Health and Human Services encouraging the federal government to reopen the exchange to allow uninsured Americans to enroll in health insurance plans. They indicated, ‘It is imperative for patients to receive covered care, regardless of whether they test positive or negative for the virus.’ The Centers for Medicare & Medicaid Services released a statement stating that it would not offer a special enrollment period but would continue to consider options. It indicated that consumers might qualify for special enrollment periods for job loss or other reasons. States vary in their approach to the special open enrollment period. Nevada and Maryland are making enrollment available to people who are uninsured and people who only have short-term health plans without comprehensive coverage. Other states, like Massachusetts and Washington, are offering enrollment only for people who are completely uninsured. Consumers have already begun signing up for coverage. According to Lindsay Lang, director of Rhode Island's exchange, almost 175 people had enrolled within the first 72 hours of the special enrollment period. In Maryland, over 1,500 people had enrolled in 48 hours, according to Michele Eberle, executive director of the state's exchange. Washington had 530 enrollments and 2,970 applications. 'There are things beyond our control that may happen, such as the coronavirus,' noted Eberle, ‘and it's really helpful to have that peace of mind ? such as health insurance.’ Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University indicated that insurers could face financial risks due to the demand for health insurance during the special enrollment period. The special enrollment period could lead to increases in the risk pool and changes in how much insurers need to charge for insurance to balance the risk. Consumers will be able to purchase insurance at the price that was set last year before the pandemic was in sight. According to state officials, insurers have been in favor of the reopening of enrollment periods in response to the coronavirus pandemic. State officials considered the risk for insurers, deciding that reopening enrollment did not unfairly reward residents for choosing not to enroll in coverage last year. They are hopeful that convincing people without insurance to sign up for coverage will bring more younger, [FN15] healthier people into the risk pool, bringing down the overall cost for insurers. Researchers Address Coverage for COVID-19 Treatment While the three COVID-19 stimulus bills passed by Congress provided additional funding for hospitals and coverage of testing for coronavirus through Medicaid for uninsured people, the legislation did not specifically allocate money for treatment of the virus. President Trump indicated that hospitals would be reimbursed for treating uninsured people for coronavirus through the $100 billion in funding provided under the Coronavirus Aid, Relief, and Economic Security (CARES) Act. However, the legislation did not specify how funding would be used, allowing the Secretary of Health and Human Services to allocate the funds. Administration officials indicated that hospitals would receive reimbursement at Medicare rates, a significantly lower rate than private insurance rates. Few details about reimbursement were released, such as cost estimates. It is uncertain how much of the $100 billion allocated under the CARES Act will go toward covering the cost of treating uninsured individuals. Researchers from KFF estimated a range of costs for the treatment of COVID-19 for people without insurance coverage. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -12- Researchers also addressed questions about the Trump administration's new policy. They estimated that between 20% and 60% of people in the United States would become infected with the coronavirus. Approximately 15% of people will likely require hospitalization for the disease. Adjusting for the number of hospitalized people over the age of 65 (who are likely insured) resulted in a 12% hospitalization rate for purposes of considering most uninsured people. Researchers estimated that 15% of hospitalizations will require intensive care. They estimated that between 2% and 7% of uninsured people will require hospitalization, which translates into approximately 670,000 to over 2 million hospital admissions. To estimate costs of hospitalizations, researchers looked to the average Medicare payment for respiratory infections with complications in 2017: $13,297. For severe hospitalization, cost estimates were $40,218. Researchers added 20% to the costs due to the add-on to Medicare inpatient reimbursement included under the CARES Act. Not considering the 20% add-on, payments through Medicare amount to roughly half the cost of care paid by private insurers. Without the new proposed policy of reimbursing hospitals at Medicare rates for uninsured patients, hospitals would charge their undiscounted “list prices” for care. These charges are usually significantly higher than what private insurance companies pay for the same services. Researchers estimated that the total costs for the treatment of uninsured patients for the coronavirus under the Trump administration policy would be between $13.9 billion and $41.8 billion. The cost could run over 40% of the $100 billion in funds allocated under the CARES Act. The CARES Act funding was intended to also cover the purchase of medical supplies, the construction of temporary facilities, and other needs. Researchers were not confident that the funding could cover all costs. Researchers pointed out that the Trump administration's policy could result in a larger portion of the funding going to states with higher numbers of uninsured people, particularly states that chose not to expand the Medicaid program under the Affordable Care Act. States choosing to reopen enrollment in state-run health insurance exchanges could also potentially receive less funding due to higher numbers of insured people. Researchers indicated, “While the Trump administration policy will provide relief to uninsured patients who become severely ill from COVID-19, and the hospitals that treat them, how much relief will depend on a number of implementation details that are not yet clear. For example, the administration statement refers to reimbursement of hospitals for care delivered to uninsured patients. However, hospital-based physicians typically bill patients separately for the physician service component of their care, and uninsured patients may still be responsible for those bills.” Researchers warned that patients could face significant medical bills for outpatient care since the Trump administration policy only contemplated covering the cost of hospitalizations for uninsured people. The policy could encourage more people to seek care in the expensive hospital setting instead of outpatient care that will not be covered by the federal government, increasing costs for the government. The Trump administration has not indicated if it will cover the cost of hospital care for people who seek treatment for symptoms but ultimately test negative for the virus. It is uncertain if uninsured individuals will be responsible for cost sharing if the federal government pays the Medicare rate for a hospitalization. Secretary Azar did indicate that hospitals receiving federal funding would not be allowed to balance bill patients. Medicaid patients will have no cost sharing for treatment for COVID-19. Researchers concluded, “Ultimately, while this policy will help uninsured patients and discourage them from delaying care if they [FN16] develop COVID-19, it is not a substitution for comprehensive health insurance.” Insurance Companies Waive Cost-Sharing for COVID-19 Some insurance companies, including Blue Cross and Blue Shield, decided to temporarily waive cost-sharing for the treatment of COVID-19. Blue Cross and Blue Shield (BCBS) companies are coordinating with state and local governments and partners in the health care system to address treatment needs associated with the COVID-19 pandemic. The Blue Cross Blue Shield Association announced the waiving of cost-sharing from independent and locally operated companies throughout the United States and the BCBS Federal Employee Program (FEP). Cost-sharing for treatment of COVID-19 will be waived through May 31. Included in the cost-sharing waiver are costs for testing and administered treatments. Inpatient hospital stays qualify for the cost- sharing waiver. The participating BCBS companies are offering to reimburse health care providers at in-network or Medicare rates that apply. The companies have committed to following all relevant state regulations. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -13- “It is important that our members feel safe and secure during these unprecedented times, which is why we are committed to ensuring our members who are dealing with a diagnosis of COVID-19 can easily access the care they need,” said Scott Serota, BCBSA president and CEO. On March 6, all BCBS companies committed to steps to support the essential needs of their members and medical communities including: -Waiving prior authorizations for diagnostic tests and related covered services that are medically necessary and consistent with the Centers for Disease Control and Prevention (CDC) guidance for members if diagnosed with COVID-19. -Covering, with no cost to members, the appropriate medically necessary diagnostic tests for COVID-19, where it is not covered as a part of the Public Health Services response, and covering any subsequently needed care once COVID-19 diagnosis occurs, consistent with the standard provisions of the member's health benefits. -Increasing access to prescription medications by waiving early medication refill limits on 30-day prescription maintenance medications (consistent with members' benefit plans) and/or encouraging members to use their 90-day mail order benefit. -Expanding access to telehealth and nurse/provider hotlines. BCBS companies are participating in broader, more comprehensive efforts to combat the coronavirus pandemic. They are coordinating with public officials to help meet the needs of local communities. They are sharing relevant data and expertise with local public health departments, working with communities to donate funds and direct resources to local relief efforts, joining efforts with local nonprofit organizations, providers, businesses and government agencies to address the broader, social needs of local communities. The company indicated, “These actions will apply to fully-insured, individual, and Medicare members. BCBS companies are committed to working with state Medicaid and CHIP agencies to ensure that beneficiaries have access to needed testing and services.” BCBS encouraged beneficiaries to obtain more information regarding benefits, services and network coverage from local BCBS [FN17] companies. HHS Announces Plan to Cover COVID-19 Treatment for Uninsured Health and Human Services Secretary Alex Azar announced the federal government's plan to use CARES Act funding to cover the cost of COVID-19 treatment for uninsured patients. Under the CARES Act, $100 billion in funding was authorized to support health care providers treating patients for COVID-19 during the pandemic. Azar announced that the federal government will pay providers for treating uninsured people for COVID-19 treatment. Providers will receive Medicare rates to reimburse care to the uninsured. Claims beginning February 4 will be eligible, the date that CMS created billing codes for COVID-19 related procedures. A new HRSA website contains the specific details relating to the program. Providers participating in the program will not be permitted to balance-bill patients who do not have health insurance coverage. HHS divided the $100 billion in CARES money into four new funding allocations: a general allocation, a targeted allocation, a rural allocation, and a tribal allocation. According to Azar, “Our goal in all of the decisions we're making is to get this money out the door as quickly as possible while targeting it to those suffering the most from the pandemic.” He indicated that the agency is attempting to direct the money for covering the uninsured directly to areas where COVID-19 has infected people. He said, “Then, we know there are two reasons providers are hurting right now. First, almost all healthcare providers have been affected by the need to cancel elective procedures and avoid unnecessary office visits. Second, we know that providers in areas particularly impacted by the virus, such as New York, are hurting even more. Both of these challenges are greater for providers who already operate on thin margins, like rural hospitals.” He announced the following new programs: • the uninsured program • a general allocation • an allocation targeted to areas with particular impact • a rural allocation • an allocation to the Indian Health Service, predominantly serving rural areas Measures to prevent fraud and misuse of funds are built into the terms and conditions of the programs. Recipients will be required to submit documents verifying that the funds were used for healthcare-related expenses or lost revenue caused by the pandemic. