tag:theconversation.com,2011:/global/topics/affordable-care-act-aca-95517/articlesAffordable Care Act (ACA) – The Conversation2023-10-27T12:18:30Ztag:theconversation.com,2011:article/2158702023-10-27T12:18:30Z2023-10-27T12:18:30ZWhite patients are more likely than Black patients to be given opioid medication for pain in US emergency departments<figure><img src="https://images.theconversation.com/files/556165/original/file-20231026-19-8q0th6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5499%2C3663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doctors have struggled to find the balance between effective pain management and the very real addiction risks that come with prescription pain medication.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/macro-of-oxycodone-opioid-tablets-with-prescription-royalty-free-image/1162845770?phrase=pain+treatment&adppopup=true">BackyardProduction/iStock via Getty Images Plus</a></span></figcaption></figure><p>White people who visit hospital emergency departments with pain are 26% more likely than Black people to be given opioid pain medications such as morphine. This was a key finding from <a href="https://doi.org/10.1007/s11606-023-08401-2">our recent study</a>, published in the Journal of General Internal Medicine. We also found that Black patients were 25% more likely than white patients to be given only non-opioid painkillers such as ibuprofen, which are typically available over the counter. </p>
<p>We examined more than 200,000 visit records of patients treated for pain, taken from a representative sample of U.S. emergency departments from 1999 to 2020. Although white patients were far more likely to be prescribed opioid medication for their pain, we found no significant differences across race in either the type or severity of patients’ pain. Furthermore, racial disparities in pain medication remained even after we adjusted for any differences in insurance status, patient age, census region or other potentially important factors.</p>
<p>Our analysis of prescribing trends spanning over two decades’ worth of records found that opioid prescribing rates rose and fell, reflecting changing attitudes in clinical practice toward the use of opioid drugs. Notably, however, there appeared to be little change over time in the prescribing disparity across race.</p>
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<h2>Why it matters</h2>
<p>These findings are important because they suggest that efforts to promote equitable health care in the U.S. over the past two decades, such as <a href="https://www.hhs.gov/healthcare/about-the-aca/index.html">the Affordable Care Act</a>, or “Obamacare,” do not appear to have translated to clinical practice – at least with regards to pain management in hospital emergency departments.</p>
<p>There’s no question that as the <a href="https://www.nytimes.com/2023/02/20/nyregion/sudden-deaths-overdoses-fentanyl-nyc.html">ongoing opioid crisis</a> <a href="https://www.npr.org/2023/08/30/1196343448/fentanyl-deaths-teens-schools-overdose">continues to escalate</a>, a careful balance must be struck between the risks and benefits of prescribing opioids. But their appropriate use is an essential component of pain control in the emergency department, and they typically provide superior relief to non-opioids for short-term moderate to severe pain. </p>
<p>Undertreated pain produces unnecessary suffering and can result in a range of negative outcomes, even including a <a href="https://doi.org/10.1111/j.1526-4637.2010.00983.x">greater likelihood of developing long-term pain</a>. There are over <a href="https://doi.org/10.1007/s11606-023-08401-2">40 million pain-related emergency department visits annually</a>, so it is clear that equitable pain treatment is a fundamental component of a fair health care system. </p>
<h2>What still isn’t known</h2>
<p>We do not know why such marked racial disparities exist. Some researchers <a href="https://doi.org/10.1056%2FNEJMsa2034159">have argued</a> that prescribing fewer opioids may be beneficial for Black patients as it reduces the risk of addiction. But this argument doesn’t square with the data, which show that overdose rates have traditionally been <a href="https://doi.org/10.1111/add.15233">lower in Black populations compared with white people</a>. However, this trend has <a href="https://doi.org/10.1111/add.15233">started to change in recent years</a>. </p>
<p>In addition, some evidence suggests that clinicians <a href="https://doi.org/10.1073/pnas.1516047113">may hold unconscious biases</a>, incorrectly believing Black patients to be less sensitive to pain or that certain racial groups are <a href="https://doi.org/10.1371/journal.pmed.1001411">less willing to accept pain medication</a>. </p>
<p>While there is preliminary evidence that these factors may be important, there is not enough research that examines the degree to which they influence clinical practice. Researchers like us also know very little about whether promising remedial strategies based on these factors – such as educational training during medical school that challenges stereotypical beliefs – are effective, or indeed even implemented, in the real world. </p>
<h2>What’s next?</h2>
<p>The need for tackling racial disparities in health was brought into focus once more in February 2023, when the <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2023/02/16/fact-sheet-president-biden-signs-executive-order-to-strengthen-racial-equity-and-support-for-underserved-communities-across-the-federal-government/">Biden-Harris administration</a> signed an executive order on further advancing racial equity. Given the long history of these issues, it is clear that more research is needed to help develop better strategies for tackling health inequalities.</p>
<p>The most effective strategies for addressing racial disparities in pain treatment are likely to be those that target the underlying causes. We are currently undertaking research to try to better understand these causes, how they contribute to disparities in real-world clinical practice and whether strategies designed to address them are actually effective.</p><img src="https://counter.theconversation.com/content/215870/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Undertreated pain can result in unnecessary suffering and a greater likelihood of long-term chronic pain.Trevor Thompson, Associate Professor of Clinical Research, University of GreenwichSofia Stathi, Professor of Social Psychology, University of GreenwichLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2030372023-04-07T13:48:03Z2023-04-07T13:48:03ZMillions of Americans at risk of losing free preventive care after Texas ruling on ACA<figure><img src="https://images.theconversation.com/files/519403/original/file-20230404-473-pq24if.jpg?ixlib=rb-1.1.0&rect=19%2C0%2C2121%2C1406&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Raising the cost barriers for health care will harm the most vulnerable patients.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/mother-talking-with-daughter-while-male-doctor-royalty-free-image/1321467310">Maskot via Getty Images</a></span></figcaption></figure><p>Many Americans breathed a sigh of relief when the Supreme Court left the Affordable Care Act in place following the law’s <a href="https://www.supremecourt.gov/opinions/20pdf/19-840_6jfm.pdf">third major legal challenge</a> in June 2021. This decision left <a href="https://source.wustl.edu/2017/02/americans-divided-on-obamacare-repeal-poll-finds/">widely supported policies</a> in place, like ensuring coverage <a href="https://www.healthcare.gov/coverage/pre-existing-conditions/">regardless of preexisting conditions</a>, granting coverage for <a href="https://www.healthcare.gov/young-adults/children-under-26/">dependents up to age 26</a> on their parents’ plan and removing <a href="https://www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits/">annual and lifetime benefit limits</a>.</p>
<p>But now, millions of people in the U.S. are holding their breath again <a href="https://storage.courtlistener.com/recap/gov.uscourts.txnd.330381/gov.uscourts.txnd.330381.114.0_1.pdf">following a March 30, 2023 ruling</a> in Braidwood v. Becerra that would <a href="https://www.healthaffairs.org/content/forefront/texas-judge-just-invalidated-preventive-services-mandate-happens-next">eliminate free coverage</a> for many basic preventive care services and medications.</p>
<h2>Litigating preventive care</h2>
<p><a href="https://www.law.cornell.edu/cfr/text/29/2590.715-2713">Section 2713</a> of the ACA requires insurers to offer <a href="https://www.healthcare.gov/coverage/preventive-care-benefits/">full coverage of preventive services</a> endorsed by one of three federal groups: the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices or the Health Resources and Services Administration. If one of those groups recommends a preventive care service as essential to good health outcomes, then you shouldn’t have to pay anything out of pocket. For example, <a href="https://www.congress.gov/bill/116th-congress/house-bill/748/">the CARES Act</a>, which allocated emergency funding in response to the COVID-19 pandemic, used this provision to ensure COVID-19 vaccines would be free for many Americans.</p>
<p>Immunizations, including COVID-19 vaccines, require a recommendation from the <a href="https://www.cdc.gov/vaccines/acip/index.html">Advisory Committee on Immunization Practices</a> of the Centers for Disease Control and Prevention, while women’s health services require approval from the <a href="https://www.hrsa.gov/womens-guidelines/index.html">Health Resources and Services Administration</a>. Most other preventive services require an A or B rating from the <a href="https://uspreventiveservicestaskforce.org/uspstf/home">U.S. Preventive Services Task Force</a>, an independent body of experts trained in research methods, statistics and medicine, and supported by the <a href="https://www.ahrq.gov/cpi/about/otherwebsites/uspstf/index.html">Agency for Healthcare Research and Quality</a>.</p>
