Originally posted on acasignups.net as a guest post titled "Why Are We Waiting for the Federal Goverment to Offer Comprehensive Testing and Contact Tracing?"
In almost the middle of June 2020, with over three months of an international pandemic behind us, over 100,000 Americans and more around the world dead from Covid19 and its complications, what are we waiting for? We know that our administration has done everything possible to impede the facilitation of needs and resources to our country. Special interests are running rampant, price gouging is the norm, government agencies have been scooping up supplies from states that are desperately needed, and the GOP controlled Senate is more focused on packing courts with unqualified ideologues than with passing bills to assist Americans financially affected by the pandemic.
It feels like much of the progress we’ve made as a society, the labor reforms people fought and died for, the governmental regulations meant to ensure our safety and our ability to trust that the medicine we take or the food we eat is safe, it feels like those hard fought battles are being rolled back faster than we can even register our outrage. Companies are still selling unreliable coronavirus test kits with no real oversight, and untrustworthy results. After years of fighting for better pay, suddenly minimum and low-wage workers have been deemed “essential,” yet have seen no pay raise, while many of their employers dragged their feet on creating safer conditions for workers, only acting when strikes and public outrage forced their hands. Many of these workers, due to delayed and insufficient economic assistance are forced to make a choice: work, and face the possibility of becoming sick and spreading infection to their family, or potentially losing their income and home. Millions of others have lost their jobs, with unemployment higher than any time since the Great Depression. In Texas, Ohio, and across the country, lines for food banks have stretched for miles as many Americans can no longer afford to feed their families. All while the president tweets increasingly incoherent and dangerous tirades, and those in his administration find ways to profit from a disaster, if not of their own doing, then one greatly magnified by their greed and incompetence.
Because of our continued insistence in linking healthcare to our employment status, millions of Americans find themselves not only out of work, but now without insurance in the middle of a pandemic.. Those in states that refused to expand Medicaid have essentially three choices: see if they qualify for an expensive COBRA plan to continue their existing plan, especially if they have already met their deductibles for the year, attempt to navigate the complicated maze of enrolling in an ACA exchange, or simply go without insurance at all. These millions of Americans must make this complicated choice while the administration works to overturn the Patient Protection & Affordable Care Act (ACA) - their opening arguments before the Supreme Court are due in mere weeks.
So - what are we waiting for? Seriously. Why are we still waiting for the federal government to fix this? To guarantee enough testing, to make sure there are enough treatment centers, especially in rural areas of our country. Why are we waiting for a cohesive contact tracing system, for more PPE, for anything else to trickle down from the top, especially when it seems the administration has moved on from talking about the current healthcare crisis? We have seen some modest improvements in some areas of the country, but it is not enough, it is not comprehensive, and we are starting to see more outbreaks due to states easing their lockdown rules.
The fact is, we can do this together. States are already working together in regional coalitions. Nonprofits and grassroots organizations are doing their best to fill in gaps. Imagine if we all worked together to address the issues we now face with this pandemic.
Every county in this nation has a health department. Many of these are stretched now - and frankly most of the time - but the fact remains that they represent the best place to build a nationwide effort focused on using local programs to do the contact tracing that is needed to open our country. They remain the best central base to make sure testing can be done in rural and underserved urban neighborhoods. A partnership made up of local county health departments, states, federal funds, and private funds and donations can be made to work. County health departments make the most logical place to create dedicated mobile health units that can function for contact tracing, testing, as well as primary care. Rather than inefficient and slapdash responses to a crisis, we could take this time to build a method of delivering dedicated, routine, regular primary care to those who need it, but can’t get it. Dedicated, routine, regular primary care.
What about the tech answers being bandied about - why not wait for the next cell phone app to do the tracing for us? In too much of this country, cellular networks are insufficient, and internet connections are spotty at best. Many of the communities most in need are comprised of people without the money to buy a smartphone. Once again, those most in need would be left behind.