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -14- HHS and the Office of the Inspector General will perform anti-fraud and auditing work for the programs. Half of the CARES fund, $50 billion, will be given to providers based on their 2018 revenue. The first $30 billion was sent to providers based on their previous Medicare fee-for-service revenue. The remaining $20 billion will be given to providers based on the net patient revenue they received from all sources in 2018. HHS will launch a new portal where providers can submit revenue information to apply for the funding. HHS is working to quickly validate information and send out payments to providers. In order to receive general funds, providers will have to agree to terms and conditions, including agreeing not to charge patients surprise billing. Providers will not be allowed to charge COVID-19 patients out-of-pocket costs for out-of-network treatment greater than what they would charge for in-network treatment. According to Azar, “This protection comes on top of the fact that most major insurers have pledged not to charge patients anything out- of-pocket for COVID-19 care.” An additional $10 billion of CARES funding will go toward a targeted allocation program for hospitals in areas hardest hit by COVID-19. A rural allocation program will also receive $10 billion. This money will go to rural hospitals and health centers, based on the operating expenses of the facilities. Approximately 2,000 rural hospitals will be eligible. Rural hospitals have already received $165 million from HRSA treatment and telehealth resource centers. [FN18] $400 million will be allocated to the Indian Health Service, based on facility operating expenses. Michigan Insurance Companies Agree to Cover Cost-Sharing for COVID-19 Treatment The Michigan Department of Insurance and Financial Services (DIFS) announced that most of the insurance companies in the state had agreed to cover the costs of testing and treatment for COVID-19 without cost-sharing for their beneficiaries. The companies will waive copays, deductibles, and other forms of coinsurance for COVID-19 patients. The Whitmer Administration and DIFS negotiated with the companies to convince them to waive the costs. “Michiganders that are fighting for their lives should not have the extra burden of fighting with their health insurer to cover the costs of their care,” said Governor Gretchen Whitmer. “I am thankful that health insurers agreed to cover Michiganders' coinsurance, deductibles, and copays as we fight this virus. It's going to take all of us doing our part to slow the spread of COVID-19. We will get through this together” Michigan residents with individual or group health plans from the participating companies will not have to pay cost-sharing for coronavirus-related medical treatment. Treatment includes primary care visits, laboratory testing, emergency room visits, ambulance services, and FDA-approved medications and vaccines for COVID-19. “This announcement is a clear demonstration of our governor's ability to get things done for Michiganders during this emergency,” said DIFS Director Anita G. Fox. “I applaud these health insurers for working with Governor Whitmer to remove financial barriers for those seeking treatment during this crisis.” The participating insurers include: • Aetna Better Health of Michigan • Blue Cross Blue Shield of Michigan, Blue Care Network, MI Blue Cross Complete • HAP, Alliance Health • Humana Insurance • McLaren Health Plan • Meridian Health Plan • Molina Healthcare Michigan • Physicians Health Plan (PHP) • Priority Health, Priority Health Insurance Co., Priority Health Choice, Total Health Care • United Healthcare Insurance, United Healthcare Community Plan The cost-sharing waiver applies to commercial health insurance policies available through participating insurers. Consumers with [FN19] questions about their specific policies were encouraged to contact their health plan. California Exchange Sees Surge in Enrollment Over 58,000 people signed up for health insurance plans through California's health insurance exchange, Covered California, since March 20, the beginning of the special enrollment period in response to the COVID-19 pandemic. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -15- The website has also experienced a significant surge in consumer visits. The website's Medi-Cal page was also having an increase in visitors. California residents without insurance who are eligible to enroll in health care coverage through Covered California will have access to plans through June 30. [FN20] Medi-Cal enrollment is available year-round for eligible consumers. Hospitals, Health Systems, Businesses, Insurers Ask Congress to Protect Coverage for Americans The U.S. Chamber of Commerce, the American Hospital Association and America's Health Insurance Plans (AHIP), and nearly 30 other organizations joined in a coalition to ask Congress to protect Americans' health care coverage in its response to the COVID-19 health emergency. The coalition sent a letter to Congress addressing their concerns. The group indicated that stable health insurance coverage is essential for Americans, particularly during the global health crisis. Access to coverage allows people to be more confident in seeking testing or treatment for COVID-19. “As Americans continue to be impacted by the severity of the COVID-19 crisis, the possibility of losing their health coverage should not have to be a concern,” said Neil Bradley, Executive Vice President and Chief Policy Officer, U.S. Chamber of Commerce. “There are many items that we'd like to see Congress focus on in future legislation, and maintaining health benefits and increasing coverage options need to be top priorities in order to continue supporting individuals, families and employers. Our letter outlines several important legislative proposals that Congress should advance to ensure the American people have access to affordable health coverage.” “Nothing is more important than your health,” said Rick Pollack, President and CEO of the American Hospital Association. “In these uncertain times, coverage can give you, your friends and family peace of mind. And this is critical as we seek to flatten the curve, fight this deadly virus and put America back to work.” “In these critical and uncertain times, we know that the private sector and government working together can help overcome this crisis,” said Matt Eyles, President and CEO of AHIP. “Health insurance providers are taking decisive actions to ensure that the tens of millions of Americans we cover have the best possible access to care. But those actions do not help American families if they lose their coverage.” The coalition encouraged Congress to quickly consider and pass legislation that: • Provides employers with temporary subsidies to preserve current health benefits. • Covers the cost of coverage through the Consolidated Omnibus Budget Reconciliation Act (COBRA). • Expands use of Health Savings Accounts (HSA). • Opens a Special Enrollment Period (SEP) for health insurance marketplaces. • Increases eligibility and federal financial assistance subsidies to buy coverage in the health insurance marketplaces. The coalition supported these actions to strengthen access to health insurance and care throughout the United States. The actions would also support health care providers caring for people during the pandemic. According to the group, “Congress has taken important actions to support Americans through this crisis but, swift actions are needed to ensure continuity of coverage and the stability of our health care system as we continue to fight this virus and reopen our economy. America's health care and business leaders are committed to working with state, federal, and local officials in every way possible. Working together, the nation will overcome the COVID-19 crisis.” The U.S. Chamber of Commerce is the largest business federation in the world. It represents over 3 million small and large businesses throughout all regions. The American Hospital Association (AHA) is a not-for-profit association of health care provider organizations and individuals focused on improving community health. AHIP is a national association of health insurers that works toward improving affordability, value, access and well-being for consumers. [FN21] Poll: 14% of Americans Would Avoid Care for COVID-19 Due to Cost According to a new Gallup poll, one out of every seven (14%) of adults in the United States indicated that they would avoid healthcare treatment for the symptoms consistent with COVID-19 for themselves or a member of their household because of concerns over the cost of treatment and their ability to pay. When the question specifically asked if they would seek treatment if they believed if they had been infected with the novel coronavirus, 9% or respondents indicated that they would avoid treatment due to cost. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -16- Adults younger than 30, non-whites, people with a high school education or less, and people in households earning less than $40,000 per year were the groups most likely to answer that they would avoid seeking care. Gallup and West Health have been conducting an ongoing special study to gather information about public opinion in the United States regarding the cost of healthcare. Researchers collected data from April 1-14, 2020. Researchers asked respondents about two of the most common symptoms of COVID-19, fever and a dry cough. According to researchers, “Unwillingness to seek out care due to concerns over cost is related to familiar socioeconomic distinctions. Hispanics and blacks are less likely to have health insurance than are non-Hispanic whites, and those in lower-income households are far more likely to be influenced by cost when considering if they will follow recommended medicine or procedures from their doctors.” They pointed to a lack of clarity over the common symptoms of COVID-19 as a possible factor in the difference between answers when researchers asked specifically about the disease. Mentioning the virus by name reduced the percentage of people unwilling to seek medical treatment by a third. Among the respondents answering that they would avoid care due to costs, 6% of respondents, which represents about 15 million adults in the United States, reported that they or their families have experienced a denial of care due to the heavy patient volume from the pandemic. This care could include elective surgeries and related appointments canceled due to state restrictions. People living in the Northeast region (11%) were the most likely to indicate they had been denied care. In the West, 8% reported the same. Five percent in the South and 3% in the Midwest reported being denied care. Researchers pointed to the regional differences in COVID-19 diagnoses as the potential reason behind these differences. The largest number of confirmed cases in the United States by far is in New York state. New Jersey, Pennsylvania, and California all had high numbers of cases, representing the Northeast of Western regions of the U.S. Researchers found that race did not strongly relate to the denial of care. Income level was inversely related. Three percent of people in households earning more than $100,000 reported instances of denial of care. Eleven percent of people living in households with incomes under $40,000 reported denial of care. Researchers noted, “The seriousness of the COVID-19 pandemic is multi-faceted. In addition to the threat of infection by the coronavirus itself, workers worldwide have lost their jobs, with many now suffering extreme economic hardship. Compounding these effects is the cost of healthcare generally. Recent research has shown that millions of Americans know someone who has died in the last 12 months due to their inability to pay for treatment and that $88 billion in borrowing occurred over the last year for healthcare. As such, results that show 14% unwilling to seek treatment for COVID-19 symptoms and another 9% unwilling to seek treatment -- even when coronavirus is suspected -- should not be shocking, even amid the outbreak.” According to the authors, seeking treatment when experiencing symptoms of COVID-19 is important when fighting the pandemic. Testing is also an important part of combatting the spread of the virus. Currently, approximately 150,000 Americans are receiving testing. Harvard researchers recommend that testing should be increased to 500,000 to 700,000 to effectively identify infected individuals. Researchers indicated that people had valid concerns over the costs associated with testing for the novel coronavirus. Even though many insurance companies have agreed to waive co-pays for coronavirus testing, and a federal law that requires Medicare, Medicaid, and other government sponsored insurance programs to cover the cost of the test, individuals could still be responsible for the cost of a trip to the hospital to obtain a test. Consumers are concerned that physicians could determine that a visit does not justify a test, is out-of-network, or the visit requires [FN22] treatments not associated with COVID-19. In those cases, consumers could be responsible for the cost. Pennsylvania Announces Federal Funding to Cover COVID-19 Testing and Treatment for Uninsured Pennsylvania Governor Tom Wolf announced that the federal government will reimburse the cost of testing and treatment of COVID-19 for people without health insurance coverage. The funding is available through the federal stimulus bills. “All Pennsylvanians should have access to necessary testing for COVID-19 and this federal funding will help eliminate any financial burden on those both providing and receiving tests,” Gov. Wolf stated. The Pennsylvania Department of Human Services (DHS) encouraged eligible Pennsylvania residents to obtain health insurance coverage through the Pennsylvania Medicaid program, Medical Assistance (MA), or the Children's Health Insurance Program (CHIP). “We are also pleased to work with the federal government to ensure that people who are uninsured can receive COVID-19 testing and treatment without worrying about how to pay for it. No Pennsylvanian should forego medically-necessary testing for fear of what it might cost, and providers will be able to collect payment for testing and services directly from the federal government,” said DHS Secretary Teresa Miller. “Affordable health care and access to it is a necessity at all times, but it is especially vital during a health crisis. DHS is © 2021 Thomson Reuters. No claim to original U.S. Government Works. -17- always working to make sure that people who need coverage to protect themselves and their children have it. I encourage anyone who may need coverage to apply for Medicaid or CHIP.” Under the Family First Coronavirus Relief Act and CARES Act, the U.S. Department of Health and Human Services will reimburse health care providers at Medicare rates for the cost of testing people without insurance