<p>The lead plaintiff in the ACA case, <a href="https://khn.org/news/article/braidwood-becerra-aca-preventive-services-court-decision-reed-oconnor/">Braidwood Management</a>, is a Christian for-profit corporation owned by Steven Hotze, a physician and conservative activist who has <a href="https://www.texastribune.org/2013/05/15/republican-donor-releases-songs-opposing-obamacare/">previously filed</a> multiple lawsuits against the Affordable Care Act. Braidwood and its co-plaintiffs, a group of conservative Christian employers, objected to being forced to provide their 70 employees free access to pre-exposure prophylaxis, or PrEP, a medicine that is <a href="https://www.cdc.gov/hiv/basics/prep/prep-effectiveness.html">nearly 100% effective</a> in preventing HIV infection. Hotze claimed that PrEP “facilitates and encourages homosexual behavior, intravenous drug use and sexual activity outside of marriage between one man and one woman,” despite a lack of evidence to support this. He also claimed that his religious beliefs prevent him from providing insurance that covers PrEP.</p>
<p>PrEP received an <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis">A rating</a> from the U.S. Preventive Services Task Force in June 2019, paving the way for it to be covered at no cost for millions of people. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Red ribbon hanging from the North Portico of the White House" src="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">PrEP is a key tool to helping the U.S. reach its goal of substantially reducing new HIV infections by 2030.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/ObamaWorldAidsDay/c146dee7e944420482f3e5786d4d2e50">AP Photo/Pablo Martinez Monsivais</a></span>
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<p>Though Section 2713 of the ACA <a href="https://doi.org/10.1016/j.ypmed.2021.106690">doesn’t work perfectly</a>, sometimes leaving patients frustrated by <a href="https://www.washingtonpost.com/national/health-science/getting-charged-for-free-preventive-care/2014/01/17/98fbd1fa-7ec2-11e3-95c6-0a7aa80874bc_story.html">unexpected bills</a>, it has made a huge difference in reducing costs for services like <a href="https://doi.org/10.1001/jamanetworkopen.2021.1248">well-child visits</a> and <a href="https://doi.org/10.1097/MLR.0000000000000610">mammograms</a>, just to name a few.</p>
<p><a href="https://aspe.hhs.gov/sites/default/files/documents/786fa55a84e7e3833961933124d70dd2/preventive-services-ib-2022.pdf">Over 150 million Americans</a> are enrolled in private health insurance, allowing them to benefit from free preventive care, with <a href="https://www.healthsystemtracker.org/brief/preventive-services-use-among-people-with-private-insurance-coverage/">about 60%</a> using at least one free preventive service each year. Raising the cost barrier again for PrEP, for example, would <a href="https://doi.org/10.1001/jamanetworkopen.2021.22692">disproportionately harm</a> younger patients, people of color and those with lower incomes.</p>
<p>As public health researchers at <a href="https://www.bu.edu/sph/profile/paul-shafer/">Boston University</a> and <a href="https://sph.tulane.edu/sbps/kristefer-stojanovski-phd-mph">Tulane University</a> who study <a href="https://scholar.google.com/citations?user=bDT820kAAAAJ&hl=en">health insurance</a> and <a href="https://www.researchgate.net/profile/Kristefer-Stojanovski-2">sexual health</a>, we believe that prevention and health equity in the U.S. stand to take a big step backward with this policy in jeopardy.</p>
<h2>What preventive services are affected?</h2>
<p>The ruling in Braidwood rests in large part on the <a href="https://www.law.cornell.edu/constitution/articleii">appointments clause</a> of the U.S. Constitution, which specifies that certain governmental positions require presidential appointment and Senate confirmation, while other positions have a lower bar. </p>
<p>Texas federal <a href="https://www.healthaffairs.org/content/forefront/texas-judge-just-invalidated-preventive-services-mandate-happens-next">District Judge Reed O'Connor ruled</a> that because the U.S. Preventive Services Task Force is an independent volunteer panel and not made up of officers of the U.S. government, they do not have the appropriate authority to make decisions about which preventive care should be free, unlike the Advisory Committee on Immunization Practices or Health Resources and Services Administration. O'Connor also ruled that being forced to cover PrEP violated the religious freedom of the plaintiffs.</p>
<p>Following his initial ruling in September, both sides submitted briefs that tried to inform the “remedy,” or solution, the judge would ultimately recommend. He could have chosen, as the <a href="https://storage.courtlistener.com/recap/gov.uscourts.txnd.330381/gov.uscourts.txnd.330381.112.0_3.pdf">federal government advocated</a>, to grant only the plaintiffs an exemption from covering PrEP under the Religious Freedom Restoration Act. But O'Connor instead chose to make his “remedy” apply nationally and cover more services.</p>
<p>He invalidated all of the task force’s recommendations since the Affordable Care Act was passed in March 2010, returning the power to insurers and employers to decide which, if any, preventive care would remain free to patients in their plans. A few of the <a href="https://www.bloomberg.com/opinion/articles/2023-04-01/braidwood-ruling-further-weakens-aca-on-prep-drugs-preventive-care">recommendations covered by his ruling</a> include PrEP; blood pressure, diabetes, lung and skin cancer screenings; and medications to lower cholesterol and reduce breast cancer risk. As of 2022, <a href="https://www.commonwealthfund.org/blog/2022/aca-preventive-services-benefit-jeopardy-what-can-states-do">15 states</a> have laws with ACA-like requirements for plans in the insurance marketplace, but not for large employer plans generally <a href="https://blog.petrieflom.law.harvard.edu/2023/04/03/three-reactions-to-braidwood-v-becerra/">exempt from state oversight</a>.</p>
<p>Insurance contracts are typically defined by calendar year, so most people will <a href="https://www.kff.org/policy-watch/qa-implications-of-the-ruling-on-the-acas-preventive-services-requirement/">see these changes</a> starting only in 2024. Importantly, these services will likely still need to be covered by health insurance plans as <a href="https://www.law.cornell.edu/uscode/text/42/18022">essential health benefits</a> through a separate provision of the ACA – they just won’t be free anymore. </p>
<p>Other U.S. Preventive Services Task Force recommendations and those made by the Advisory Committee on Immunization Practices or Health Resources and Services Administration – namely, immunizations and contraception, respectively – will remain free to patients <a href="https://www.kff.org/womens-health-policy/issue-brief/explaining-litigation-challenging-the-acas-preventive-services-requirements-braidwood-management-inc-v-becerra/">for now</a>.</p>
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<a href="https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Demonstrator holds a sign saying 'Save the ACA' in front of the U.S. Supreme Court." src="https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The Affordable Care Act has faced many legal challenges over the years.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/SupremeCourtHealthCare/af7a18ea1fc84b39af301fa84aec0672">AP Photo/Alex Brandon</a></span>
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<h2>What’s next?</h2>
<p>The <a href="https://storage.courtlistener.com/recap/gov.uscourts.txnd.330381/gov.uscourts.txnd.330381.115.0.pdf">federal government appealed</a> the ruling to the 5th U.S. Circuit Court of Appeals on March 31, 2023, buoyed by a <a href="https://newsroom.heart.org/news/23-national-health-organizations-respond-to-braidwood-v-becerra-ruling-that-threatens-no-cost-preventive-care">coordinated response</a> from 23 patient advocacy groups. They have asked for a stay while the case continues, which pauses the effects of the ruling. If either O'Connor or a higher court grants their request, it will leave the status quo of free preventive care in place. </p>
<p>But there are also concerns that either the 5th Circuit orthe Supreme Court could take the ruling even further, endangering the free coverage of contraception and other preventive care that remains in place. </p>
<p>The ending to this case may still be several years off, with <a href="https://news.yahoo.com/americans-surprise-medical-bills-health-care-loopholes-131630868.html">even more frustration</a> ahead as the courts undermine national goals in <a href="https://www.whitehouse.gov/cancermoonshot/">fighting cancer</a>, <a href="https://www.whitehouse.gov/briefing-room/presidential-actions/2022/10/31/a-proclamation-on-national-diabetes-month-2022/">diabetes</a> and <a href="https://www.cdc.gov/endhiv/index.html">ending the HIV epidemic</a>.</p>