This must be done in a non-profit, non-private, non-profit motivated manner. This is not something that we, as a nation, can afford to rely on private medical conglomerates to do, or to abdicate our responsibilities to private equity firms looking for the next quick profit venture. We cannot afford to exclude anyone based on insurance networks or being uninsured. These clinics must be available to everyone regardless of their insurance status. Medicare, Medicaid, private insurance, ACA exchange plans, underinsured, uninsured - everybody must have access.
Who will staff them? We have millions of health care professionals - from doctors to nurses, technicians, administrators and more - currently out of work, at the height of a national pandemic. Many were laid off from medical staffing firms at the beginning of the pandemic so as to protect the profit margins of the private equity firms that own them. Others were laid off as clinics that were deemed non-essential were closed. A report from the American Academy of Family Physicians estimates the closure of upwards of 60,000 family clinics by June, impacting over 800,000 workers. We can get these trained experts back to work at the same time we expand necessary healthcare across the country..
This whole system can be run out of the county health offices that already exist to handle this crisis. There have been significant advancements in logistical technology over the last several years. That same technology can be used to implement effective, quick, and thorough testing and contact tracing. There are foundations and donors looking to give money to programs that can make a difference, so let’s use them. We have too many different groups focused on reinventing the wheel rather than looking to existing models around the world for guides on how to build a functioning system. Rather than relying on profit-driven corporations to build proprietary walled gardens, we could be building a universal system, one that works with and for every person in America, regardless of income.
Once up and running, these mobile healthcare facilities can be utilized for community contact tracing and testing, a response to the pandemic that we desperately need. Later, as this crisis is brought under control, we can continue to fund this program in order to offer real primary care facilities that go to the people in need, those otherwise unable to travel to perhaps distant medical centers. If we can create a regular schedule, making appointments, offering school physicals, vaccinations, maternal and prenatal care, and providing chronic care monitoring, we can create relationships and extend care in areas that are chronically underserved. Not only will we keep those without primary care physicians out of the emergency room, but by extending healthcare into these communities we can improve overall health by addressing chronic conditions and providing preventative care to those who need it most..
To meet the long-term demand for doctors and nurses a program like this will create, we need more than just money. We will need Congress to open up the caps on residency openings in this country in order to train the numbers of primary care physicians this country will need long after we get through this pandemic. In addition, pressure must be brought to bear in order to stop the repeated attempts to slash the funding of Medicare and Medicaid, the programs we rely on to pay for these residency positions. Building on the success of the Teach for America program we can introduce a similar initiative that will allow medical students to work in underserved communities to pay off their medical school expenses. This would give our young doctors and nurses valuable practical and personal experience in treating patients in need.
Our nation’s healthcare system faces challenges on so many fronts, with so many things in need of attention that we can feel paralyzed by how much there is to do. Unfortunately, the cost of the status quo has grown too high to be allowed to continue. By focusing on a community based solution that can be built into a nationwide network, we can get started on the mountain of challenges in front of us, while laying the groundwork for a continued and necessary way to treat the most vulnerable among us. This is something we can do now to make real change and have a positive impact on the lives of millions. The health of millions, and of the nation, rests on our resolve to act now.
“…An eligible employer-sponsored plan is affordable for a related individual if the portion of the annual premium the employee must pay for self-only coverage does not exceed the required contribution percentage…” (Federal Register, Feb 1, 2013. 78-22, p. 7265)
Once upon a time I was an enrollment assister in rural West Virginia, helping community members get signed up for ACA-compliant health insurance coverage. I have hundreds of success stories under my belt, and hopefully not as many failures. Most frequently, I can say with confidence, those failures could be attributed to the family glitch. Most Americans have never heard of the family glitch unless it has affected them personally. Actually, even if they’ve experienced this glitch, they may not understand what it is. It’s complicated, but important to understand when you’re parsing through all the new ACA-fix bills circulating out there. A family glitch fix is essential to allowing more people to access affordable health coverage.