coverage for COVID-19 and for the cost of treating uninsured people with a COvid-19 diagnosis. The Health Resources & Services Administration (HRSA) will handle the payments for uninsured individuals. HRSA will begin processing claims on May 6. Claims dating back to February 4, 2020 will be eligible for federal funding coverage. A list of covered services, a description of eligibility standards, and more information is available for providers at the HRSA website https://coviduninsuredclaim.linkhealth.com/. Providers can submit claims through the website. Coverage for COVID-19 testing is mandatory under individual and marketplace health insurance plans, Medicare, Medicaid, and CHIP. Enrollment for eligible individuals is open throughout the year for Medicaid and the Children's Health Insurance Program (CHIP). In Pennsylvania, there are no income limits for children to qualify for coverage through CHIP. “The Affordable Care Act has ensured that we have health insurance options available, even if people lose the coverage they currently have,” Insurance Commissioner Jessica Altman indicated. “Individuals and families can sign-up for health coverage through the marketplace at healthcare.gov, outside of the annual open enrollment period, if they experience a life change that qualifies them from a Special Enrollment Period. These circumstances include the loss of health insurance provided by an employer, which many individuals may experience during the COVID-19 outbreak. There are several resources available for displaced employees during this difficult time, so I encourage those affected to reach out for guidance and assistance.” Pennsylvania residents can seek enrollment assistance for free through the Pennsylvania Association of Community Health Centers (PACHC). Certified Exchange Assisters are available throughout the state to help residents enroll in health insurance coverage through [FN23] the Health Insurance Marketplace, Medical Assistance (MA), Medicare and CHIP. Coverage for At-Home COVID-19 Tests Uncertain Companies have been developing tests for SARS-CoV-2, the virus that causes COVID-19, that can be performed at home. However, one barrier to the wide use of the at-home tests is uncertainty about insurance coverage of the cost of the tests. LabCorp received emergency use authorization (EUA) from the Food and Drug Administration (FDA) for the first SARS-CoV-2 test with a home collection option in mid-April. The company has been making the tests available to healthcare workers and first responders and hopes to make the tests more widely available. In early May, Rutgers' RUCDR Infinite Biologics received FDA EUA approval for an at-home test using a saliva specimen. The tests have the benefit of increasing the number of people tested while also reducing exposure risk in health care settings. However, one of the barriers to the widespread use of at-home testing for SARS-CoV-2 is the cost of the testing and insurance coverage. At-home testing has been available for sexually transmitted diseases for several years; however, private insurance and Medicaid rarely cover the full cost of these at-home tests. The cost of the test kits ranges from $24 to $522. Even if the kits are covered, the cost of the accompanying consultation fee that some companies charge if often not covered. Costs range from $10 to $99. Companies that do accept private insurance in some states still charge consumers $75 for the kit and processing fees. The test approved by the FDA from LabCorp for SARS-CoV-2 costs $119 as of late April. The company claims that individuals can file their insurance or use federal funds to cover the upfront cost of the test. Home-testing companies have historically not accepted insurance coverage for at-home testing, so there is no method in place to [FN24] charge insurers for in-home testing to make testing more widely available. Georgia Sees Increased Enrollment in Medicaid and CHIP According to data from Georgia, the state is seeing an increase in enrollment in Medicaid and the Children's Health Insurance Program (CHIP) due to the coronavirus pandemic. Over the past two months, the COVID-19 health emergency has created an economic crisis in the state leading to new enrollment in Medicaid and PeachCare. Enrollment increased 38% compared to the same time enrollment period last year. The state saw smaller increases in enrollment in the programs in January and February of 2020. Through March and April, 88,000 new enrollees entered the programs in Georgia. Last year, those months included 64,000 new enrollments in the programs. Economic downturns generally lead to increased enrollment in Medicaid. Job loss is often linked to a loss of insurance coverage for individuals and families. As a result, some children and adults gain coverage through enrollment in safety-net programs such as Medicaid and CHIP. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -18- Approximately 2 million Georgia residents are enrolled in Medicaid or PeachCare. Most of those enrollees are children. States that chose to expand eligibility for their Medicaid programs under the Affordable Care Act (ACA) will most likely see even higher increases in enrollment in Medicaid. Expansion allows more low-income adults without children to enroll. According to Bill Custer, a health insurance expert at Georgia State University, the state will probably experience a large increase in the number of people without insurance coverage. Georgia is already the state with the third-highest rate of uninsured residents. Approximately 13.7% of people lack insurance coverage. “We could easily get back to 20% or over that we had before the ACA,‘’ Custer noted. “Most people think we're in for a fairly long recession.‘’ Another option for people experiencing job loss and related health insurance loss is COBRA, a federal program that allows workers to purchase insurance coverage after they lose their jobs. However, the coverage is generally very expensive. People losing employment can also qualify for a special enrollment period to purchase individual coverage through a state health insurance exchange. Those plans qualify for federal tax subsidies based on income levels. Insurance Commissioner John King recently prohibited all health insurers in Georgia from canceling policies due to non-payment until [FN25] the end of May. Trump Administration Asks Supreme Court to Repeal ACA, Democrats Introduce Legislation Supporting Law The Trump administration urged the Supreme Court to repeal the Affordable Care Act (ACA). The Trump administration indicated that “the entire ACA act must fall.” The comments came shortly after Republican state attorneys general, who filed the case challenging the federal healthcare reform law, submitted briefs to the case. Many Republican legislators have opposed the ACA since it became law in 2010. One of President Trump's significant platforms in the 2016 election was overturning the ACA. The global COVID-19 pandemic and resulting economic crisis has not changed the Trump administration's position on the law. In May, Trump indicated, “We want to terminate health care under Obamacare.” The Supreme Court will likely decide the case in the spring. House Speaker Nancy Pelosi (D-CA) released a statement indicating, ‘President Trump and the Republicans' campaign to rip away the protections and benefits of the Affordable Care Act in the middle of the coronavirus crisis is an act of unfathomable cruelty.’ Trump ended the tax penalty for the individual mandate contained in the law in 2017. The mandate requires all Americans to obtain health insurance coverage to create a more sustainable risk pool for health insurance plans. In 2019, the Fifth Circuit of the United States Court of Appeals found the individual mandate in the ACA unconstitutional. According to the filing, “Congress deliberately designed the ACA and its goal of expanding healthcare coverage around the individual mandate. Without the mandate, the guaranteed-issue and community-rating provisions not only malfunction but result in the opposite of what Congress intended.” Eighteen attorneys general, including Attorney General Ken Paxton of Texas, filed the brief. Paxton indicated, “Congress declared in the text of the law that the individual mandate is the centerpiece of Obamacare. Without the unlawful mandate, the rest of the law cannot stand. Obamacare has failed, and the sooner it is invalidated, the sooner each state can decide what type of health care system will best provide for those with preexisting conditions, which is the way the Founders intended.” Staunch opposition has arisen against the push to eliminate the law. Many pointed to the devastating timing of reducing access to health insurance during a pandemic. House Democrats introduced legislation aimed at supporting the ACA in response to the briefs opposing the law. The focus of the legislation is expansion of access to health insurance, decreasing costs for coverage, and decreasing costs for prescription drugs. The bill, the Patient Protection and Affordable Care Enhancement Act, would also reward states for choosing to expand Medicaid. ”It's commonsense legislation that takes the savings from lower prescription drug costs and invests it into lowering health care premiums and expanding access to affordable care,” indicated Health Committee Chairman Frank Pallone Jr, D-New Jersey. “All around, that's a win for the American people. We must take action to lower these soaring costs, expand access to health care, rein in the Trump Administration's efforts to sabotage the ACA and protect people with pre-existing conditions.” The Centers for Medicare & Medicaid Services released a report indicating that an increased number of people had enrolled in health insurance plans during April and May 2020 due to the special enrollment period (SEP) created in response to the coronavirus pandemic. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -19- CMS noted, ‘By month, the largest gain in loss of minimum essential coverage SEP enrollments occurred in April 2020, with enrollments increasing by 139% when compared to April 2019.’ Not all Republicans agree with repealing and replacing the ACA, even though it has been a popular platform for conservative politicians during elections. Some Republicans are concerned that the stance could turn voter sentiment against Trump and other Republicans in the 2020 election. “Politically, it's pretty dumb to be talking about how we need to repeal Obamacare in the middle of a pandemic,” Republican strategist Joel White indicated. “We need quick solutions here; we need stuff that we can do tomorrow, because our countrymen are hurting.” Health industry experts also oppose eliminating the ACA, arguing that it would have negative consequences in an industry already troubled by the racial and economic differences brought further to light by the coronavirus pandemic. “The ACA has had a tremendous effect and without the ACA, we would be in even worse shape right now heading into this double whammy of a public health crisis and an economic crisis,” Larry Levitt, MPP, executive vice president for health policy at the Kaiser Family Foundation noted. “Without the ACA, we would have upward of 20 million more people uninsured, and there would be no safety net as people are battling these [issues], as people are losing their jobs and their health insurance.” The Center on Budget and Policy Priorities published commentary indicating that an estimated 20 million Americans would lose health insurance coverage if the ACA is repealed. With a recession likely due to the pandemic, that number will only increase. “Forecasts predict that economic hardship will continue through next spring, when the Supreme Court will render its decision. At that time, with unemployment projected to be about 10% and more people relying on Medicaid expansion and the marketplace's premium assistance, many more people could lose coverage than projected pre-crisis,” researchers indicated. Research indicated that an elimination of the ACA would widen racial disparities in health care, a phenomenon that has also been brought into sharper focus by the COVID-19 health emergency. According to the Urban Institute, even without considering the pandemic, ending the ACA would lead to health coverage loss for 1 in 10 black Americans and 1 in 10 Hispanic Americans. One in 16 white Americans would lose coverage. Researchers also indicated that ending the ACA would decrease funding for the CDC and public health programs researching COVID-19. It would also eliminate requirements that insurers cover basic services like vaccines without cost sharing and would [FN26] endanger access to coverage for people with preexisting conditions. Bill to Strengthen ACA Introduced Congressman Steven Horsford (D-NV) introduced a bill aimed at strengthening the Affordable Care Act (ACA) and adding more protections for health care consumers in the United States. The Patient Protection and Affordable Care Enhancement Act focuses on decreasing health care costs and prescription drug prices. “While we continue to grapple with the COVID-19 pandemic, Nevadans need to know that their health care is protected and that the costs of their prescription drugs will no longer increase exponentially and prohibitively,” said Congressman Horsford. “I'm working every day in Congress to lower the cost of healthcare for Nevada's families. We must pass this legislation speedily through the House and the Senate and urge President Trump to drop the dangerous lawsuit to destroy the ACA in the middle of the coronavirus crisis.” The legislation would significantly increase the federal tax subsidies available under the ACA to help cover the cost of health insurance plans on the individual market. The increased eligibility would apply to more middle-class families. The bill would limit the cost of a benchmark silver plan in the ACA marketplace to a maximum of 8.5 percent of income for people purchasing health insurance plans through the ACA exchanges. According to Horsford, many the cost of health insurance premiums for many Americans would decrease