<p><em>Portions of this article originally appeared in previous articles published on <a href="https://theconversation.com/the-next-attack-on-the-affordable-care-act-may-cost-you-free-preventive-health-care-166087">Sept. 7, 2021</a>, <a href="https://theconversation.com/hiv-prevention-pill-prep-is-now-free-under-most-insurance-plans-but-the-latest-challenge-to-the-affordable-care-act-puts-this-benefit-at-risk-171086">Dec. 1, 2021</a>, and <a href="https://theconversation.com/free-preventive-care-under-the-aca-is-under-threat-again-a-ruling-exempting-prep-from-insurance-coverage-may-extend-nationwide-and-to-other-health-services-190317">Sept. 13, 2022</a>.</em></p><img src="https://counter.theconversation.com/content/203037/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Shafer has received funding in the past three years from the Commonwealth Fund, Arnold Ventures, Robert Wood Johnson Foundation, Kate B. Reynolds Charitable Trust, Starbucks Coffee Company, and Renova Health.</span></em></p><p class="fine-print"><em><span>Kristefer Stojanovski does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>On the basis of government appointment technicalities and religious freedom, Americans may lose free coverage for cancer and blood pressure screenings, HIV prevention medication and other essential services.Paul Shafer, Assistant Professor of Health Law, Policy and Management, Boston UniversityKristefer Stojanovski, Research Assistant Professor of Social, Behavioral and Population Sciences, Tulane UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1978472023-01-31T13:15:07Z2023-01-31T13:15:07ZMedicaid coverage is expiring for millions of Americans – but there’s a proven way to keep many of them insured<figure><img src="https://images.theconversation.com/files/506912/original/file-20230127-14-1rdh23.jpg?ixlib=rb-1.1.0&rect=0%2C49%2C8179%2C4488&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research indicates that having a streamlined process makes a big difference.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-doctor-doing-a-medical-examination-royalty-free-image/1345288567">mixetto/E+ via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>Getting everyone who is eligible for free or discounted health insurance to sign up for it requires making it as easy as possible to enroll – and that convenience especially matters for young, healthy and low-income people. Those are the key findings of <a href="http://doi.org/10.3386/w30781">a recent study</a> <a href="https://scholar.google.com/citations?user=TOts234AAAAJ&hl=en&oi=sra">I conducted</a> with <a href="https://scholar.harvard.edu/mnwagner">Myles Wagner</a>, an economics Ph.D. student. </p>
<p>We examined the subsidized health insurance program for <a href="https://obamacarefacts.com/romneycare-romneyhealthcare/">low-income Massachusetts residents</a> enacted in 2006 when <a href="https://www.npr.org/2006/04/08/5330854/romneys-mission-massachusetts-health-care">Mitt Romney served as the state’s governor</a>. The Massachusetts program – dubbed RomneyCare – resembled the program created by the Affordable Care Act and <a href="https://www.politifact.com/factchecks/2011/aug/12/tim-pawlenty/pawlenty-says-obamacare-patterned-after-romneycare/">served as its model</a>. For residents below the poverty line, which then stood at <a href="https://aspe.hhs.gov/2010-hhs-poverty-guidelines">about US$22,000 for a family of four</a>, coverage cost nothing.</p>
<p>Even when they didn’t have to pay a dime, eligible residents still had to sign up using a two-step process: After applying, they chose a plan among four or five options.</p>
<p>But the program didn’t always work this way. The state government didn’t make beneficiaries choose a plan until 2010. Instead, anyone who qualified but didn’t respond when asked to select one was automatically enrolled in a plan the state picked out. This meant that no one would go without insurance if they forgot to respond or got confused by the rules.</p>
<p>We compared the number and socioecononomic characteristics of residents who enrolled in the program before and after the change, with a control group unaffected by the policy because they had higher incomes and were not eligible for auto-enrollment.</p>
<p>We found that having a streamlined process makes a big difference. With automatic enrollment, 48% more people signed up for coverage each month. This meant one-third more people obtained coverage over the long run, and it reduced the uninsured rate among low-income people eligible for this coverage by about 25%.</p>
<p>A one-step process also had other consequences. Those who were automatically enrolled were especially likely to be young and healthy, with health care costs 44% below average. </p>
<p>They were also more likely to reside in low-income neighborhoods.</p>
<p>Massachusetts ended auto-enrollment in 2010 for budgetary reasons, and it didn’t reinstate it when the state <a href="https://www.politico.com/story/2014/05/massachusetts-romneycare-health-care-exchange-106362">shifted to an Affordable Care Act market in 2014</a>. </p>
<h2>Why it matters</h2>
<p><a href="https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision">About 5 million to 14 million Americans</a> could soon lose their health insurance coverage through Medicaid – the government-funded U.S. health insurer for low-income Americans.</p>
<p>That’s because once the federal government designated the COVID-19 pandemic a “<a href="https://theconversation.com/1-in-4-americans-are-covered-by-medicaid-or-chip-a-program-that-insures-low-income-kids-176424">public health emergency</a>” in March 2020, it <a href="https://aspe.hhs.gov/sites/default/files/documents/15c1f9899b3f203887deba90e3005f5a/Uninsured-Q1-2022-Data-Point-HP-2022-23-08.pdf">changed Medicaid rules</a>.</p>
<p>In exchange for agreeing to <a href="https://www.kff.org/medicaid/issue-brief/medicaid-maintenance-of-eligibility-moe-requirements-issues-to-watch/">not remove anyone from the program</a>, the states got more funding to run it.</p>
<p>The number of people enrolled soared to <a href="https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision">90.9 million in September 2022</a>, up 28% from February 2020. That’s roughly 1 in 4 of all Americans.</p>
<p>But the government’s <a href="https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision">continuous enrollment policy is slated to expire</a> <a href="https://www.cnbc.com/2023/01/30/biden-administration-plans-to-end-covid-public-health-emergency-on-may-11.html">starting in April</a> and the <a href="https://abc7ny.com/biden-administration-will-end-covid-19-emergencies-on-may-11/12751912/">public health emergency is scheduled to officially end</a> on May 11, 2023.</p>
<p>Unless those whose coverage expires actively sign up for new coverage, they could become uninsured – even if, <a href="https://www.kff.org/health-reform/state-indicator/distribution-of-eligibility-for-aca-coverage-among-the-remaining-uninsured">like many uninsured Americans today</a>, they would qualify for free or discounted coverage if they were to apply <a href="https://www.healthinsurance.org/glossary/health-insurance-exchange/">through an ACA health insurance exchange</a>.</p>
<p><iframe id="2LN1J" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/2LN1J/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>What still isn’t known</h2>
<p>It’s still unclear how automatic enrollment policies can comply with the ACA’s rules to limit the number of people who will otherwise become uninsured when they lose Medicaid coverage.</p>
<p>But <a href="https://doi.org/10.1377/forefront.20180501.141197">there are a variety</a> of <a href="https://www.brookings.edu/research/making-aca-enrollment-more-automatic-for-the-newly-unemployed/">different</a> <a href="https://doi.org/10.1056/NEJMp2114189">proposals</a> out there. Some states, including <a href="https://www.marylandhealthconnection.gov/easyenrollment/">Maryland</a>, <a href="https://hbex.coveredca.com/data-research/library/CoveredCA-Medicaid-to-Marketplace-AutoenrollmentStrategy-FactSheet-v1.pdf">California</a> and – no surprise – <a href="https://www.masslegalservices.org/content/new-system-updates-online-application-mahealthconnectororg">Massachusetts</a>, are starting to experiment with different approaches.</p>
<p>So once the pandemic-related Medicaid policies end, there will probably be new evidence that suggests which design works best.</p><img src="https://counter.theconversation.com/content/197847/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Shepard has received research funding from the National Institutes of Health, the Commonwealth Fund, the Arnold Foundation, and Harvard University.</span></em></p>Evidence from Massachusetts suggests that a multistep process discourages enrollment. The findings could help policymakers stave off a sharp decline in coverage when COVID-19 policies change.Mark Shepard, Associate Professor of Public Policy, Harvard Kennedy SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1949952023-01-12T13:21:13Z2023-01-12T13:21:13ZCongress investigates presidents, the military, baseball and whatever it wants – a brief modern history of oversight<figure><img src="https://images.theconversation.com/files/504124/original/file-20230111-47547-2vxcga.jpeg?ixlib=rb-1.1.0&rect=17%2C0%2C5697%2C3795&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Speaker of the House Kevin McCarthy walks to the speaker's ceremonial office at the Capitol on Jan. 9, 2023. </span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/Congress/b9c29b908c04433fb3b7438eb8427703/photo?Query=Kevin%20McCarthy&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=now-14d&totalCount=722&currentItemNo=23">AP Photo/Jose Luis Magana</a></span></figcaption></figure><p>After regaining a slim majority in the House of Representatives in the November 2022 midterm elections, Republicans unveiled their plans for a series of <a href="https://www.cnn.com/2023/01/10/politics/gop-investigations-new-congress/index.html">investigations into the Biden administration</a>. </p>
<p>The new Republican majority – after four years in the relatively powerless minority – plans to investigate <a href="https://www.cnn.com/2022/11/17/politics/house-republicans-white-house-hunter-biden/index.html">the Biden family’s connections to foreign businesses</a>, the possible impeachment of <a href="https://www.voanews.com/a/five-key-house-republican-investigations-/6911266.html">Homeland Security Secretary Alejandro Mayorkas</a> and <a href="https://www.washingtonpost.com/politics/2022/12/20/gop-afghan-probe-worries-white-house/">the withdrawal of American troops from Afghanistan</a>.</p>