I’ll start with an example:
Maria comes to me hoping to purchase a subsidized Marketplace plan for her husband who is a stay at home dad. She is working a full time job making $53,000/year. Maria has coverage through her employer for $175/month (about 4% of her income). However, to add her husband to her plan it would cost her $575/month (about 13% of her income) which she cannot afford. At $53,000/year for a family of 3, Maria’s husband should qualify for a healthy tax credit to help him pay for his coverage. So what’s the glitch? In this case, Maria’s husband is not eligible for a tax credit to help him pay. Here’s why:
An individual may not receive a tax credit to purchase Marketplace coverage if s/he has an offer of affordable employer-sponsored insurance coverage (ESI). “Affordable,” in 2019, according to the ACA/IRS, means the total cost of self-only premiums must equal no more than 9.86% of an individual’s total household income. “Self-only” is the key term. While Maria’s ESI cost for her family is well over 9.86% (at 13%), the cost of her self-only coverage is well under 9.86% (at 4%) and is thus deemed affordable. Therefore, her husband has an offer of “affordable” ESI and is not eligible for a tax credit.
How can this be? Turns out, it’s not a glitch. The IRS and the GAO have decided to interpret the law in such a way so as to cut costs. Fewer people eligible for tax credits means less money the government has to dole out. It all comes down to the interpretation of the phrase “required contribution.” Because the law states that the required contribution, as it relates to the individual mandate, will be calculated based on self-only cost, the IRS determined that “required contribution” as it relates to tax credit eligibility should also be calculated based on self-only cost, though the law does not explicitly state this.
Two to four million people are stuck in the glitch, with no options for affordable coverage. Back in 2014, Senator Al Franken first introduced the Family Coverage Act to fix the family glitch. His bill went nowhere because of concerns over- you guessed it- cost. But here we are in 2019, with a plethora of ACA-fix and health system reform ideas filling our inboxes and bungling our brains. Most notable, for the sake of this issue, is HR 1884: The Protecting Pre-Existing Conditions and Making Healthcare More Affordable Act, better known in health policy circles as ACA 2.0 thanks to the unsurpassable Charles Gaba. The upside is it passed the House in May, which is quite a feat given previous pushback. The down side is, well, Mitch McConnell will never let it come to a vote in the Senate. It is also worth it to check out Senator Sherrod Brown’s (D-OH) reintroduction of the Family Coverage Act, introduced in June, which specifically targets the family glitch. This bill would allow families to access Marketplace tax credits if the cost of employer-sponsored family coverage is greater than 9.86% of income, providing access to affordable coverage to millions of individuals.
So, what is there to do if you have found yourself in the family glitch? The hard answer is “not much.” Here are some true but maybe unhelpful answers:
What you should actually do:
The “family glitch” is essentially health policy jargon, so families may have experienced this without even realizing. They just know that the ACA hasn’t helped them, and they are owed an explanation.
Let’s educate, enlighten, and demand change for those who deserve access to affordable health insurance coverage.
This weekend marks the second anniversary of the Senate vote to repeal the ACA. This vote was a culmination of a contentious battle on Capitol Hill and around the country, with protesters in the halls of Congress being arrested, protests, town halls demanding lawmakers protect the law and the health care of millions of Americans, office protests and petition deliveries to those lawmakers who refused to hold town halls or meet with their constituents. Prior to the Senate vote we witnessed a callous and childish celebration on the grounds of the White House by certain members of Congress and the current President chortling with glee at their successful vote to rip protections and somewhat affordable access to health care from tens of millions of Americans (complete with a purported keg party in the halls of the House).
Those of us who had been advocating and calling, protesting, marching, exhorting our lawmakers to do the right thing sat riveted. Millions who had been sleeping poorly in terror of losing health insurance, in horror of losing protections for those with medical histories that were preventing insurance companies from denying coverage awaited the final vote anxiously. The millions of Americans who finally could access health insurance either through the exchanges or through Medicaid expansion sat on tenterhooks when the final vote came in the Senate. That vote, a party-line vote showing the distinct ideological differences and implacable indifference of some lawmakers to the wishes and desires of those who elected them over the support of special interests, lobbyists, and the like - that vote signified a moment of sanity and a breath of relief. Some lawmakers stood up to the barrage of party pressure and voted for the greater good, despite potential campaign backlash. Just enough Senators voted to stop the juggernaut of inebriation brought on by finally controlling the executive and legislative branches of our government.
