On Aaron Carroll's Coronavirus cap-and-trade

It feels odd for me to take issue with recommendations from Aaron Carroll on how to deal with the risk of coronavirus infection, individually and collectively. In March, Carroll was prescient on what we as a country needed to do (and, with Trump in charge, inevitably failed to do) after we'd already let community transmission run rampant -- reduce infections via shelter-in-place, and use the breathing room to ramp up testing. He is a trusted source on nutrition, medicine and healthcare policy, able to sift through piles of published studies and assess the evidence, as he did on core nutritional questions in The Bad Food Bible.

But I feel there's something off about Carroll's approach in today's column to risk balancing in response to the pandemic. No one should have any beef with the main point: when you give up one major form of risk mitigation (e.g, when you go back to school), don't give up all others (e.g., by congregating in basements). But how, then, to balance risks? Envisioning our individual conduct as "piles" of risk-mitigating and risk-enlarging decisions, Carroll writes:

The ACA wars through a pandemic lens: Nicholas Bagley looks back

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I spoke to Nicholas Bagley, health law professor at the University of Michigan, about measures to limit Americans' out-of-pocket exposure for coronavirus treatment -- assuming that in the U.S., simply covering all OOP for everyone treated for the disease at government-set payment rates to providers is not going to happen.

My thought was that Bagley could speak to avoiding legal pitfalls in any such measures. But his sense is that in the current crisis, legal concerns pertain mainly to potential administrative actions  (for example,  Can the CDC Pay for Everyone's Coronavirus Testing?).

Given normal U.S. legislative sclerosis, seeking regulatory authority to do what needs to be done is often fertile ground for legal analysis. Right now, though, the cards may line up for decisive legislative action, as they do in this country when (and only when) Republican political survival depends on it. And while there are multiple constraints to regulatory action, "there are fairly few constraints on Congress's legislative power," Bagley said. "Congress doesn't quite have carte blanche, but close to it. The question is not what does the Constitution allow Congress to do. We should be asking, 'what do we think ought to happen?' And then we should do it."

Limit Americans' out-of-pocket exposure for Coronavirus treatment

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The bill passed by the House yesterday to ease the economic impact of the coronavirus pandemic, H.R. 6201, purports to make coronavirus testing available at no cost to all Americans. That includes office visits, urgent care center visits, and emergency room visits that lead to an order for testing.* It does not, however, include treatment for those who become seriously ill.

David Anderson and Nicholas Bagley are calling for Congress to rise to the crisis by protecting Americans against balance billing -- either by passing comprehensive consumer protection that's been stalled since last fall or, at a minimum, passing a bill to limit out-of-network billing for Coronavirus treatment.

That's vital. I've worried since late February that fear of balance billing would inhibit some Americans from seeking treatment. I've also noted a closely related problem: Americans' huge exposure to out-of-pocket costs for in-network care:

Coronavirus alert: How about an emergency Special Enrollment Period for the ACA marketplace?

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Update, 3/12: As noted in the updates at bottom, as of now five state-based marketplaces are running Special Enrollment Periods open to all, two of them triggered by the coronavirus emergency. CMS should do it for the healthcare.gov states. 3/14: Rhode Island makes six. 3/16: New York comes on board. 3/17: Nevada is in. 3/18: Connecticut announces SEP. And Colorado will announce imminently. 3/20: Covered California, already open via a tax-season SEP, available to anyone who affirms they were not aware of the state's new individual mandate, today makes it unconditional with an emergency SEP open to all. And it's open through June 30, by far the longest emergency SEP. 3/20 II: MNSure announces a SEP running March 23 - April 1. 3/20 III: Vermont comes on board, sort of.

Every SBE except Idaho now has enrollment open to the uninsured.

If the coronavirus causes major economic disruption, as now seems likely, the ACA marketplace (including Medicaid enrollment) is likely to get a major stress test.

As I've noted previously, the marketplace has never experienced a recession; the unemployment rate has dropped steadily since it launched in 2014, and enrollment has been basically flat since 2016. It stands ready as a shock absorber when people are laid off.  Those who lose insurance through their jobs are eligible for a Special Enrollment Period.  The machinery for processing SEP requests had better be smooth.

Since subsidy eligibility depends on annual income, the earlier in the year layoffs begin, the more people will qualify for marketplace subsidies (annual income up to $49,960 for an individual) or Medicaid ($17,236). In Medicaid expansion states, even those who have crossed those earnings thresholds should be eligible for Medicaid one month forward if their income is below the monthly Medicaid threshold.* Under various emergency authorities, governors and the president can extend Medicaid eligibility and expedite enrollment, as was done in the wake of 9/11, Hurricane Katrina, and the Flint water crisis.

The marketplace also might be put to more immediate use.  CMS should declare a national Special Enrollment Period for the marketplace (Medicaid enrollment is year-round).

Will Americans' fear of high medical bills hinder Coronavirus containment?

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On Wednesday, I noted that the high out-out of pocket costs that most insured Americans under age 65 are exposed to might deter people who contract the Coronavirus (or suspect they may have contracted it) from seeking treatment.

In employer-sponsored insurance, the average single-person deductible in 2019 was $1,655, according to the Kaiser Family Foundation. 28% of covered workers had a single -person deductible over $2,000.  The median annual maximum out-of-pocket (MOOP) limit (after which the plan pays 100% of covered expenses) was $4,000 (the maximum allowable is $8,100). About two thirds of employer plans require coinsurance for inpatient hospital stays, averaging 20%.

Today, Sarah Kliff reports that an American father and daughter who were subject to mandatory quarantine when they returned from Wuhan province in China were also subject to two mandatory stays in an isolation unit at a nearby children's hospital after the child was heard coughing. After release, "they found a pile of medical bills waiting: $3,918 in charges from hospital doctors, radiologists and an ambulance company."  The father's employer provided health coverage in China, where he had been working, but does not provide it in the U.S.

The card spells MOOP: Will Covid-19 expose Americans to financial risk?

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The Miami Herald reports that a man who developed flu-like symptoms after a business trip to China did what he felt was the right thing and went to the hospital to get tested for the Coronavirus. Hospital officials wanted to give him a CT-scan, but since he knew his insurance was limited, he asked for a flu test first.  Smart move. He tested positive for flu, and that was that -- except for the $3,270 bill that came later, with more to come.

The hospital told him that his share of the bill was $1,400. The story then focused on the fact that this man was in a short-term, limited duration plan that demanded he supply three years of medical records to prove that he didn't have a "pre-existing condition," i.e., a recent prior bout of flu.

That's outrageous, but it misses a broader point about Americans' financial exposure when the Coronavirus spreads. If this individual's medically underwritten policy does pay out, he's not necessarily in a worse financial position than the average insured American who walks into a hospital with suspected Covid-19.