<p>Republicans will also establish a Select Committee on China to assess the growing power of what GOP House Speaker Kevin McCarthy calls “<a href="https://www.republicanleader.gov/leader-mccarthy-announces-rep-mike-gallagher-as-chairman-of-the-china-select-committee/">the greatest geopolitical threat of our lifetime</a>.”</p>
<p>And the House will establish a special Judiciary subcommittee to <a href="https://www.nytimes.com/2023/01/10/us/politics/house-republican-committee-weaponization-government.html">investigate “weaponization of the federal government</a>” and potential bias against conservatives in federal investigations. That subcommittee would give GOP Chair Jim Jordan of Ohio the power to subpoena information from ongoing Department of Justice investigations into former President Donald Trump.</p>
<p><a href="https://theconversation.com/jan-6-hearings-are-only-the-tip-of-the-iceberg-when-it-comes-to-important-congressional-oversight-hearings-185369">Investigations are a legitimate function of Congress</a>. But there’s another explanation from political science scholarship for all this digging for dirt: Congressional investigations aimed at the White House <a href="https://www.journals.uchicago.edu/doi/abs/10.1017/s0022381613001448">can diminish the president’s approval rating</a>. And House Republicans’ legislative agenda may be frustrated by the Senate Democratic majority and the veto power of Democratic President Joe Biden – they won’t be able to pass bills. </p>
<p>So it’s unsurprising that <a href="https://www.jstor.org/stable/40263459">congressional investigations increase under divided government</a>, when Congress and the presidency are controlled by opposing parties, and decrease when the president’s party allies control Congress. </p>
<p>Oversight and investigations almost always occur at the committee level and are dictated by the majority on most panels. House Republicans have the autonomy to initiate investigations into virtually any issue they choose. </p>
<h2>A political weapon?</h2>
<p>Leaders in both parties <a href="https://thehill.com/blogs/congress-blog/economy-a-budget/72494-how-oversight-should-work-rep-darrell-issa/">have stressed</a> that good oversight <a href="https://www.politico.com/magazine/story/2018/09/04/trump-investigation-house-democrats-congress-219624/">requires diligent, nonpartisan work that prioritizes fact-finding</a> over political theater. </p>
<p>Yet each party also regularly <a href="https://schiff.house.gov/news/press-releases/rep-schiff-blasts-republican-benghazi-report-">accuses the other</a> of <a href="https://www.wsj.com/articles/we-wont-talk-to-the-jan-6-committee-democrats-gop-secrets-lefitimacy-trump-weaponizing-government-power-11653597483">using oversight as a political weapon</a>. </p>
<p>Thus, to retain credibility, congressional leaders under divided government are strategic when choosing what to investigate. </p>
<p>Historically, new majorities have targeted the incumbent administration under divided government. But they have also established oversight targets that highlight pet issues, from wasteful government spending to private-sector abuses. </p>
<p>I’m <a href="https://theconversation.com/profiles/claire-leavitt-1351188">a scholar of government oversight</a> who worked as a fellow on the the House Committee on Oversight and Reform. Here are notable investigations pursued by four different Congresses since 1995. They show the range of congressional oversight, from baseball to the conduct of a president – and a would-be president. </p>
<h2>1. Republican takeover in the 104th Congress of 1995-1996</h2>
<p>In 1994, during President Bill Clinton’s first term, <a href="https://www.politico.com/story/2007/11/congress-runs-into-republican-revolution-nov-8-1994-006757">Republicans regained control of the House</a> for the first time in 40 years. They took over the Senate for the first time in eight years. </p>
<p>New House Speaker Newt Gingrich prioritized the Republicans’ reform agenda, known as the “<a href="https://web.archive.org/web/19990427174200/http://www.house.gov/house/Contract/CONTRACT.html">Contract with America</a>.” The contract emphasized Republicans’ commitment to rooting out waste, fraud and abuse in government spending, including within Congress itself. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/504086/original/file-20230111-32622-hndvs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man in a coat and tie sits in front of a microphone and gestures." src="https://images.theconversation.com/files/504086/original/file-20230111-32622-hndvs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504086/original/file-20230111-32622-hndvs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504086/original/file-20230111-32622-hndvs4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504086/original/file-20230111-32622-hndvs4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504086/original/file-20230111-32622-hndvs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=496&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504086/original/file-20230111-32622-hndvs4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=496&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504086/original/file-20230111-32622-hndvs4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=496&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">House Speaker Newt Gingrich was the first Republican to lead the House in decades.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/HouseSpeakerNewtGingrich/bd06ec65e7514f8892ad23bef050a335/photo">AP Photo/Greg Gibson</a></span>
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<p>An <a href="https://www.washingtonpost.com/archive/politics/1995/07/18/independent-house-audit-finds-millions-wasted-controls-limited/c9dd3d37-1a38-4573-9f76-94d188fd2be6/">independent private audit</a> of the House’s accounting practices commissioned by the Republican majority revealed wasteful spending by House officers and member failure to abide by House spending rules. </p>
<p>Republicans in the 104th Congress also launched major investigations into the Clinton administration. The Committee on Oversight and Government Reform held several hearings into the alleged politically motivated <a href="https://www.congress.gov/congressional-report/104th-congress/house-report/849/1">firing of seven White House Travel Office employees</a>. In 1998, an independent prosecutor concluded that <a href="https://www.chicagotribune.com/news/ct-xpm-1998-11-20-9811200161-story.html">there was no evidence to charge the Clintons for wrongdoing</a>. </p>
<p>Additionally, the Senate established a special committee to investigate property investments in the Whitewater Development Corp. made by Bill and Hillary Clinton when they were governor and first lady of Arkansas. After a 13-month investigation, the Republican majority’s final report accused the Clinton administration of “<a href="https://www.govinfo.gov/content/pkg/CRPT-104srpt280/pdf/CRPT-104srpt280.pdf">highly improper conduct</a>” but did not provide evidence of criminality.</p>
<h2>2. Democratic takeover in the 110th Congress, 2007-2008</h2>
<p>In the midterm elections of 2006, during President George W. Bush’s second term, <a href="https://www.washingtonpost.com/politics/2022/11/16/house-control-by-year/">Democrats won control of both chambers</a>. </p>
<p>Democrats devoted significant attention to oversight of nongovernment organizations. <a href="https://www.govinfo.gov/content/pkg/CHRG-110hhrg55749/pdf/CHRG-110hhrg55749.pdf">They investigated the use of steroids in professional baseball</a> and <a href="https://www.govinfo.gov/content/pkg/CHRG-110hhrg45219/pdf/CHRG-110hhrg45219.pdf">abuses of private security contractors</a> in Iraq and Afghanistan. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/504088/original/file-20230111-17-474ltv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Three men sit in suits sit at a table, with a chart behind them showing oil company profits rising over time." src="https://images.theconversation.com/files/504088/original/file-20230111-17-474ltv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504088/original/file-20230111-17-474ltv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=423&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504088/original/file-20230111-17-474ltv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=423&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504088/original/file-20230111-17-474ltv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=423&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504088/original/file-20230111-17-474ltv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=531&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504088/original/file-20230111-17-474ltv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=531&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504088/original/file-20230111-17-474ltv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=531&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The House Energy Independence and Global Warming Committee investigated oil company profits and other issues relating to climate change.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/from-left-rep-jay-inslee-d-wash-and-rep-earl-blumenauer-d-news-photo/99576140">Bill Clark/Roll Call/Getty Images</a></span>
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<p>Democrats also investigated the Bush administration’s handling of the Iraq War, as well as intelligence failures <a href="https://www.intelligence.senate.gov/sites/default/files/publications/110345.pdf">in the run-up to the 2003 invasion</a>. </p>