And, just like two years ago, this weekend starts the August recess for Congress. A time for lawmakers to go back to their districts and states, to meet with constituents, to hold town halls (or not), march in parades, kiss babies, and get their photos in the paper during the dog days of summer.
While this year has not been as fraught with tension and fear, it has had its own terrors and its own Sword of Damocles dangling over the state of health care in this nation. A current lawsuit, called spurious and ridiculous by experts on both sides of the aisle, awaits decision and eventual appeal to the Supreme Court. Our department of Health and Human Services is issuing rules changes to strip nondiscrimination protections from women, immigrants, and members of the LGBTQ community, with the potential aim of stripping racial discrimination protections from patients seeking care, not to mention a rule which would allow medical providers to refuse medical treatment that they felt went against the provider’s moral beliefs.
Debate ranges on Capitol Hill to help address the out-of-control prices of life saving medications, as well as prescriptions that allow people to live the best lives they can. Bills have been passed in the House to address the so-called premium subsidy cliff, which if passed and signed, would allow millions of Americans who make over 400% of the federal poverty level to access premium tax subsidies to help them afford plans on the exchanges - many of these between the ages of 50 and 64, who see significant premium increases due to age-rating (or charging those in that age range up to 3 times the premiums of someone who is 26). A bill has been introduced to address the so-called ‘family glitch,’ which prevents family members with access to employer-based benefits that cost more than 9% of the family income from accessing less expensive plans on the exchanges. Other bills have been introduced to help states create their own exchanges, to codify protections for those with ‘pre-existing conditions,’ a term created by the insurance industry to justify denying insurance to those with medical histories they find objectionable.
We are once again hearing how if the ACA is struck down by the courts, GOP leadership will protect those with medical histories, but we have seen no such legislation from them. It is all still a nebulous concept that they will get to if and when needed. We are seeing that while there is a bipartisan bill to address prescription pricing, the lobbyists for the pharmaceutical and insurance industry meet at the White House to push against any regulations or laws that may impede their ability to seek excess and uncontrolled profit from the suffering of their fellow citizens. We are seeing large hospital associations sue the poorest patients for bills, seeing people being charged up-front for treatment and testing above and beyond a patient’s copay, we are seeing more social funding appeals for those hit with surprise bills totaling tens or hundreds of thousands of dollars, and we are seeing bankruptcies due to health expenses once again on the rise.
One thing that makes this year different from two years ago is the sheer number of bills and plans that have been introduced to address the problems with health care in this country. One could say there are too many plans to keep track of. Some call for a wholesale overhaul of our nation’s health care system, others call for modest steps toward an eventual goal of universal affordable, comprehensive, equitable, and quality health care. Find one that you like, or support all of them. Steps to fix the current system make sense while we work to see what happens next November. A complete sea-change in our nation’s health care is predicated on a change in Washington and could not be implemented for at least 3 years, but incremental fixes have been proposed, and some have passed the House and are just waiting to be brought up in the Senate.
So, this weekend once again marks a period where we, the People, must take up our signs, our phones, our keyboards, and make sure that the lawmakers in Washington hear from us when they are home. Now is the time to write letters to the editor to demand lawmakers stop holding the health care of this country hostage. Now is the time to gather friends and family, go to town halls, coffees on the corner, office open houses, and yes, even candidate fundraisers if you can. Now is the time to discuss your personal stories, explain what health care means to your family, put a face to the issue with your lawmakers. If you don’t like your lawmaker’s position, seek out their campaign opponent and talk with them.