by half or more: • A family of four earning $40,000 would save nearly $1,600 in premiums each year. • A 64-year-old earning $57,420 would save more than $8,700 in premiums each year. • A single adult with income of $31,900 would see premiums cut in half. • An adult earning $19,140 would see premiums cut to zero, saving $800 dollars a year. The legislation would also allow for negotiation of prescription drug prices, decreasing the cost of prescriptions from pharmaceutical companies to the prices they charge for the same drugs in other countries. It also would reward states for expanding Medicaid eligibility to approximately 4.8 million Americans currently ineligible for the program. [FN27] Oklahoma Expands Medicaid © 2021 Thomson Reuters. No claim to original U.S. Government Works. -20- Oklahoma voters chose to expand eligibility for Medicaid in the state. Oklahoma is the first state to expand access to the government- sponsored health insurance program during the coronavirus pandemic. Voters passed the measure by a margin of less than one percent. Urban and rural voters were on opposite sides of the issue. The vote will add a new article to Oklahoma's state constitution making adults with incomes up to 133 percent of the federal poverty level eligible for coverage under Medicaid. Voters also agreed to protect the expansion of the program from significant changes. The legislature will not be able to create additional restrictions making it more difficult to qualify for the expanded coverage. This aspect of the measure will stop lawmakers from adding work requirements to eligibility for Medicaid. Advocates for the measure pointed to the nearly 200,000 state residents who will become newly eligible for coverage under Medicaid. The change will also result in over a billion dollars of federal funding for health care providers in the state. The additional funding is much needed for struggling rural hospitals. Oklahoma governor Kevin Stitt and others opposed the measure, calling the expansion too costly. Stitt made a statement that, “From day one, I've said one-time funds are not the way to pay for Medicaid expansion.” He vetoed a bill that would have opened up funding for expansion. Stitt had at first agreed on a plan for expansion that would have utilized the Healthy Adult Opportunity block grant demonstration from the Center for Medicare & Medicaid Services. He withdrew his support for the plan after discovering that the hospital fee would not create enough revenue. Under the voters' decision, the state is required to expand Medicaid by July 2021. Voters chose to expand Medicaid during the continued spread of the coronavirus pandemic in the state. Between March and the end of June, over 13,100 cases of coronavirus were confirmed by the Oklahoma State Department of Health. The Kaiser Family Foundation encouraged federal and state governments to expand the Medicaid program in the face of the global pandemic to increase access to health insurance during the pandemic. The Kaiser Family Foundation suggested three methods of expanding the program. States could make more people eligible (like Oklahoma did by increasing the income level for eligible enrollees). States could also adopt measures that facilitate enrollment of eligible individuals in Medicaid. Additionally, states could request waivers from CMS that would increase coverage and flexibility of access. According to an Urban Institute study in May 2020, states that had already expanded Medicaid were better off during the increasing unemployment due to the pandemic than states that declined to expand the program. “With historic levels of joblessness around the corner, millions of workers and their families are about to lose their employer coverage,” Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, indicated. “Our safety net is about to be tested, and it's going to work a lot better in states that expanded Medicaid.” If unemployment reaches 20 percent in states that expanded Medicaid, over half of people losing employer-sponsored health insurance, or approximately 9 million people, would be eligible for Medicaid. In states that did not expand Medicaid, only one-third of people losing employer-sponsored insurance, or 3 million people, would be eligible for the program. [FN28] Thirty-seven states plus the District of Columbia have chosen to expand eligibility for Medicaid. Bill to Increase Access to Telehealth Introduced U.S. Senators Bill Cassidy, M.D. (R-LA), Tina Smith (D-MN), Dan Sullivan (R-AK) and Doug Jones (D-AL) introduced legislation that would direct the Department of Health and Human Services (HHS) to inventory telehealth programs throughout the United States with the aim of improving access to health care particularly during health emergencies. “Telehealth has been instrumental in connecting patients and health care professionals during Covid-19. It saves lives, allows doctors to spend more time with patients, and allows access to care for those who normally could not access. This bill examines what's worked across the country so we can more effectively respond to future health emergencies,” said Dr. Cassidy. “Tele-health has been especially valuable during this pandemic. It can help prevent exposure and spread of the virus while providing patients with care from their homes,' said Smith. ‘As we continue to respond to the pandemic?and prepare for future public health emergencies?we should be actively working to improve our nation's tele-health infrastructure and make sure it's accessible by all Americans.” Under the bill, HHS would be required to report on the issue every five years. It directs HHS to: • conduct an inventory of telehealth initiatives in existence, including their capacity to handle increased volume during the response to a public health emergency; © 2021 Thomson Reuters. No claim to original U.S. Government Works. -21- • identify methods to expand and interconnect regional health information networks and state and regional broadband networks; • evaluate ways to prepare for, monitor, respond rapidly to or manage the events of a public health emergency through the enhanced use of telehealth technologies; • promote greater coordination among existing federal interagency telehealth and health information technology initiatives; and • make recommendations related to updates on the use of telehealth in public health emergencies in Federal and State public health preparedness plans and any actions taken to implement such recommendations. “The revolution of telemedicine has provided a lifeline for millions of Americans in rural areas, including thousands of Alaskans,” said Sullivan. “The benefits of telehealth services, which empower patients to receive care in their homes rather than traveling great distances, have only become more pronounced in the age of the COVID-19 pandemic and social distancing orders. With this legislation, we have the opportunity to build on existing telehealth efforts in Alaska and across the nation to make sure patient-centered [FN29] care is accessible to everyone, no matter where they live.” House Passes Bill to Protect ACA The U.S. House of Representatives passed a bill aimed at protecting and expanding the Affordable Care Act. It was nearly a party-line vote at 234-179. The “Patient Protection and Affordable Care Enhancement Act” (H.R. 1425) is unlikely to pass in the Republican-controlled Senate. President Trump would likely veto the bill if it did pass in the Senate. The bill is aimed at decreasing health care costs and prescription drug prices, continuing protections for people with pre-existing conditions, strengthening Medicaid and CHIP and funding increased outreach, education, and enrollment efforts. According to Mike Thompson (CA-5), a senior member of the House Ways and Means Subcommittee on Health, who supported the bill, “Since the first day of this Congress, we have been working to expand access to quality, affordable health care for people across our nation. In the middle of a global pandemic, this work is important now more than ever. That's why today I was proud to vote to pass the Patient Protection and Affordable Care Enhancement Act, a bill to expand the progress we have made under the Affordable Care Act.” The legislation aims to improve health care by: • Lowering the cost of health care coverage by expanding tax credits and subsidies that help Americans afford coverage through the ACA Marketplaces, • Allowing for the negotiation of prescription drug prices, • Expanding coverage by encouraging hold-out states to expand Medicaid and providing funds to Federal and state efforts to increase enrollment and establishing state-based Marketplaces, • Combating health inequities facing Black Americans and people of coverage, and • Strengthening the protections for people with pre-existing conditions that have delivered affordable care to millions over the last ten [FN30] years. Attorneys General Sue Trump Administration Over Health Care Discrimination Twenty-three attorneys general including Minnesota Attorney General Keith Ellison filed a lawsuit to block a new Trump Administration rule that will allow health care providers and insurance companies to discriminate against several classes of people, such as LGBTQ+ individuals, people with limited English language proficiency, and women. The rule removes express protections for these groups in Health and Human Services regulations related to the nondiscrimination provision of the Affordable Care Act (ACA). Under the nondiscrimination provision of the ACA, health care providers receiving federal funds cannot discriminate based on race, color, national origin, sex, disability, or age. “As the worst pandemic in a century gets even worse, the Trump Administration is once again showing Minnesotans that it's willing to sacrifice the health and health care of folks they just don't care about,” Attorney General Ellison said. “We asked them not to go ahead with this, and they did anyhow. When the federal government abandons its duty to protect all Minnesotans ? no exceptions ? it's my job as Attorney General to step in and hold them accountable. So today, I took them to court.” The coalition of attorneys general asked the Trump administration twice to withdraw the rule, once in August 2019 and again in April 2020. HHS regulations implementing Section 1557 date back to 2016 under the Obama administration. The regulations indicated that discrimination based on gender identity, nonconformity to sex stereotypes and pregnancy are sex discrimination prohibited by the statute. Section 1557 prevents health care programs, including insurers, receiving federal funding from discriminating against individuals because of race, color, national origin, sex, disability, or age. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -22- According to federal courts, the statute's prohibition on sex discrimination applies to transgender people and other LGBTQ+ people. Recently, the Supreme Court agreed, confirming the view in Bostock v. Clayton County, ruling that discrimination based on sexual orientation and transgender status are forms of sex discrimination under federal civil rights legislation. Ellison noted, “But, despite numerous failed legislative and legal battles to repeal and dismantle the ACA, the Trump Administration's new rule would now eliminate many of the express protections contained in the Section 1557 regulations, unlawfully exclude many health insurers from Section 1557's scope, and would embolden health care providers and health insurers to deny care and insurance coverage. The new rule would also impose unreasonable barriers and impede timely access to health care for Americans, in violation of Section 1554 of the ACA.” The attorneys general argued in the lawsuit filed in the U.S. District Court for the Southern District of New York that HHS has violated the law by opening vulnerable populations up to discrimination under the new regulation. They argue that HHS has no justification for rejecting prior policy, including the policy to explicitly prohibit discrimination in health care and the policy to assist individuals with limited English proficiency. The lawsuit also alleges that the Trump administration made changes based on animus toward the transgender community. The attorneys general argue that the regulation is arbitrary, capricious, and violates the law under the Administrative Procedure Act (APA). They also assert that it violates the equal protection guarantee of the 5th Amendment. Joining the lawsuit are New York Attorney General Letitia James, California Attorney General Xavier Becerra, and Massachusetts Attorney General Maura Healey, who co-led the lawsuit, and the attorneys general of Colorado, Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maine, Maryland, Michigan, Nevada, New Jersey, New Mexico, North Carolina, Oregon, Pennsylvania, [FN31] Rhode Island, Vermont, Virginia, and Wisconsin. Study: 10 Million Stand to Lose Health Insurance A new study from the Urban Institute revealed that over 10 million people are predicted to lose employer-provided health insurance due to job loss related to the COVID-19 pandemic during 2020. Researchers' predictions were based on estimates expected between April and December 2020. The study included an assessment of pandemic-related job loss. Researchers found that approximately 48 million nonelderly people throughout the United States are expected to be a member of a household experiencing job loss due to the COVID-19 pandemic and associated economic upheaval. The authors utilized projected data for employment losses based on industry, state, and demographic characteristics published by the U.S. Department of Labor. They estimated that the 48 million people will fall into the following categories: Many of the workers and family members experiencing job loss within the family either had insurance through another family member's job (34%) or through Medicaid or the Children's Health Insurance Program (CHIP) (27%) prior to the pandemic. About one-fifth of these people (10.1 million) had insurance tied to the job lost due to COVID-19. Smaller shares had coverage through the nongroup insurance market, other public programs, or were uninsured. Projections show 3.3 million of those people will regain employer-sponsored insurance by being added to a family member's policy, 2.8 million people will enroll in Medicaid, and 600,000 people will enroll in the individual market, mainly via the Affordable Care Act's marketplace. Still, 3.5 million people will become uninsured. Researchers concluded that the lower numbers predicted to lose employer-sponsored health insurance compared with the number of people predicted to be affected by job loss are due to the disproportionate effect of the COVID-19 recession on workers in low-wage positions that do not include health insurance benefits. States that did not choose to expand eligibility for Medicaid will likely see higher numbers of people losing access to health insurance [FN32] coverage. Kentucky Agency Helping Residents Obtain Health Insurance Kentucky River Foothills Development Council, Inc. (KRFDC) is helping Kentucky residents and small businesses access to health insurance coverage through the Kentucky Health Benefit Exchange program. The agency's program is an effort to help families obtain health insurance coverage during the COVID-19 pandemic. According to KRFDC, “Through this program it is the agency's goal to help as many families as possible understand their health care options and guide them in choosing which option(s) will best suit their health care needs.” The agency has hired trained Navigators to assist individuals and families searching for affordable health insurance plans. They will also help eligible residents sign up for coverage through Medicaid and Kentucky Children's Health Insurance Program. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -23- Navigators assist with signing up for coverage at no cost to beneficiaries. They provide both education services and enrollment assistance. The health insurance coverage options include expanded Medicaid, Qualified, Health Plans, and Small Business Health Options Program (SHOP). Businesses with between 2 and 50 employees qualify for SHOP. Plans available through the Marketplace include coverage for all essential health benefits, such as physician visits, hospital and emergency care, medications, and pregnancy care. Individuals without health insurance may qualify for Presumptive Eligibility Medicaid. This program provides access to health insurance for three months for individuals and families without coverage. Full Medicaid benefits are available to people with eligible income limits. The following limits apply: • Individuals age 18 to 64 making less than $17,604* qualifies for Medicaid • An individual age 18 to 64 making $18,735* can use the Advance Premium Tax Credit (APTC) to pay most of the insurance premium for a silver plan on HealthCare.gov and receive extra savings on cost-sharing when receiving medical care • A family of four making less than $36,625* qualifies for Medicaid • A family of four making $38,625* can use the Advance Premium Tax Credit (APTC) to pay most of their insurance premium for a silver [FN33] plan on HealthCare.gov and receive extra savings on cost-sharing when receiving medical care. Survey: Two in Five Adults Face Health Insurance Coverage Issues According to a recent survey, two out of every five adults in the United States do not have stable health insurance coverage. Over one-third of adults face issues with medical bills. The survey, conducted by the Commonwealth Fund, pointed to a potential crisis in the affordability of health care resulting from the COVID-19 economic downturn. Researchers found that 43 percent of adults lacked stable health insurance coverage during the first half of 2020. Reasons for unstable health insurance coverage included: • 12.5% lacked any health insurance • 9.5% experienced a coverage gap • 21% had insurance with high out-of-pocket costs or deductibles Researchers conducted the latest Biennial Health Insurance Survey between January and June 2020. They indicated that the survey “offers a big-picture look at Americans' health insurance, including the quality and extent of their coverage and whether or not they could afford health care.” According to Sara Collins, lead author of the study and Commonwealth Fund Vice President for Health Care Coverage and Access “The survey shows a persistent vulnerability among U.S. working-age adults in their ability to afford coverage and health care. That vulnerability could worsen if the COVID-19 pandemic and related economic downturn continue. Coverage inadequacy is compromising people's ability to get the care they need and leaving many with medical debt at a moment of widespread health and financial insecurity, and an uncertain future.” Researcher highlighted the following key findings: -People of color, small-business workers, people with low incomes, and young adults had the highest uninsured rates. ? More than one-third of Latino adults, small-business workers, and adults with low incomes were either uninsured or spent some time uninsured in the past year. -The growth in the underinsured since 2010 has been driven by employer health plans with inadequate coverage. ? One-quarter of adults with employer plans were underinsured. ? In 2010, only 7 percent of people in private plans, either employer or © 2021 Thomson Reuters. No claim to original U.S. Government Works. -24- individual market, had deductibles that amounted to 5 percent or more of income. This is a key indicator of underinsurance. By 2016, the share had doubled (15%). ? Between 2010 and 2020, the share of privately insured adults with deductibles of $1,000 or more doubled ? from 22 percent to 46 percent. -Many U.S. adults struggle to pay their medical bills, though people with inadequate coverage tend to have more problems. ? One-quarter of working-age adults with adequate coverage for the full year reported medical bill problems or debt in the past year. ? Half of adults who spent any time uninsured or underinsured reported problems paying medical bills or that they were paying off medical debt over time. ? Blacks were significantly more likely than whites to report problems with medical bills (45% vs. 35%). -Medical debt leaves people with lingering financial problems. Among adults who reported any medical bill or debt problem: ? thirty-seven percent said they had used up all their savings to pay their bills. ? forty percent had received a lower credit rating due to medical debt. ? one-quarter (26%) were unable to pay for necessities such as food, heat, or their rent. Researchers recommended several state and federal policy actions that could increase the rate of adequate health care coverage in the United States. The actions included expanding Medicaid in the remaining 12 states that have not chosen to expand eligibility for the program. They also recommended enhancing and extending the Affordable Care Act (ACA) subsidies for premiums and cost-sharing. Researchers suggested allowing people who cannot afford their employer-sponsored health insurance plans to buy subsidized coverage through the insurance marketplaces. The marketplaces should possibly offer a public plan. Additional recommended policies include increasing outreach and enrollment efforts to educate people about coverage options, especially for people who lose employer coverage in the COVID-19 economic downturn. Also, researchers supported banning short- term health insurance policies and other non-ACA-compliant plans that do not cover catastrophic health care costs. According to David Blumenthal, M.D., Commonwealth Fund President, “This survey examined Americans' health insurance as our country slid into the worst public health and economic crisis in generations. What we found is troubling. Even before the pandemic, people were struggling with inadequate health coverage and mounting medical debt. It has never been more important to ensure that all U.S. residents have affordable, comprehensive [FN34] coverage to survive this pandemic and beyond.” Study: Rural Areas Have Higher Prices, Less Choice for Health Insurance A recent study showed that rural areas in the United States have higher prices for health insurance plans and fewer options than other areas of the country. The University of Minnesota School of Public Health looked at the cost of individual health insurance plans and the variety of plans available by location across the United States. According to researchers, “The study highlights one of many areas of society experiencing health care financial pressure that will likely only increase during the COVID-19 pandemic.” Professor Jean Abraham led the study. It appeared in a special issue of the Russell Sage Foundation journal that highlighted the effects of the Affordable Care Act (ACA) at the tenth anniversary of the federal healthcare reform law. The law created health insurance marketplaces where consumers and small businesses can purchase health insurance plans. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -25- Researchers looked at changes in insurer marketplace participation and plan premiums from 2015 to 2019 to determine the vulnerability and volatility of local markets. These measures note the number of insurers offering plans in a particular area and the cost of those plans. Researchers classified rural areas as higher vulnerability in 2019 if only one insurer offered plans and the cost of a premium for a 50- year-old nonsmoker exceeded $769/month. High vulnerability urban areas had two or fewer insurers and premiums that cost more than $653 per month for a 50-year-old nonsmoker. Volatility measured the degree of change between 2015 and 2019. For example, an area was volatile if many insurers left an area or significantly increased the cost of health insurance premiums. High volatility areas had more than a 50% reduction in the number of insurers serving the area and premium cost increases of more than 79.2% for the target plan at the silver level for an average consumer. The following characteristics were associated with higher volatility and vulnerability of healthcare markets: • smaller in population and more rural; • have a higher percentage of non-white persons; • have lower average wages per worker; • have a higher percentage of the population reporting fair or poor health status; • and are more likely to be in states that chose not to expand Medicaid eligibility. “States continue to pursue actions to ensure or create stability within individual markets,” indicated Abraham. “One approach is to seek 1332 waivers through the ACA, which allow states to attract insurers by creating government programs that absorb some of the expense of high-cost enrollees. Other actions for increasing choice and affordability include offering a state-based public health insurance option and regulating short-term, limited-duration health plans to make sure that they offer reasonable value for consumers.” Researchers predicted that the COVID-19 pandemic will increase volatility in the individual health insurance market. Insurers will be making decisions about prices and plan offerings during the nationwide health emergency and the resulting uncertainty surrounding consumer enrollment and cost of care. “Unemployment will remain high and people are worried about getting COVID-19. There is a real risk of hospitalization and the costs that come with that care,” stated Abraham. “We have to keep monitoring the individual market because this type of coverage will be increasingly relied upon during the recession and insurers face considerably more uncertainty than normal with respect to who is [FN35] purchasing coverage and how much medical care they may consume, given the pandemic.” Cigna Increases Access to Care Cigna Corp, a global health service company, announced that it is increasing access to health coverage by offering more plans through the Affordable Care Act (ACA) marketplace individual health insurance exchange. The company indicated that the plans aim to increase access to quality health care and keep out-of-pocket costs affordable. The new offerings will be available to customers in almost 80 new counties beginning in 2021. The plans increase customer reach by over 50 percent. According to the company, “This growth will enable Cigna to make health care more affordable, predictable and simple for more people across the country.” 'Our first priority is to ensure that our customers have access to the care they need ? especially in this unprecedented time,' said Brian Evanko, president of Cigna's government business. ‘We have maintained a continuous and growing presence in the individual exchanges since their launch in 2014, and are excited by the opportunity to serve even more customers in 2021 and beyond.’ Due to the expansion, Cigna will offer individual and family plans through the ACA exchanges in 2021 to people in 220 counties and 10 states, including Arizona, Colorado, Florida, Illinois, Kansas, Missouri, North Carolina, Tennessee, Utah and Virginia. Cigna plans feature: • $0 virtual care that now includes behavioral health providers for most plans; • A new diabetes care plan** available in most counties that includes $0 benefits for diabetes equipment and additional supplies; • Coverage for holistic services including acupuncture in select counties; • Enhancements such as the Patient Assurance Program to cap insulin costs at $25 per month for a 30-day supply of covered eligible insulin; • Access to a customer loyalty program in most markets that rewards healthy lifestyle activities. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -26- The company will improve digital interactions to facilitate access to care and medications. The myCigna mobile app and Cigna One Guide will assist customers in choosing high quality and cost-effective healthcare providers, sites of care, and health tools. Cigna also developed a real time benefit check program that increases financial predictability for beneficiaries. It allows physicians to quicky assess the cost of treatment options during an appointment. 