<p>The new Democratic majority also elevated issues it believed Bush had neglected. For instance, <a href="https://www.markey.senate.gov/imo/media/globalwarming/mediacenter/pressreleases_id=0045.html#main_content">accusing Republicans of “play[ing] the politics of climate change denial</a>,” House Democrats established the <a href="https://www.markey.senate.gov/imo/media/globalwarming/index.html">Select Committee on Energy Independence and Global Warming</a>. </p>
<p>The committee held 80 hearings over the next four years to investigate, among other issues, the influence of the oil and gas industry on <a href="https://www.markey.senate.gov/imo/media/globalwarming/mediacenter/pressreleases_2008_id=0059.html#main_content">policy made by the Environmental Protection Agency</a>. </p>
<h2>3. Republican majority in the 112th Congress, 2011-2012</h2>
<p>In the 2010 midterm elections during President Barack Obama’s first term, Republicans recaptured the House majority. <a href="https://www.cbsnews.com/news/obamas-2010-shellacking-is-like-bushs-2006-thumping/">Obama described it as a “shellacking</a>.”</p>
<p>House Republicans focused their attention on examining a range of issues, including <a href="https://www.congress.gov/event/112th-congress/house-event/LC3118/text?s=1&r=15">Islamic radicalization</a> and <a href="https://oversight.house.gov/hearing/impact-of-obamacare-on-job-creators-and-their-decision-to-offer-health-insurance/">the economic impacts of the Affordable Care Act</a>. </p>
<p>Republicans also aggressively conducted oversight of the Obama administration. House and Senate committees launched a major investigation into the so-called “<a href="https://www.grassley.senate.gov/news/news-releases/grassley-issa-release-first-part-final-joint-report-operation-fast-and-furious">Fast and Furious” gun-running operation at the Department of Justice</a>. The inquiry led to the House’s holding Attorney General Eric Holder <a href="https://www.politico.com/story/2012/06/holder-held-in-contempt-of-congress-077988">in contempt of Congress</a> for failing to respond to committee subpoenas. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/504089/original/file-20230111-26-r0cqi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A row of men in suits sit at a table. One leans forward and gestures with his hand." src="https://images.theconversation.com/files/504089/original/file-20230111-26-r0cqi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504089/original/file-20230111-26-r0cqi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504089/original/file-20230111-26-r0cqi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504089/original/file-20230111-26-r0cqi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504089/original/file-20230111-26-r0cqi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504089/original/file-20230111-26-r0cqi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504089/original/file-20230111-26-r0cqi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Led by South Carolina Republican Trey Gowdy, second from right, the House Select Committee on Benghazi investigated a 2012 attack on a U.S. consulate in Libya.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/BenghaziInvestigation/3bf01f8d31df443bafd8b865172240e5/photo">AP Photo/Carolyn Kaster</a></span>
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<p>Toward the end of the 112th Congress, Republicans also began to investigate the Obama administration’s handling of the <a href="https://www.cnn.com/2013/09/10/world/benghazi-consulate-attack-fast-facts/index.html">deadly terrorist attacks on the American consulate in Benghazi, Libya</a>, on the night of Sept. 11, 2012. In the next Congress, Republicans established a special committee <a href="https://www.congress.gov/114/crpt/hrpt848/CRPT-114hrpt848.pdf">dedicated to investigating the Benghazi attacks</a>.</p>
<p>That investigation revealed that when she was secretary of state Hillary Clinton had used a private email server, not the government server she was required to use. The ensuing scandal may have contributed to Clinton’s <a href="https://fivethirtyeight.com/features/the-comey-letter-probably-cost-clinton-the-election/">loss to Trump in the 2016 presidential election</a>. </p>
<h2>4. Democrats take over House in the 116th Congress, 2019-2020</h2>
<p>In the <a href="https://newsroom.ap.org/detail/Congress/0bf43b961da74226ab031cb7d9230c5c/photo">2018 midterm elections</a> during Trump’s term, Democrats regained control of the House. </p>
<p>The new majority quickly turned its attention to the Trump administration. In one of the first high-profile hearings of the 116th Congress, the House Oversight and Reform Committee <a href="https://www.youtube.com/watch?v=8rKCWG0VOYw">heard testimony from former Trump lawyer Michael Cohen</a> about, among other issues, Trump’s alleged payments to adult film star Stormy Daniels.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/504093/original/file-20230111-46586-883wtq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A group of men and women in suits stands around a wooden table." src="https://images.theconversation.com/files/504093/original/file-20230111-46586-883wtq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504093/original/file-20230111-46586-883wtq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504093/original/file-20230111-46586-883wtq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504093/original/file-20230111-46586-883wtq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504093/original/file-20230111-46586-883wtq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504093/original/file-20230111-46586-883wtq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504093/original/file-20230111-46586-883wtq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Democrats in the U.S. House investigated President Donald Trump’s income tax returns.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/democratic-members-of-the-house-ways-and-means-committee-news-photo/1245766550">Kent Nishimura / Los Angeles Times via Getty Images</a></span>
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<p>The House Ways and Means Committee began its quest to obtain Trump’s tax returns as part of its probe into accounting practices at the Internal Revenue Service. This investigation led to a <a href="https://www.nytimes.com/2022/11/22/us/supreme-court-trump-taxes-house-democrats.html">protracted legal battle</a> and culminated in a <a href="https://www.cnn.com/2022/12/20/politics/trump-tax-summary-ways-and-means-committee/index.html">final report issued at the end of 2022</a> and the <a href="https://int.nyt.com/data/documenttools/house-ways-and-means-trump-tax-report/ee70519acd75513e/full.pdf">public release of six years of Trump’s returns</a> soon after. </p>
<p>And in the fall of 2019, the House began its impeachment inquiry into allegations that Trump had threatened to withhold military aid to Ukraine in order to <a href="https://www.govinfo.gov/app/details/CDOC-116sdoc13/context">damage one of his primary political opponents, Joe Biden</a>. Trump was impeached by the House for abuse of power and obstruction of justice, though he was acquitted by the Senate in February 2020. </p>
<p>Democrats also launched major inquiries into the private sector, including into <a href="https://www.washingtonpost.com/health/2021/12/10/house-democrats-find-three-year-investigation-that-drug-prices-are-unsustainable-unjustifiable-unfair/">drug-pricing practices in the pharmaceutical industry</a> and the <a href="https://www.cnn.com/2019/06/13/politics/juul-house-investigation-krishnamoorthi-health/index.html">marketing of e-cigarettes to teenagers</a>. </p>
<h2>It’s all legit</h2>
<p><a href="https://www.washingtonpost.com/politics/2023/01/10/house-vote-republicans-committee-investigate-government/">A Washington Post headline</a> on Jan. 10, 2023, described one of the newly announced GOP probes this way: “House Republicans form committee to investigate the government.” </p>
<p>That’s a broad brief for a committee. But the range of past investigations has shown that Congress can, essentially, investigate what it wants to investigate. Baseball one year, government the next.</p><img src="https://counter.theconversation.com/content/194995/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Leavitt has received funding from the Project on Government Oversight (POGO) and the Levin Center for Oversight and Democracy. </span></em></p>The House GOP has announced a slew of investigations, including a review of the conduct of the Department of Justice and its investigations of Donald Trump.Claire Leavitt, Assistant Professor of Government, Smith CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1904942022-09-20T15:21:32Z2022-09-20T15:21:32ZMedicaid enrollment soared by 25% during the COVID-19 pandemic – but a big decline could happen soon<figure><img src="https://images.theconversation.com/files/485409/original/file-20220919-376-q3sx0f.jpg?ixlib=rb-1.1.0&rect=211%2C50%2C6498%2C4194&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Growth outpaced new enrollment from the Affordable Care Act's Medicaid expansion.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/doctor-wearing-surgical-mask-examining-royalty-free-image/1349349174">bymuratdeniz/E+via Getty Images</a></span></figcaption></figure><figure class="align-center zoomable">
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<p>Medicaid, the government-funded U.S. health insurer for people with low incomes, <a href="https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-chip-enrollment-data/monthly-medicaid-chip-application-eligibility-determination-and-enrollment-reports-data/index.html">grew by about 25%</a> between February 2020 and May 2022 as <a href="https://www.kff.org/medicaid/issue-brief/medicaid-maintenance-of-eligibility-moe-requirements-issues-to-watch/">policies adopted at the outset of the COVID-19 pandemic</a> expanded the program’s reach.</p>