By all means, go to the beach, see friends, enjoy the flowers and concerts. But, wear a pin at the concerts that says #ProtectOurCare or another health care slogan, join with others who want to protect and defend the health care of everyone you know, get involved, write letters to the local paper, join local grass roots functions. Together we can make some noise and remind lawmakers that we expect them to do the jobs they were elected to do. Remind lawmakers that we are watching and will support them if they are supporting us. Remind them that some lawmakers were brave two years ago, and that we expect them to continue being brave until doing the right thing - on both sides of the aisle - is no longer a thing of political bravery, but an expectation of the position they sought, a position which requires them to protect and defend the Constitution of this great country, and its people.
Words matter. Language is important in communicating ideas and positions. It is critical to use clear, concise language to convey exact meanings and avoid misunderstandings and confusion. Utilizing terms that were crafted by those who oppose one’s position help to undermine one’s position or argument. To that end, I propose we stop using the term ‘pre-existing conditions’ immediately.
In many other countries, previous diagnoses and health issues, chronic conditions, and injuries are simply referred to as an individual's medical history.
We seem to have accepted the concept that a 'pre-existing condition' is a perfectly reasonable and normal reason for someone to be denied health insurance coverage. Even though the ACA actually outlawed insurance companies from using PECs to deny insurance in qualified plans under the law, we have allowed ourselves to be convinced that being sick or injured is a justifiable reason for not being eligible for health insurance in the future. This is fundamentally wrong, and it must stop.
The term pre-existing condition was created by the U.S. insurance industry to identify conditions and diagnoses that would allow them to exclude insurance coverage for individuals who had purchased health insurance. This was done with the ultimate goal of realizing greater and greater profits for insurance companies, their executives, and their shareholders.
There is no comprehensive industry-wide list of PECs. Each insurance company has their own internal list. These lists change and have even been expanded when consumers, who had faithfully paid their monthly premiums, became ill. There have been documented cases where consumers received a diagnosis or experienced a critical accident and the insurance company would work to find anything, no matter how specious, that would allow them to exclude coverage for that individual retroactively - coverage that individual had paid for in good faith, and leaving the individual on the hook for sometimes hundreds of thousands of dollars.
In addition, PECs are used by short-term and so-called unqualified plans under the ACA - those that still require underwriting - to preclude medical conditions from coverage, up to and including gender. One case documented in the past year noted a young woman who had experienced incredibly heavy menstrual cycles. One month, she hemorrhaged and needed surgery and several blood infusions to save her life. The short-term insurance company declared that simply being a woman, and therefore subject to potential complications from menstruation, was a pre-existing condition and denied coverage for any of her treatment.
There is a significant difference between so-called PECs, which again are a wide category of insurance company-identified reasons for declining insurance coverage, and chronic medical conditions. Unfortunately, over the last couple of years, they have come to mean the same thing, or be used interchangeably. Many PECs have nothing to do with chronic medical conditions. A broken ankle is not the same as arthritis or multiple sclerosis.
Further, the fear of having a potential PEC become part of a one’s medical history has led some people to avoid or delay medical treatment. In case the ACA protections are stripped away and we lose them altogether, some people are delaying treatment until their care can no longer be ignored for fear of having a diagnosis on their medical record that could be used to deny future insurance coverage. These delays frequently result in much higher costs than if they had been treated earlier.
The longer we continue to use the expression PEC, or ‘pre-existing condition,’ the longer we are allowing the health insurance industry in this country -- a for-profit industry focused on their bottom line and keeping their shareholders and Wall Street happy -- to dictate the discussion. It is time to simply stop using their terminology. It is time to stop letting them dictate what constitutes comprehensive medical care and coverage.
It is past time for us to retake the narrative, and begin working for a comprehensive, equitable, affordable, quality, universal health care system on our own terms - for the benefit of the people.
It is past time to simply state that we are all more than our medical history.
It is past time to declare that our health is no one’s commodity.
It is past time that we agreed that every single person deserves quality affordable care based on the concept of humanity and decency, and on the core precepts of our country - that all are created equal and all are endowed with the unalienable rights of life, liberty and the pursuit of happiness, which includes universal, affordable, comprehensive, equitable, quality health care.
It is past time we stopped calling our medical history ‘pre-existing conditions.’