Wednesday, August 31, 2022

Democrats have twelve years of healthcare accomplishment to run on

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Chuck Schumer tours Adirondack Medical Center

HuffPost reports that Priorities USA is urging Democrats to tout recent healthcare achievements:

In a memo set to be published Wednesday, Priorities USA says the most popular achievements of President Joe Biden’s tenure are giving Medicare the power to negotiate prescription drug pricescapping the price of insulin and continuing expanded subsidies for the Affordable Care Act.

Priorities USA recommends focusing on these issues while also attacking Republicans for working to restrict abortion rights in the wake of the Supreme Court decision overturning Roe v. Wade.

Amen. And below those top lines -- the healthcare provisions in the Inflation Reduction Act passed this month -- Democrats should also tout a long tail of recent accomplishments that have improved healthcare affordability and access. Their claim to be the party of healthcare bears not only recent but cumulative weight.

Healthcare was a potent issue for Democrats in 2018, with Republicans fresh off their failed attempt to repeal the ACA's core programs in 2017.  Because they failed, the ACA Medicaid expansion and subsidized marketplace survived to catch the newly uninsured when more than 20 million Americans lost their jobs in the first onslaught of the COVID-19 pandemic. 

Democrats moved swiftly to shore up that ragged but intact safety net, imposing a moratorium on Medicaid disenrollments in March 2020 via the Families First Act in March 2020 and massively increasing premium subsidies in the ACA marketplace in the American Rescue Plan Act (ARPA) in March 2021.  As a result -- and thanks also to pandemic relief that enabled a swift rebound in the job market -- the uninsured rate held steady during the worst of the pandemic and hit an all-time low of 8% in early 2022.

Thanks to Democratic initiatives in the pandemic era:

  • Medicaid enrollment increased by 18 million (28%) from February 2020 to May 2022. In the adult group rendered eligible specifically by ACA criteria (income under 138% FPL), enrollment rose by 5.2 million (33%), from 15.5 million to 20.7 million, from March 2020 to July 2021.

  • ACA marketplace enrollment increased by more than 3 million (27%) from the end of Open Enrollment for 2020 to the end of OE for 2022 (by 21% in 2022 alone, the first full year in which the ARPA subsidy boosts were in effect). In the 12 states that have refused to enact the ACA Medicaid expansion, marketplace enrollment is up 45% in those two years.

  • Taking advantage of an ARPA provision, states are opting to provide 12 months of postpartum coverage to women enrolled in Medicaid during pregnancy (the previous norm was 2 months). To date, 24 states have implemented the 12-month extension, and another 10 states are planning to.
Also during the pandemic era, Democrats joined with Republicans in December 2020 to pass the No Surprises Act, banning most "surprise" bills -- bills in excess of the amount owed under the terms of the patient's insurance plan. Surprise bills are sent to emergency room patients by out-of-network providers working at in-network facilities, or, in scheduled procedures, by out-of-network providers supplying ancillary care (e.g., radiology, pathology, or assistance in surgery) to in-network providers. Surprise billing has been a scourge to which all commercially insured Americans were vulnerable, affecting about one sixth of Americans over a two-year period, according to a KFF survey, and causing two thirds of Americans to worry about unexpected medical bills. In a sense, rampant and growing surprise billing (juiced by private equity-owned practices) rendered all commercial health insurance in the U.S. illusory, in that any patient could be confronted with unlimited demands for payment.

Finally, just as I'm finishing this post, CMS has announced a major new initiative to ease administrative barriers to Medicaid enrollment and reduce the "churn" (frequent transitions in and out of coverage) that plagues the program. A new proposed rule

if finalized, would standardize commonsense eligibility and enrollment policies, such as limiting renewals to once every 12 months, allowing applicants 30 days to respond to information requests, requiring prepopulated renewal forms, and establishing clear, consistent renewal processes across states.

That rule should also ease the disruption looming when the pandemic-induced Public Health Emergency ends, and with it the moratorium on Medicaid "redeterminations" and disenrollments. CMS has  engaged states in extensive planning for the end of the PHE, allowing twelve months to process the backlogged redeterminations and urging states to make concerted efforts to update enrollees' contact information, draw them into the redetermination process, and point them toward marketplace coverage if they no longer qualify for Medicaid.

The American healthcare system is still dysfunctional in myriad ways, plagued by a lack of pricing discipline, market concentration, providers and insurers alike focused on maximizing revenue, relentless privatization of the management of Medicaid and Medicare, and increasing inroads by private equity. That said, since 2010 Democratic initiatives have cut the uninsured population almost in half (from 50 million to 26-27 million), implemented some substantive cost control (trimming payment rates for hospitals and Medicare Advantage plans in the ACA, making a start on Medicare negotiation of prescription drugs and imposing inflation caps on drug prices in the IRA), and reduced individuals' exposure to catastrophic cost with annual out-of-pocket caps in commercial insurance (ACA), Medicare Part D caps (IRA), and (with Republicans) an end to the worst surprise billing. That's a lot to run on.


  1. Great summary, thanks! My only amendment would be that I do not think surprise billing actually affects one sixth of all Americans. There is virtually no surprise billing in Medicare or Medicaid, and right there you have about 130 million people. Then of the commercially insured Americans, many of them go through the year without any claims. Some of them are in true HMO's, which have no surprise billing.
    It is still a hideous practice, though.

    1. Agreed the claim should be trimmed to a degree: the KFF survey was of insured adults 18-64 -- including those insured by Medicaid or, for that matter disability Medicare.

    2. I have been on Medicare for 9 years, and two of my sons have been on Minnesota Care (our Basic plan). There are occasional bills, and they are a surprise, but so far they have been for peanut amounts. Good luck, I guess.