<p>All told, the number of people enrolled in Medicaid and the <a href="https://www.cms.gov/newsroom/news-alert/cms-releases-latest-enrollment-figures-medicare-medicaid-and-childrens-health-insurance-program-chip">Children’s Health Insurance Program</a>, or CHIP, which serves kids in families with low to moderate incomes, <a href="https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-chip-enrollment-data/monthly-medicaid-chip-application-eligibility-determination-and-enrollment-reports-data/index.html">increased from 71 million to 89 million</a>. That’s roughly 27% of all Americans.</p>
<p>The pandemic-related increase in Medicaid enrollment was slightly larger than the <a href="https://www.macpac.gov/subtopic/medicaid-enrollment-changes-following-the-aca/">24.7% increase seen after the Affordable Care Act</a> (ACA) expanded Medicaid for adults, starting in 2014.</p>
<p>But unlike Medicaid expansion under the ACA, these pandemic policies are temporary. They will end once the federal government’s COVID-19 public health emergency expires. Some experts predict Medicaid enrollment could fall by as many as <a href="https://www.urban.org/sites/default/files/publication/104785/what-will-happen-to-unprecedented-high-medicaid-enrollment-after-the-public-health-emergency_0.pdf">15 million</a> people when this happens, <a href="https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/index.html">disrupting health care</a> for many Americans.</p>
<p>In a new article we published in the <a href="http://doi.org/10.1001/jama.2022.14791">Journal of the American Medical Association</a> on Sept. 20, 2022, we examine how Medicaid serves Americans, analyze the program’s importance for health equity, and assess how Medicaid grew and changed during the COVID-19 pandemic. </p>
<p>As <a href="https://scholar.google.com/citations?hl=en&user=I6Sh5rEAAAAJ">health policy</a> <a href="https://scholar.google.com/citations?user=PunTAhEAAAAJ&hl=en&oi=ao">researchers</a>, we believe that Medicaid’s growth since 2020 highlights the program’s importance during economic and public health crises. It also underscores how painful the unwinding of these pandemic policies is likely to be to those who may end up uninsured.</p>
<p><iframe id="q3La8" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/q3La8/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Federal changes</h2>
<p>In March 2020, Congress passed the first of several large spending packages, called the <a href="https://theconversation.com/why-states-didnt-go-broke-from-the-pandemic-157471">Families First Coronavirus Response Act</a>. To help states shoulder increased Medicaid costs associated with the pandemic, that measure increased the share of Medicaid spending the federal government pays for by 6.2 percentage points in all states.</p>
<p>This aid has made a big difference for states, which <a href="https://www.kff.org/wp-content/uploads/2013/01/8352.pdf">split the costs of Medicaid with the federal government</a>. Before the pandemic, the federal government was paying about 65% of Medicaid’s costs overall, with the precise share varying based on a state’s average income. States picked up the other 35% of Medicaid costs. These costs accounted for <a href="https://www.nasbo.org/reports-data/state-expenditure-report/state-expenditure-archives">more than one-fourth</a> of state budgets before the pandemic.</p>
<p>The extra federal money for Medicaid came with an important requirement: states accepting funds <a href="https://www.kff.org/medicaid/issue-brief/medicaid-maintenance-of-eligibility-moe-requirements-issues-to-watch/">could not remove anyone from Medicaid</a> who was enrolled as of March 2020 or gained Medicaid afterwards – as long as the official public health emergency, <a href="https://www.federalregister.gov/documents/2020/03/18/2020-05794/declaring-a-national-emergency-concerning-the-novel-coronavirus-disease-covid-19-outbreak">first declared on Jan. 31, 2020</a>, remained in effect. These <a href="https://aspe.hhs.gov/sites/default/files/documents/404a7572048090ec1259d216f3fd617e/aspe-end-mcaid-continuous-coverage_IB.pdf">policies also applied to CHIP</a>. </p>
<p><a href="https://www.urban.org/sites/default/files/publication/104785/what-will-happen-to-unprecedented-high-medicaid-enrollment-after-the-public-health-emergency_0.pdf">All 50 states and the District of Columbia </a> accepted the higher federal payments in exchange for keeping Medicaid enrollment stable during the pandemic.</p>
<h2>Greater stability</h2>
<p>These changes helped to address longstanding instability in Medicaid coverage for many people. Before the pandemic, <a href="https://www.kff.org/medicaid/issue-brief/unwinding-the-phe-what-we-can-learn-from-pre-pandemic-enrollment-patterns/">nearly 25%</a> of those with Medicaid would enter or exit the program each year as their short-term circumstances changed.</p>
<p><a href="https://www.kff.org/medicaid/issue-brief/unwinding-the-phe-what-we-can-learn-from-pre-pandemic-enrollment-patterns/">People would lose Medicaid coverage</a> when their income ticked up, their family circumstances changed, they aged out of CHIP, or they failed to complete required paperwork. Losing Medicaid coverage can lead to someone ending up <a href="https://aspe.hhs.gov/sites/default/files/migrated_legacy_files/199881/medicaid-churning-ib.pdf">without any health insurance</a> at all, which increases the likelihood they will postpone or never get needed care. Having the same people frequently entering and exiting the program also increases the program’s administrative costs over time.</p>
<p>Changes to Medicaid policy in response to the pandemic made it much easier for everyone enrolled in Medicaid to keep their coverage. To illustrate, just over half of Wisconsin’s Medicaid growth in 2020 came from that state <a href="http://doi.org/10.1001/jamahealthforum.2021.4752">keeping existing enrollees in the program</a> who might otherwise have lost coverage for at least a few months.</p>
<p>Young adults, especially those <a href="http://doi.org/10.1001/jamahealthforum.2022.1996">aged 18 and 19</a>, and Americans who <a href="http://doi.org/10.1377/hlthaff.2016.1241">recently gave birth</a> are two groups that benefited from this change in Medicaid policy.</p>
<h2>What’s next</h2>
<p>Even with many aspects of daily life getting back to normal, and <a href="https://www.cbsnews.com/news/biden-covid-pandemic-over/">President Joe Biden’s comments to the media</a> about the pandemic being “over,” the official public health emergency that spurred Medicaid enrollment growth still remains in force.</p>
<p>When the <a href="https://aspr.hhs.gov/legal/PHE/Pages/covid19-15jul2022.aspx">government renewed the declaration for the 10th time</a> in July 2022, it set a <a href="https://www.asha.org/news/2022/federal-public-health-emergency-updates-for-2022/">new expiration date of Oct. 13, 2022</a>. The administration also said it would provide states with 60 days notice before it would end the federal emergency declaration, which suggests the declaration will be renewed at least one more time.</p>
<p>When the emergency ends, states will have to reevaluate eligibility for everyone with Medicaid within <a href="https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/index.html">12 months</a>. Extra federal funding for states will also end.</p>
<p>These changes will have profound consequences. Millions of people will have to reestablish their eligibility for Medicaid and are at risk of losing coverage if they do not complete the required paperwork on time.</p>
<p>The administration may ultimately decide to renew the COVID-19 emergency declaration again, as <a href="https://covid.cdc.gov/covid-data-tracker/#trends_dailydeaths_select_00">hundreds of Americans are still dying</a> daily from the disease. Keeping it in place would prevent a massive drop in Medicaid enrollment and make it easier to continue other COVID-19 public health policies, such as making <a href="https://www.kff.org/coronavirus-covid-19/issue-brief/what-happens-when-covid-19-emergency-declarations-end-implications-for-coverage-costs-and-access/">free COVID-19 testing and vaccinations</a> <a href="https://www.cnbc.com/2022/09/03/how-you-can-still-get-at-home-covid-tests-for-free.html">widely available</a>.</p>
<p>Beyond extending the public health emergency, we believe that states and the federal government can seek new ways to <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2788765">minimize disruptions</a> in coverage and to make Medicaid <a href="https://aspe.hhs.gov/sites/default/files/migrated_legacy_files/199881/medicaid-churning-ib.pdf">more accessible</a> to the millions of Americans who depend on it for health insurance.</p><img src="https://counter.theconversation.com/content/190494/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julie Donohue receives funding from the Pennsylvania Department of Human Services. </span></em></p><p class="fine-print"><em><span>Eric T. Roberts does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Pandemic-related policies made it easier for states to afford to cover more people and made that coverage more stable for millions of Americans who rely on the program for health care.Julie Donohue, Professor and Chair of Health Policy and Management, University of PittsburghEric T. Roberts, Assistant Professor of Health Policy and Management, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1878172022-09-15T12:22:25Z2022-09-15T12:22:25ZIn states where abortion is banned, children and families already face an uphill battle<figure><img src="https://images.theconversation.com/files/482819/original/file-20220905-14-wr41ei.jpg?ixlib=rb-1.1.0&rect=21%2C26%2C3540%2C2344&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Of the 10 most child-friendly states, only one has attempted to ban abortion.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/katherine-merlos-a-pre-k-3-student-centron%C3%ADa-gives-a-thumbs-news-photo/1239430403">Sarah L. Voisin/The Washington Post via Getty Images</a></span></figcaption></figure><p>Some proponents of abortion bans and restrictions say they are concerned about “supporting not just life,” but what they call “<a href="https://missouriindependent.com/2022/07/06/states-with-strong-antiabortion-laws-have-high-maternal-and-infant-mortality-rates/">quality of life worth living</a>,” saying they want to <a href="https://www.theatlantic.com/politics/archive/2022/06/anti-abortion-movement-dobbs-roe-overturned/661393/">promote laws and policies that help families</a>. Three authors from Brigham Young University, for instance, have noted that the overturning of Roe v. Wade provides a “<a href="https://www.thepublicdiscourse.com/2022/06/82906/">genuine opportunity for pro-lifers to work with people of diverse political persuasions</a> to seek a more just and compassionate world. This world would be not only pro-life, but also pro-child, pro-parent and pro-family.”</p>