'Cigna remains deeply committed to providing affordable access to quality care ? when and where our customers want to use their benefits ? with offerings that encourage and support whole-person health,' said Lisa Lough, president of Cigna's Individual and Family Plans business. ‘Our plans on the individual exchange are designed with an understanding of our customers' needs and preferences for their health care, delivered in a collaborative relationship with physician partners across the country ? many of whom are in value-based care arrangements.’ The Open Enrollment Period (OEP) for health plans through the individual exchange begins Nov. 1 and continues through Dec. 15. [FN36] Health plans will begin on Jan. 1, 2021. Legislation to Protect Health Insurance Coverage for Unemployed Workers Introduced U.S. Senators Dick Durbin (D-IL) and Catherine Cortez Masto (D-NV) joined 13 Senate Democrats to introduce the Worker Health Coverage Protection Act. The legislation would protect millions of unemployed or furloughed workers from losing health insurance coverage by helping them keep coverage through subsidizing COBRA coverage. Under the bill, unemployed workers in nearly all employment-based health plans would receive a 100 percent subsidy to cover the cost of COBRA health insurance premiums to continue coverage during the COVID-19 pandemic. “Losing your health care coverage in this pandemic would be devastating. I know the pain of being a father with no health insurance when my child was very sick, and I don't want others to experience that. Tens of millions of Americans are at risk of losing their health insurance along with their jobs. Congress has to step up to assist them as we've done in the past. The bill I'm introducing today gives unemployed Americans peace of mind that they can maintain health care insurance through this public health crisis,” Durbin indicated. “Congress must ensure that Nevadans who have been laid-off or furloughed due to the coronavirus pandemic have access to comprehensive health coverage, whether it be through Nevada Health Link, Nevada Medicaid, or their employer,” said Cortez Masto. “That's why I'm proud to introduce this legislation to fully subsidize health insurance premium costs under COBRA for Nevadans who are facing furlough or unemployment through no fault of their own. My bill has the support of a broad coalition of workers, including the Culinary Worker's Union, health care providers, consumer groups and large employers. They know this policy best meets the needs of Nevadans impacted by COVID-19 so they can continue to access quality, affordable health insurance.” Approximately 57 million Americans have filed for unemployment benefits since the middle of March. Approximately 10 to 15 million of those people have lost employer-sponsored health insurance coverage. In Illinois alone, over 650,000 residents claimed unemployment benefits. Many of those people went without health insurance coverage during the pandemic due to the cost of coverage. Unemployed workers often prefer to remain covered through their employer health plan. COBRA coverage allows the continuation of coverage, but it is often prohibitively expensive. The average cost of COBRA coverage for a family is $1,700 per month. U.S. Senators Sherrod Brown (D-OH), Jeanne Shaheen (D-NH), Dianne Feinstein (D-CA), Michael Bennet (D-CO), Jack Reed (D- RI), Amy Klobuchar (D-MN), Tina Smith (D-MN), Jeff Merkley (D-OR), Richard Blumenthal (D-CT), Tammy Duckworth (D-IL), Debbie Stabenow (D-MI), Jacky Rosen (D-NV), and Bob Menendez (D-NJ). Joined in supporting Durbin and Cortez Masto in introducing the bill. The following organizations have also endorsed the Worker Health Coverage Protection Act: AFL-CIO, UNITE HERE, UNITE HERE Local 1, National Coordinating Committee for Multiemployer Plans, Families USA, American Hospital Association, and Alliance to Fight for Health Care, Actors' Equity Association, Air Line Pilots Association, International (ALPA), Alliance for Retired Americans (ARA), American Federation of State, County and Municipal Employees (AFSCME), American Federation of Teachers (AFT), Communications Workers of America (CWA), Guild of Italian American Actors (GIAA), International Alliance of Theatrical Stage Employees (IATSE), International Association of Sheet Metal, Air, Rail and Transportation Workers (SMART). International Brotherhood of Boilermakers, Iron Ship Builders, Blacksmiths, Forgers and Helpers (IBB), International Brotherhood of Teamsters (IBT), International Union, United Automobile, Aerospace and Agricultural Implement Workers of America (UAW), United Steel, Paper and Forestry, Rubber, Manufacturing, Energy, Allied Industrial & Service Workers International Union (USW). “In the middle of a national health crisis, 12 million working people have lost our job-based coverage due to loss of work, leaving millions in a financial bind if someone in their family needs care. We thank Senators Durbin and Cortez Masto for introducing crucial © 2021 Thomson Reuters. No claim to original U.S. Government Works. -27- legislation to support workers' coverage, an essential element of the federal response needed for this emergency,” said Richard Trumka, President of the AFL-CIO. Under the Worker Health Coverage Protection Act, workers would be able to access subsidized COBRA coverage for nearly all employment-based health plans when they are involuntarily terminated. Coverage would include private sector plans covered by the Employee Retirement Income Security Act (ERISA), multiemployer plans, state and local government plans, and the Federal Health Benefits Program. The bill would provide a 100 percent subsidy of COBRA health insurance premiums owed by unemployed workers allowing for continuous coverage during the COVID-19 global pandemic. Furloughed workers who are still receiving employer-sponsored health benefits would receive 100 percent subsidies for the cost of health benefits for the period that their pay is suspended. The subsidies would not factor into eligibility for unemployment benefits or other types of government assistance. The pending legislation would also extend the period during which workers can receive COBRA coverage and would allow workers who [FN37] initially declined COBRA coverage to obtain it with the subsidy. Insurance Costs Increase for Employer-Sponsored Plans The Kaiser Family Foundation reported that the annual family premiums for employer-sponsored health insurance plans increased 4% this year to an average cost of $21,342 per year. Data came from the 2020 benchmark KFF Employer Health Benefits Survey. Employers cover most of this cost with workers contributing an average of $5,588 toward the cost of family coverage. According to researchers, the survey captures data from January to July and may not include the full impact of the COVID-19 pandemic and economic crisis. Increases in workers' earnings at 3.4% and inflation at 2.1% were similar to the increase in the cost of premiums. Over time, the cost of premiums continues to increase more rapidly than wages and inflation. The average cost of family premiums has increased 55% since 2010, which is twice as fast, or more than wages and inflation have increased at 27% and 19%. The rate of covered workers with a deductible in their plan remained similar to the rate last year at 83%. Ten years ago, about 70% of covered workers paid a deductible. The average deductible is $1,644, close to the average deductible last year of $1,655. Ten years ago the average deductible was $917. The trends increase the burden of deductibles for covered employees by 111%. “Conducted partly before the pandemic, our survey shows the burden of health costs on workers remains high, though not getting dramatically worse,” KFF President and CEO Drew Altman said. “Things may look different moving forward as employers grapple with the economic and health upheaval sparked by the pandemic.” Approximately 157 million Americans receive employer-sponsored health insurance coverage. Researchers surveyed almost 1,800 small and large employers to determine trends for employee insurance. Employers largely made decisions about premiums and deductibles prior to the full impact of the COVID-19 pandemic and resulting economic crisis. Researchers indicated that the survey next year will have a fuller picture of the impact of the pandemic on employer-sponsored insurance. Researchers also charted the data trends by firm size, industry, and other firm characteristics. Data showed that 83% of employers offering coverage were satisfied with the overall choice of providers the insurance plans included. Fewer employers, 67%, indicated they were satisfied with the range of mental health and substance abuse networks. Approximately 19% of the employers indicated that their mental health networks were somewhat or very narrow. Researchers expressed concern that workers would have limited options for mental health care during the pandemic and subsequent increases in stress and anxiety. “The coronavirus pandemic has increased the need for access to mental and behavioral health services, for which the provider networks are often more narrow than for other services,” said Gary Claxton, a KFF senior vice president and director of the Health Care Marketplace Project, the lead author of the study and Health Affairs article. “Some plans have been able to increase access by supporting telehealth, though it's unclear whether such options will become a permanent feature.” Researchers also found the following: -Offer rates remained steady. 56% of employers offered health insurance coverage, mostly unchanged over the past five years. Larger employers were more likely to offer health insurance coverage to some or all employees. Approximately 53% of employers with fewer than 50 employees and almost all employers (99%) with at least 200 employees offered health insurance benefits. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -28- -Out of pocket maximums. Almost all employees with health insurance benefits had plans that limited in-network cost sharing, also known as out-of-pocket maximums for single coverage. The limits varied from less than $2,000 for 11% of covered workers to at least $6,000 for 18% of covered workers. -Wellness programs. 81% of large employers offered at least one type of wellness or health promotion program. Only 11% of those employers viewed the programs as very effective at reducing costs. Researchers collected data for the employer survey between January and July of 2020. Approximately half of the interviews were conducted prior to the effect of the full extent of the coronavirus pandemic on employers. Researchers selected 1,765 non-federal public and private firms with three or more employees that answered all the questions in the [FN38] survey. 1,817 additional employers responded to a single question regarding offering coverage. Study: Eliminating Surprise Billing Could Significantly Reduce Premiums A recent study showed that eliminating surprise billing could significantly reduce the cost of health insurance premiums. Researchers looked at data to determine the proportion of health plan spending on services that commonly include surprise billing. Data came from radiologists, anesthesiologists, pathologists, emergency physicians, emergency ground ambulances, and emergency outpatient facilities. Researchers then estimated the potential impact of addressing surprise billing on the cost of health insurance premiums. The study included an analysis of 2017 commercial claims data from the Health Care Cost Institute. Researchers considered 568.5 million claims for 44.8 million covered beneficiaries from 3 large United States health insurance companies. The companies were UnitedHealthcare, Aetna, and Humana. Researchers calculated the share of total health plan claims spending for ancillary and emergency services. They estimated the impact on the cost of premiums of proposed federal policies to address surprise billing. The policies are aimed at reducing out-of-network payments for surprise billing services. The study contemplated reducing payments for surprise billing by either 15% of current charges or to 150% of traditional payment rates for Medicare services. Researchers found that over 10% of health care spending is due to surprise billing for ancillary and emergency services. By reducing surprise billing payments 15%, premiums would cost 1.6% less per year. By reducing the payments to 150% of the rate of traditional Medicare payments for those services, premiums would cost 5.1% less. Savings for the nation's entire commercially insured population would range from $12 billion to $38 billion per year. Researchers indicated, “Proposed surprise-billing legislation would not only protect patients from unexpected out-of-pocket expenses, but also likely affect negotiated payments for the ancillary and emergency services that generate most surprise bills.” Surprise medical bills usually occur in emergencies or when patients receive care at in-network facilities from out-of-network health care providers. Public and policy attention has been turned to these surprise billing practices in recent years. The general focus of attention on surprise billing policies has been the individual effect on patients receiving the potentially large, unexpected bills. The researchers took the concern a step further to address the overall effect of surprise billing on health insurance premiums throughout the US. According to researchers, evidence suggests that the ability to surprise bill is used as leverage by providers to increase in-network payments. The CEO of TeamHealth, a large emergency physician staffing company acknowledged in a letter to Congress that “balance billing—is a contract leveraging tool.” The increased in-network payments increase the cost to consumers of health insurance plans as well as taxpayers in the form of increased health insurance premiums. Researchers noted, “Therefore, although the surprise bills themselves are burdensome to individual patients, the higher in-network [FN39] payments resulting from this leverage have a broader impact on total health care spending for consumers.” Premiums on Federal Exchange Decrease The Centers for Medicare & Medicaid Services (CMS) released a report showing that the average premium costs for health insurance plans available through healthcare.gov decreased by 2% for 2021 plans. This decrease continues the trend of lower premiums and increased participation in the Affordable Care Act federal health insurance exchange. The metrics are based on the cost of silver plan, which is the benchmark plan for the exchange. It is the mid-priced plan category. CMS announced that 22 more issuers will offer coverage for 2021. A total of 181 insurance companies will offer health insurance plans through the federal exchange. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -29- CMS attributed the change to improving market conditions and new policies of the Trump administration. The decrease represents the third year that the cost of the average benchmark plan premiums decreased, leading to a combined 8% premium reduction across healthcare.gov since 2018. In 2021, four states will have double-digit decreases for the cost of the average benchmark plan for 27-year-old beneficiaries: Iowa, Maine, New Hampshire and Wyoming. Two states, Maine and New Hampshire, received State Innovation Waivers under Section 1332 of the Patient Protection and Affordable Care Act to institute state-based reinsurance programs, leading to the decreases in cost of premiums. Reinsurance programs allow states to use federal money to cover the cost of the most expensive health insurance consumers for the private insurance companies that participate in the ACA exchanges. The increase in the number of insurance companies participating in the exchange represents a continuation of a trend, leading to more choice for consumers. The percentage of healthcare.gov enrollees with access to only one provider decreased from 28% in 2018 to 4% in 2021. Over seventy-five percent of enrollees in healthcare.gov plans have access to at least three issuers in 2021. CMS released the 2021 Issuer Participation County Map for states with Exchanges that use HealthCare.gov to highlight the geographic distribution of this change. CMS also released data on state-based exchanges with increased insurance company participation. The portion of counties served by a single insurance company decreased from 50% in 2018 to 24% in 2020. In 2021, it will drop to 9%. In 2021, 288 counties will remain served by a single insurance company offering plans through the federal exchange. This number represents an 80% decrease from the 1,582 counties with only single health insurance issuers offering plans through healthcare.gov in 2018. CMS credited the administration's efforts for working to stabilize the health insurance market. However, the agency also pointed out that the average cost of premiums is still significantly higher than when the ACA was first implemented a decade ago. CMS noted that “affordability remains a significant challenge for people who do not qualify for a premium tax credit and must pay the entire premium themselves. The average benchmark plan premium for a typical family of four has increased from $794 in 2014 - the first year the ACA's main requirements were introduced - to $1,486 in 2021. As premiums increase, a recent report by CMS on enrollment among people with and without subsidies documents how unsubsidized enrollment continues to decline, suggesting middle income Americans continue to struggle to afford coverage.” The open enrollment period for plans available through healthcare.gov will begin on November 1, 2020 and run through December 15, 2020. Coverage for those plans will begin on January 1, 2021. Consumers should be aware that healthcare.gov will be unavailable during scheduled maintenance windows for the upcoming Open Enrollment Period. CMS schedules these maintenance windows to provide time to make updates and resolve issues with the website to keep enrollment available with a minimum of disruption. [FN40] Scheduled maintenance is set for Sunday mornings, which is historically the lowest-traffic period of the week for healthcare.gov. Competition Decreased in Markets where Health Insurance is Scarce The American Medical Association released an annual analysis of competition and choice in health insurance markets showing decreases in markets where health insurance is the scarcest. Researchers found, “Competition and choice continue to fade away for many patients as most highly concentrated markets for commercial health insurance have grown even more concentrated than they were five years ago.” From 2014 to 2019, the share of health insurance markets with high levels of concentration increased to 74% from 71%. Also, over half of the markets with high concentration in 2014 grew increasingly concentrated by 2019. “For many of the 70 million Americans who live in highly concentrated health insurance markets, a lack of competition is a problem that keeps getting worse as consumers have more limited health insurance options to choose,” said AMA President Susan R. Bailey, M.D. “The AMA strongly encourages a dialogue among regulators, policymakers, lawmakers, and others about the need for a better, more open and competitive marketplace to benefit patients and the physicians who care for them.” The 2020 edition of Competition in Health Insurance: A Comprehensive Study of U.S. Markets used data of market concentration in 384 metropolitan statistical areas (MSAa), the 50 states and the District of Columbia using the Herfindahl-Hirschman Index (HHI). Markets with an HHI over 2500 points are considered highly concentrated under federal guidelines. High market concentration leads to decreased competitive constraints. A decrease in competition results in higher premium costs for consumers. Researchers pointed to the commercial health insurance for Elizabethtown-Fort Knox, Ky. As an example of a highly concentrated market that has seen even more concentration during the last five years. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -30- In 2014, the MSA-level market scored an HHI of 3534. This score exceeded the federal threshold by over 1000 points. Five years later, the HHI score of this area had increased by 1625 points to 5159. The significant increase represents a large increase in market share of the dominant health insurer in Elizabethtown-Fort Knox. Anthem had a 45% market share in 2014. By 2019, Anthem's market share had increased to 70%. According to researchers, “High market shares and high concentration levels are concerning because they increase the risk of exercising market power, such as squeezing out competitors, raising prices, reducing output or diminishing innovation without fear of losing business to rival health insurers.” Researchers found similar conditions to the market concentration in Elizabethtown-Fort Knox in most of the MSAs they examined. The average HHI of an MSA-level market was 3473. This score exceeds the federal threshold for a highly concentrated market by almost 1000 points. On net between 2014 and 2019, market concentration levels increased by 151 points. Fifty-six percent of markets showed an increase in the HHI. Seventeen percent of markets showed increased by at least 500 points. The average increase for markets with a rise in HHI was 481 points. This data points to the prevalence of markets served by a single insurer with a market share of 30% or greater. 92% of MSA-level markets were in this situation. 48% of MSA-level markets had a single insurer taking a market share of 50% or more. Researchers noted, “The prospect of future consolidation in the health insurance industry should be viewed in the context of the low levels of competition in most health insurance markets. For nearly 20 years, the AMA study has been a helpful resource to researchers, lawmakers, policymakers, and regulators as they work to identify markets where future consolidation among health insurers may cause competitive harm to patients.” Researchers found that the 10 states with the least competitive commercial health insurance markets were: 1. Alabama, 2. Hawaii, 3. [FN41] Michigan, 4. Delaware, 5. South Carolina, 6. Kentucky, 7. Alaska, 8. Louisiana, 9. Illinois, 10. North Carolina. Open Enrollment Begins in NY and Across the US Open enrollment for individual health insurance plans available through the Affordable Care Act exchanges began November 1 in New York and across the United States. Governor Andrew M. Cuomo announced the launch of open enrollment for NY State of Health, the state's official health plan marketplace. Enrollment began for 2021 Qualified Health Plans. 'New York has done more than any state to expand access to healthcare and make high-quality insurance available to everyone,' Governor Cuomo said. ‘And as we continue to fight COVID-19, making sure every New Yorker is insured and has access to quality healthcare has only become more critical. If you are not insured, make 2021 the year you change that, go online or call NY State of Health for assistance.’ The state health insurance agency indicated that access to health insurance is particularly important this year as New York residents continue to confront the global COVID-19 pandemic. The agency encouraged all current enrollees in a Qualified Health Plan through NYSOH to renew coverage. It also encouraged New York residents without health insurance coverage to visit the exchange website to enroll in a plan. Open enrollment in New York will continue through January 31, 2021. New York residents enrolled in Medicaid, Child Health Plus, or the Essential Plan will receive automatic renewal of coverage due to the ongoing COVID-19 public health emergency. NY State of Health, along with the State Department of Financial Services and New York State insurers implemented a Special Enrollment Period in February 2020 due to COVID-19. It has been extended to encourage people to obtain COVID-19 testing and treatment. According to Commissioner of the New York State Department of Health Dr. Howard Zucker, ‘NY State of Health continues to serve as a safety net for consumers in need of coverage during the public health emergency and has seen enrollment levels increase to over 5.5 million people. As we look ahead to 2021, the plan choices are consistent with 2020 and we will continue to be available to help consumers enroll through both the Customer Service Center and enrollment assistors, who will be available by phone.’ New York legislators codified consumer health insurance protections from the Affordable Care Act into state law with the passage of the FY 2020 Enacted State Budget. These protections include: -the ban on preexisting condition exclusions -the prohibition on annual and lifetime dollar limits -the guarantee of quality essential health benefits -the ability to keep children on their parents' plans through age 26. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -31- NY State of Health predicted that almost 200,000 households would renew Qualified Health Plan coverage in addition to new consumers during the open enrollment period. Current enrollees, including people who signed up during the special enrollment period, have been receiving 2021 renewal notices. They may begin renewing coverage on November 16, 2020. The notices include information about the cost of premiums, the amount of tax credits, and directions on selecting plans. Renewal customers should update accounts with changes in income, address, or family size. Most NY consumers will have a choice of at least four plans in every county for coverage beginning in 2021. The agency encouraged consumers to plan for open enrollment by browsing health insurance options through the exchange. Free enrollment assistance is available in communities throughout New York. The NYS Provider & Health Plan Look-Up Tool is available for researching provider networks and health plans. The tool is aimed at helping consumers find plans that include their preferred health care providers, including physicians and hospitals. [FN42] Enrollment in the Essential Plan, Medicaid and Child Health Plus is available year-round in New York. White House Releases Plan to Distribute COVID-19 Vaccine The Centers for Medicare & Medicaid Services (CMS) released information about the White House plan to give all Americans access to the COVID-19 vaccine at no cost when it becomes available. CMS released a comprehensive plan aimed at removing barriers to a widespread distribution of the vaccine. The agency indicated that it was working toward a goal of ensuring consistent coverage and payment for the administration of the vaccine. Providers, states, and insurers received a set of toolkits to facilitate the swift administration of the eventual vaccine. The plan was designed to increase the number of providers administering the vaccine while ensuring that providers receive adequate reimbursement from the federal government for Medicare beneficiaries. Private insurance companies and Medicaid programs will have to cover the cost of the vaccine at no charge to beneficiaries. CMS is also looking into increasing reimbursement for new COVID-19 treatments that receive FDA approval. “Under President Trump's leadership, we have developed a comprehensive plan to support the swift and successful distribution of a safe and effective vaccine for COVID-19,” said CMS Administrator Seema Verma. “As Operation Warp Speed nears its goal of delivering the vaccine in record time, CMS is acting now to remove bureaucratic barriers while ensuring that states, providers and health plans have the information and direction they need to ensure broad vaccine access and coverage for all Americans.” CMS released an Interim Final Rule with Comment Period (IFC) indicating that any FDA approved vaccine, either through an Emergency Use Authorization (EUA) or licensed under a Biologics License Application (BLA) will be covered through Medicare at no cost to beneficiaries. Under the IFC, most private health insurance plans will have to cover the cost of the COVID-19 vaccine from both in and out-of-network providers throughout the public health