<p>U.S. Sen. Mitt Romney of Utah is one of three Republicans in the Senate who have sponsored a bill called the <a href="https://www.romney.senate.gov/romney-family-security-act-2-0-one-of-the-most-important-efforts-to-support-the-family-in-nearly-thirty-years/">Family Security Act</a>, billed as a “pro-family, pro-life and pro-marriage plan” that would provide a monthly cash benefit starting at pregnancy and continuing through the child turning 17.</p>
<p>But so far, these are <a href="https://www.theatlantic.com/politics/archive/2022/06/anti-abortion-movement-dobbs-roe-overturned/661393/">minority voices</a> in the anti-abortion movement. </p>
<p>As a law professor who <a href="https://scholar.google.com/citations?user=gCJEShUAAAAJ&hl=en&oi=ao">studies reproductive care</a>, policies that affect families and political partisanship, I have been following the relationship between <a href="https://www.urban.org/urban-wire/research-shows-access-legal-abortion-improves-womens-lives">abortion restrictions and family well-being</a> for decades. It turns out that states taking the strictest stands against abortion tend to have among the <a href="https://www.nytimes.com/2022/07/28/upshot/abortion-bans-states-social-services.html">worst statistics</a> on child and family well-being in the nation.</p>
<h2>Unintended pregnancy and infant mortality</h2>
<p>Take Mississippi, the state that enacted the abortion restriction law that was at the center of the Supreme Court’s June 2022 opinion in <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">Dobbs v. Jackson Women’s Health Organization</a>, which struck down federal protection for the right to get an abortion. </p>
<p>In 2019, Mississippi had the <a href="https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/unintended_pregnancy/state/U.S">highest rate of unintended pregnancy</a>, defined as the percentage of women who recently gave birth but whose pregnancies were either <a href="https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/index.htm">unwanted or happened at an unwanted time</a>. In Mississippi, 47% of women who recently had a child did not want to become pregnant or wanted to become pregnant later in life.</p>
<p>By contrast, Vermont had the nation’s lowest rate of unintended pregnancy in 2019, with <a href="https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/unintended_pregnancy/state/U.S">just 20% of women who recently had a child</a> saying they would have preferred not to get pregnant or wanted to do so at some point in the future. That state already protects abortion rights. If Vermont’s <a href="https://www.wcax.com/2022/06/23/will-vermont-become-abortion-haven-if-scotus-upends-roe-v-wade/">upcoming referendum on abortion</a> passes, the state’s constitution will protect “<a href="https://legislature.vermont.gov/Documents/2022/Docs/BILLS/PR0005/PR0005%20As%20adopted%20by%20the%20Senate%20Official.pdf">an individual’s right to personal reproductive autonomy</a>.”</p>
<p>Mississippi also has the <a href="https://www.cdc.gov/nchs/pressroom/sosmap/infant_mortality_rates/infant_mortality.htm">highest infant mortality rate</a> in the country. Five of the other nine states with the highest infant mortality <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">also have abortion bans</a>. At the other end of the spectrum, of the 10 states with the lowest infant mortality rates, <a href="https://www.cdc.gov/nchs/pressroom/sosmap/infant_mortality_rates/infant_mortality.htm">only one – Iowa</a> – has a law restricting abortions, <a href="https://www.kcci.com/article/governor-kim-reynolds-announces-legal-actions-regarding-abortion-in-iowa/40449729">although a court has prevented its enforcement</a>.</p>
<h2>Childhood poverty and teen birth rates</h2>
<p>Mississippi has the <a href="https://www.census.gov/acs/www/data/data-tables-and-tools/ranking-tables/">highest rate of child poverty in the country</a>. Six of the other 10 states with the country’s highest child poverty levels also have <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">abortion bans in effect</a>: Louisiana, Arkansas, Kentucky, Alabama, Oklahoma and Tennessee.</p>
<p>Mississippi also had the <a href="https://www.cdc.gov/nchs/pressroom/sosmap/teen-births/teenbirths.htm">highest teen birth rate in the country</a>, and eight of the other nine states with the highest teen birth rates also <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">ban abortions or have a ban blocked</a>.</p>
<p>In all 10 states with the lowest teen birth rates, <a href="https://www.washingtonpost.com/politics/2022/06/24/abortion-state-laws-criminalization-roe/">abortion is legal</a> and likely to be protected for the foreseeable future.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A pregnant person has a written message on the skin of her belly: 'My daughter deserves a choice'" src="https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A pregnant activist calls for abortion rights in Chicago on June 25, 2022.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/pregnant-woman-takes-part-in-a-protest-in-downtown-chicago-news-photo/1241562432?adppopup=true">Vincent D. Johnson/Xinhua via Getty Images)</a></span>
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<h2>Supporting families</h2>
<p>The well-being of children also depends on the availability of support for their parents.</p>
<p>For instance, <a href="https://www.ncsl.org/research/labor-and-employment/state-family-and-medical-leave-laws.aspx">11 states plus the District of Columbia legally require employers</a> to offer workers paid time off after the birth or adoption of a child. None of those jurisdictions <a href="https://www.washingtonpost.com/politics/2022/06/24/abortion-state-laws-criminalization-roe/">bans abortions</a>.</p>
<p>Another federal effort to support families came in the Affordable Care Act, enacted in 2010, with <a href="https://www.healthcare.gov/glossary/affordable-care-act/">sweeping changes</a> to the nation’s health insurance marketplace. One provision allowed states to <a href="https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/">expand Medicaid eligibility</a> to more adults, with financial support from the federal government. If Medicaid were expanded, <a href="https://www.urban.org/research/publication/3-7-million-people-would-gain-health-coverage-2023-if-remaining-12-states-were">reproductive-aged women</a> would be among the groups to experience the largest coverage gains.</p>
<p>As of August 2022, <a href="https://www.urban.org/research/publication/3-7-million-people-would-gain-health-coverage-2023-if-remaining-12-states-were">12 states</a> had not adopted the expansion: Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin and Wyoming. <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">Eight of those states</a> have either a full ban on abortion or a ban after six weeks – before many people realize they are pregnant.</p>
<p>Two of those states, <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">South Carolina and Wyoming</a>, have abortion <a href="https://www.npr.org/2022/08/04/1115542013/wyomings-new-ban-on-abortions-has-been-temporarily-blocked">laws that are tied up in the courts</a>, and Florida bans abortions after 15 weeks. </p>
<p>In a June 2022 <a href="https://www.brookings.edu/blog/up-front/2022/06/30/the-end-of-roe-will-create-more-inequality-of-opportunity-for-children/">Brookings Institution study</a> of the states that are considered most child-friendly – measured by state expenditures per child and children’s overall well-being – the authors found that among the top 10, only Wyoming was <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">even trying to ban abortion</a>. For the 10 states Brookings rated least child-friendly, nine either had a trigger ban or other abortion restriction.</p>