emergency (PHE). CMS, along with the Departments of Labor and the Treasury, will require most private health plans and issuers to cover a recommended COVID-10 vaccine and the administration of that vaccine with no cost sharing. The rule also regulates out-of-network providers, preventing them from unreasonably low rates when administering an eventual COVID-19 vaccine. CMS referenced CMS reimbursement rates as a guideline for private health insurance companies. The IFC also regulates the access of Medicare patients to new COVID-19 treatments. It establishes additional Medicare hospital payment to support these therapies for Medicare beneficiaries. Hospitals will be able to qualify for additional “outlier payments” for the inpatient treatment of COVID-19 patients if the costs exceed the fixed reimbursement amount typical for inpatient stays. CMS established a certain threshold for these additional payments. Hospitals will qualify for the additional payments if they attempt new treatments approved or authorized to treat COVID-19 as a mitigation for losses they might experience by making these treatments available. These additional payments would not be subject to the outlier payment thresholds. The IFC also addresses reimbursement rates for outpatient hospital services for COVID-19 treatment of Medicare patients. Certain innovative treatments for COVID-19 will not be subject to bundled payment arrangements. Providers will receive separate payments for these treatments. The IFC contemplates payment to hospitals for the outpatient administration of a potential monoclonal antibody product in the event [FN43] one is approved under an emergency use authorization (EUA). © 2021 Thomson Reuters. No claim to original U.S. Government Works. -32- © Copyright Thomson/West - NETSCAN's Health Policy Tracking Service [FN2] Press release, “Utah to Implement Full Medicaid Expansion,” Utah Department of Health, December 23, 2019, available at https:// health.utah.gov/featured-news/utah-to-implement-full-medicaid-expansion. [FN3] Bebinger, Martha, “Fewer Penalties Tied To Health Insurance Mandate In Mass., But Higher Fines,” WBUR, December 31, 2019, available at https://www.wbur.org/commonhealth/2019/12/31/health-insurance-mandate-penalties. [FN4] Thistle, Scott, “Health care, corrections, broadband at top of state legislative agenda,” Press Herald, January 5, 2020, available at https://www.pressherald.com/2020/01/05/health-care-corrections-broadband-at-top-of-state-legislative-agenda/. [FN5] Gorenstein, Dan, and Leslie Walker, “Reduce Health Costs By Nurturing The Sickest? A Much-Touted Idea Disappoints,” NPR, January 8, 2020, available at https://www.npr.org/sections/health-shots/2020/01/08/794063152/reduce-health-costs-by-nurturing-the-sickest-a- much-touted-idea-disappoints. [FN6] Snoderly, JoAnn, “Manchin, Morrisey continue dispute over Affordable Care Act lawsuit, WV health care legislation,” WVNews, January 15, 2020, available at https://www.wvnews.com/news/wvnews/manchin-morrisey-continue-dispute-over-affordable-care-act-lawsuit-wv/ article_55341fe1-cd08-5b34-b08d-3ab0434c5b6a.html. [FN7] Simmons-Duffin, Selena, “Trump Administration Clears The Way For Medicaid Block Grants,” Shots Health News from NPR, January 30, 2020, available at https://www.npr.org/sections/health-shots/2020/01/30/800841612/trump-administration-offers-states-a-way-to- block-grant-medicaid?utm_source=twitter.com&utm_campaign=npr&utm_term=nprnews&utm_medium=social. [FN8] Daley, John, “Expensive Health Care? Blame The Hospitals, State Report Says,” CPR News, January 23, 2020, available at https:// www.cpr.org/2020/01/23/expensive-health-care-blame-the-hospitals-state-report-says/. [FN9] Press release, “Middle-aged adults worried about health insurance costs now, uncertain for future,” EurekAlert, February 7, 2020, available at https://www.eurekalert.org/pub_releases/2020-02/mm-u-maw020520.php. [FN10] Press release, “HCCI releases 2018 Health Care Cost and Utilization Report,” Health Care Cost Institute, February 13, 2020, available at https://healthcostinstitute.org/in-the-news/2020-02-13-15-48-00. [FN11] “Oregon House OKs health care affordability, accessibility bills,” KTZV, February 21, 2020, available at https://ktvz.com/news/oregon- northwest/2020/02/21/oregon-house-oks-health-care-affordability-accessibility-bills/. [FN12] Associated press, “Georgia Bill Aims For Transparency In Health Care Pricing,” WABE, February 25, 2020, available at https:// www.wabe.org/georgia-bill-aims-for-transparency-in-health-care-pricing/. [FN13] Lisinski, Chris, “Mass. Senate Passes Bill To Boost Mental Health Care Access,” WGBH, February 14, 2020, available at https:// www.wgbh.org/news/local-news/2020/02/14/mass-senate-passes-bill-to-boost-mental-health-care-access. [FN14] Keith, Katie, “Senate Passes COVID-19 Package #3: The Coverage Provisions,” Health Affairs, March 26, 2020, available at https:// www.healthaffairs.org/do/10.1377/hblog20200326.765600/full/. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -33- [FN15] Rodriquez, Carmen Heredia, “9 States Reopen ACA Insurance Enrollment To Broaden Health Coverage,” NPR: Shots, March 20, 2020, available at https://www.npr.org/sections/health-shots/2020/03/20/818981380/9-states-reopen-aca-insurance-enrollment-to- broaden-health-coverage. [FN16] Levitt, Larry, Karyn Schwartz, and Eric Lopez, “Estimated Cost of Treating the Uninsured Hospitalized with COVID-19,” KFF, April 7, 2020, available at https://www.kff.org/uninsured/issue-brief/estimated-cost-of-treating-the-uninsured-hospitalized-with-covid-19/. [FN17] Blue Cross Blue Shield Association, “Local Blue Cross and Blue Shield Companies Waive Cost-Sharing for COVID-19 Treatment,” Blue Cross Blue Shield, April 2, 2020, available at https://www.bcbs.com/press-releases/local-blue-cross-and-blue-shield-companies-waive- cost-sharing-covid-19-treatment. [FN18] Azar, Alex M. II, “Remarks to Press on the Announcement of Additional Allocations of CARES Act Provider Relief Fund,” U.S. Department of Health & Human Services, April 22, 2020, available at https://www.hhs.gov/about/leadership/secretary/speeches/2020- speeches/remarks-press-announcement-additional-allocations-cares-act-provider-relief-fund.html. [FN19] Miller, Andrea, “Michigan's Health Insurers Agree to Provide Coronavirus Treatment at No Cost to Patients,” Michigan's Health Insurers Agree to Provide Coronavirus Treatment at No Cost to Patients, April 10, 2020, available at https://www.michigan.gov/ difs/0,5269,7-303-13222_13250-525327--,00.html. [FN20] “Covered California Enrolls Tens of Thousands as Impacts of COVID-19 Pandemic Hits California Households,” Covered California Newsroom, April 14, 2020, available at https://www.coveredca.com/newsroom/news-releases/2020/04/14/covered-california-enrolls- tens-of-thousands-as-impacts-of-covid-19-pandemic-hits-california-households/. [FN21] Press release, “American Hospitals and Health Systems, Businesses, Health Insurance Providers Unite to Ask Congress to Keep America Covered,” U.S. Chamber of Commerce, April 28, 2020, available at https://www.uschamber.com/press-release/american- hospitals-and-health-systems-businesses-health-insurance-providers-unite-ask. [FN22] Witters, Dan, “In U.S., 14% With Likely COVID-19 to Avoid Care Due to Cost,” Well-Being, April 28, 2020, available at https:// news.gallup.com/poll/309224/avoid-care-likely-covid-due-cost.aspx?mod=article_inline. [FN23] Press release, “Gov. Wolf: Federal Funding Available for COVID-19 Testing and Treatment for Uninsured Patients,” Governor Tom Wolf Newsroom, May 18, 2020, available at https://www.governor.pa.gov/newsroom/gov-wolf-federal-funding-available-for-covid-19- testing-and-treatment-for-uninsured-patients/. [FN24] Frederiksen, Brittni, “At-Home SARS-CoV-2 Diagnostic Tests Could be a Breakthrough, But What Are the Limitations?,” KFF, May 8, 2020, available at https://www.kff.org/coronavirus-policy-watch/at-home-sars-cov-2-diagnostic-tests-could-be-a-breakthrough-but-what- are-the-limitations/. [FN25] Miller, Andy, “Pandemic Pushing Medicaid Numbers Higher As Many Lose Work,” WABE, May 8, 2020, available at https:// www.wabe.org/pandemic-pushing-medicaid-numbers-higher-as-many-lose-work/. [FN26] Melillo, Gianna, “Trump Administration, Republican Attorneys General Ask Supreme Court to Repeal ACA,” AJMC, June 25, 2020, available at https://www.ajmc.com/newsroom/republican-attorneys-general-file-briefs-to-repeal-aca. [FN27] © 2021 Thomson Reuters. No claim to original U.S. Government Works. -34- Press release, “Congressman Steven Horsford Unveils Patient Protection & Affordable Care Enhancement Act,” June 25, 2020, available at https://horsford.house.gov/media/press-releases/congressman-steven-horsford-unveils-patient-protection-affordable-care. [FN28] Waddill, Kelsey, “OK Becomes First State to Adopt Medicaid Expansion During COVID-19.” Healthpayer Intelligence, July 1, 2020, available at https://healthpayerintelligence.com/news/ok-becomes-first-state-to-adopt-medicaid-expansion-during-covid-19. [FN29] Press release, “Cassidy, Smith, Sullivan, Jones Introduce ?Enhancing Preparedness Through Telehealth Act',” Tina Smith United States Senator for Minnesota Newsroom, available at https://www.smith.senate.gov/cassidy-smith-sullivan-jones-introduce-enhancing- preparedness-through-telehealth-act. [FN30] News release, “Statement on the House Passage of the “Patient Protection and Affordable Care Enhancement Act”” UNIDOS US Stronger Communities Stronger America Newsroom, June 29, 2020, available at https://www.unidosus.org/about-us/ media/press/releases/062920-UnidosUS-Press-Release-Care-Enhancement-Act; Press release, “THOMPSON VOTES TO PASS PATIENT PROTECTION AND AFFORDABLE CARE ENHANCEMENT ACT BILL EXPANDS ACA, PROTECTS PATIENTS WITH PRE-EXISTING CONDITIONS,” Mike Thompson U.S. Congress Newsroom, July 2, 2020, available at https:// www.mikethompsonforcongress.com/news/thompson-votes-pass-patient-protection-and-affordable-care-enhancement-act-bill-expands- aca. [FN31] Press release, “Attorney General Ellison sues Trump Administration to block health care discrimination,” The Office of Minnesota Attorney General Keith Ellison, July 20, 2020, available at https://www.ag.state.mn.us/Office/ Communications/2020/07/20_HealthCareDiscrimination.asp. [FN32] Banthin J., Simpson M., Buettgens M., Blumberg J.J., and Wang R., “Changes in Health Insurance Coverage Due to the COVID-19 Recession: Preliminary Estimates Using Microsimulation,” Robert Wood Johnson Foundation, July 13, 2020, available at https:// www.rwjf.org/en/library/research/2020/07/changes-in-health-insurance-coverage-due-to-the-covid-19-recession--preliminary-estimates- using-microsimulation.html. [FN33] Atkins, Karen, “KRFDC Helping Individuals and Families Obtain Health Insurance.” Kentucky River Foothills Development Council, Inc., July 20, 2020, available at https://foothillscap.org/2020/07/krfdc-helping-individuals-and-families-obtain-health-insurance/. [FN34] Press release, “NEW SURVEY: Two of Five Working-Age Adults Do Not Have Stable Health Coverage; More Than One-Third Have Medical Bill Problems,” The Commonwealth Fund, August 19, 2020, available at https://www.commonwealthfund.org/sites/default/ files/2020-08/Collins_biennial_2020_PR_v2.pdf. [FN35] “Research Brief: Rural areas have higher individual health insurance premiums and fewer plan choices,” University of Minnesota, August 5, 2020, available at https://twin-cities.umn.edu/news-events/research-brief-rural-areas-have-higher-individual-health-insurance- premiums-and-fewer. [FN36] Press release, “CIGNA EXPANDS OFFERINGS FOR INDIVIDUALS - INCREASING ACCESS TO QUALITY CARE IN MORE COMMUNITIES ACROSS THE COUNTRY,” Cigna Newsroom, September 10, 2020, available at https://www.cigna.com/newsroom/ news-releases/2020/cigna-expands-offerings-for-individuals-increasing-access-to-quality-care-in-more-communities-across-the-country. [FN37] Press release, “Durbin, Cortez Masto, Senate Dems Introduce Bill To Protected Unemployed Workers' Health Insurance During Pandemic,” Dick Durbin Newsroom, September 24, 2020, available at https://www.durbin.senate.gov/newsroom/press-releases/durbin- cortez-masto-senate-dems-introduce-bill-to-protected-unemployed-workers-health-insurance-during-pandemic. [FN38] © 2021 Thomson Reuters. No claim to original U.S. Government Works. -35- Press release, “Average Family Premiums Rose 4% to $21,342 in 2020, Benchmark KFF Employer Health Benefit Survey Finds,” KFF, October 8, 2020, available at https://www.kff.org/health-costs/press-release/average-family-premiums-rose-4-to-21342-in-2020- benchmark-kff-employer-health-benefit-survey-finds/. [FN39] Erin L. Duffy, PhD, MPH , Bich Ly, BA , Loren Adler, MS , Erin Trish, PhD, “Policies to Address Surprise Billing Can Affect Health Insurance Premiums,” AJMC, September 11, 2020, available at https://www.ajmc.com/view/policies-to-address-surprise-billing-can- affect-health-insurance-premiums. [FN40] Press release, “Premiums for HealthCare.gov Plans Are Lower for Third Consecutive Year,” CMS Newsroom, October 19, 2020, available at https://www.cms.gov/newsroom/press-releases/premiums-healthcaregov-plans-are-lower-third-consecutive-year. [FN41] Press release, “Competition shrank in majority of health insurance markets where it is scarcest,” AMA, October 14, 2020, available at https://www.ama-assn.org/press-center/press-releases/competition-shrank-majority-health-insurance-markets-where-it-scarcest. [FN42] Press release, “Governor Cuomo Announces Start of NY State of Health 2021 Open Enrollment Period,” October 29, 2020, available at https://www.governor.ny.gov/news/governor-cuomo-announces-start-ny-state-health-2021-open-enrollment-period. [FN43] Press release, “Trump Administration Acts to Ensure Coverage of Life-Saving COVID-19 Vaccines & Therapeutics,” CMS Newsroom, October 28, 2020, available at https://www.cms.gov/newsroom/press-releases/trump-administration-acts-ensure-coverage-life-saving- covid-19-vaccines-therapeutics. Produced by Thomson Reuters Accelus Regulatory Intelligence 14-Mar-2021 © 2021 Thomson Reuters. No claim to original U.S. Government Works. -36-