<p>The overall pattern is clear: A strong social safety net and other anti-poverty programs <a href="https://www.nytimes.com/2022/07/13/opinion/abortion-romney-child-tax-credit.html">are more likely to be available</a> in states that also support abortion access, while actual measures of child and family well-being are often worse in states that restrict abortions.</p><img src="https://counter.theconversation.com/content/187817/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Naomi Cahn does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>States taking the strictest stands against abortion tend to have among the worst statistics in the nation on child and family well-being.Naomi Cahn, Professor of Law, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1903172022-09-13T12:33:27Z2022-09-13T12:33:27ZFree preventive care under the ACA is under threat again – a ruling exempting PrEP from insurance coverage may extend nationwide and to other health services<figure><img src="https://images.theconversation.com/files/484101/original/file-20220912-5769-hqsuwm.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C683&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">PrEP is almost 100% effective in preventing HIV infection when taken as directed.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/thembelani-sibanda-shows-the-pre-exposure-prophylaxis-an-news-photo/888296568">The Times/Gallo Images via Getty Images Editorial</a></span></figcaption></figure><p>Many Americans breathed a sigh of relief when the Supreme Court left the Affordable Care Act in place following the law’s <a href="https://www.supremecourt.gov/opinions/20pdf/19-840_6jfm.pdf">third major legal challenge</a> in June 2021. This decision left <a href="https://source.wustl.edu/2017/02/americans-divided-on-obamacare-repeal-poll-finds/">widely supported policies</a> in place, like ensuring coverage <a href="https://www.healthcare.gov/coverage/pre-existing-conditions/">regardless of preexisting conditions</a>, coverage for <a href="https://www.healthcare.gov/young-adults/children-under-26/">dependents up to age 26</a> on their parents’ plan, and removal of <a href="https://www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits/">annual and lifetime benefit limits</a>.</p>
<p>But the hits keep coming. One of the most popular benefits offered by the ACA, <a href="https://www.kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/">free preventive care</a>, is under legal threat again by <a href="https://www.vox.com/policy-and-politics/2022/9/7/23341076/obamacare-reed-oconnor-prep-supreme-court-braidwood-becerra-affordable-care-act">Braidwood Management v. Becerra</a> – originally Kelley v. Becerra. The Braidwood plaintiffs are a mix of individuals and business owners who object to purchasing insurance that covers preexposure prophylaxis – or PrEP – a medicine that is <a href="https://www.cdc.gov/hiv/basics/prep/prep-effectiveness.html">almost 100% effective</a> in preventing HIV infection. One of the plaintiffs claimed that PrEP “facilitates and encourages homosexual behavior, intravenous drug use, and sexual activity outside of marriage between one man and one woman” and that his religious beliefs prevent him from providing insurance that covers PrEP.</p>
<p>On Sep. 7, 2022, Texas Judge Reed O’Connor issued a <a href="https://affordablecareactlitigation.files.wordpress.com/2022/09/gov.uscourts.txnd_.330381.92.0_1.pdf">ruling</a> that the requirement for insurance plans to cover PrEP violated the religious freedom of the plaintiffs. He also ruled that the ACA overstepped in delegating decisions about cost-sharing for preventive care to the U.S. Preventive Services Task Force. Who this ruling will ultimately affect and whether it will eventually get rid of the requirement to fully cover other preventive care, like free flu shots and cancer screening, has <a href="https://www.healthaffairs.org/content/forefront/court-holds-key-aca-preventive-services-requirements-unconstitutional">yet to be confirmed</a>.</p>
<p>We are public health researchers at <a href="https://www.bu.edu/sph/profile/paul-shafer/">Boston University</a> and <a href="https://sph.tulane.edu/sbps/kristefer-stojanovski-phd-mph">Tulane University</a> who study health insurance, prevention and sexual health. With this policy now in jeopardy, prevention and the push for health equity in the U.S. stand to take a big step backward.</p>
<h2>The ACA and preventive care</h2>
<p><a href="https://www.law.cornell.edu/cfr/text/29/2590.715-2713">Section 2713</a> of the ACA requires insurers to offer <a href="https://www.healthcare.gov/coverage/preventive-care-benefits/">full coverage of preventive services</a> that are endorsed by one of three federal groups: the U.S. Preventive Services Task Force (with an A or B rating), the Advisory Committee on Immunization Practices and the Health Resources and Services Administration. If they recommend the procedure or intervention as important preventive care, then you shouldn’t have to pay anything out of pocket. For example, <a href="https://www.congress.gov/bill/116th-congress/house-bill/748/">the CARES Act</a> used this provision to ensure COVID-19 vaccines would be free for many Americans.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Healthcare provider examining child in exam room." src="https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Affordable Care Act significantly reduced the costs of well-child visits since it was instated.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/girl-having-checkup-in-doctors-office-royalty-free-image/153337724">John Fedele/The Image Bank via Getty Images</a></span>
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</figure>
<p>PrEP received an <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis">A rating</a> in June 2019, paving the way for both PrEP and related services like clinic visits and lab tests to be covered at no cost for millions of people. </p>
<p>Though Section 2713 of the ACA <a href="https://doi.org/10.1016/j.ypmed.2021.106690">doesn’t work perfectly</a>, sometimes leaving patients frustrated by <a href="https://www.washingtonpost.com/national/health-science/getting-charged-for-free-preventive-care/2014/01/17/98fbd1fa-7ec2-11e3-95c6-0a7aa80874bc_story.html">unexpected bills</a>, it has made a huge difference in reducing costs for services like <a href="https://doi.org/10.1001/jamanetworkopen.2021.1248">well-child visits</a> and <a href="https://doi.org/10.1097/MLR.0000000000000610">mammograms</a>, just to name a few.</p>
<h2>The legal arguments</h2>
<p>The latest case rested on <a href="https://theconversation.com/the-next-attack-on-the-affordable-care-act-may-cost-you-free-preventive-health-care-166087">legal technicalities</a> that have nothing to do with PrEP, but rather whether the U.S. Preventive Services Task Force can wield the authority granted to them by the ACA, and whether the religious freedom of the plaintiffs was violated.</p>
<p>O’Connor <a href="https://www.healthaffairs.org/content/forefront/court-holds-key-aca-preventive-services-requirements-unconstitutional">agreed</a> that allowing the U.S. Preventive Services Task Force this authority violated the <a href="https://www.law.cornell.edu/constitution/articleii">appointments clause</a> of the Constitution, which specifies that people using government powers must be “officers of the United States.” In this case, O'Connor ruled that U.S. Preventive Services Task Force members do qualify as officers, but their appointment is unconstitutional because they are not appointed by the President and confirmed by the Senate.</p>
<p>This paves the way for the repeal of Section 2713 and allowing insurers to decide what, if any, preventive care would remain free to patients in their plans. He also argued that because the ACA “force[s] Braidwood to [cover] services to which it holds sincere religious objections … offering coverage is itself a tacit endorsement of the behaviors that [the plaintiff] believes the services encourage.”</p>
<h2>Losing access to preventive care</h2>
<p>PrEP is a major component of the prevention pillar of the United States’ “<a href="https://www.cdc.gov/endhiv/about.html">Ending the HIV Epidemic</a>” initiative and has <a href="https://www.aidsmap.com/news/sep-2019/prep-reducing-hiv-diagnoses-us-cities-independently-effect-treatment">successfully reduced HIV diagnosis rates</a> in areas where it is highly used. If this ruling were to extend nationally, over <a href="https://dx.doi.org/10.1016%2Fj.annepidem.2018.06.009">170,000 current PrEP users</a> and <a href="https://doi.org/10.1016/j.annepidem.2018.05.003">over 1 million people</a> who can benefit from this medicine could be affected.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Red ribbon hanging from the North Portico of the White House" src="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">PrEP is a key tool to helping the U.S. reach its goal of substantially reducing new HIV infections by 2030.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/ObamaWorldAidsDay/c146dee7e944420482f3e5786d4d2e50">AP Photo/Pablo Martinez Monsivais</a></span>
</figcaption>
</figure>
<p>Removing the cost barrier to PrEP made it more accessible with commercial insurance, the primary source of health coverage for <a href="https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202108-508.pdf">over two-thirds of the population</a> under age 65. Raising the cost barrier again would <a href="https://doi.org/10.1001/jamanetworkopen.2021.22692">disproportionately harm</a> younger patients, people of color and those with lower incomes. Black men who have sex with men could be particularly affected because of the structural barriers they face, despite having <a href="https://doi.org/10.1016/S0140-6736(12)60899-X">no more “risky” sexual behavior</a> on average than other men who have sex with men.</p>
<h2>What’s next?</h2>
<p>For now, the religious freedom portion of the ruling is specific to PrEP and Braidwood Management’s purchase of plans that cover PrEP. It is unclear whether the order will apply only to these plaintiffs or nationwide. </p>
<p>The next filings, where both sides will begin to provide more information on how they believe the ruling should be applied, are due by <a href="https://storage.courtlistener.com/recap/gov.uscourts.txnd.330381/gov.uscourts.txnd.330381.94.0_1.pdf">Sept. 16, 2022</a>. As of yet, there is no timeline for a concrete decision.</p>
<p>For the time being, access to PrEP, contraception, cancer screenings and all other forms of preventive care made free by the ACA continue to be available. Regardless of O’Connor’s final decision, this case seems likely to be appealed to the Supreme Court, where another showdown over the fate of a substantial part of the ACA will be decided.</p>
<p><em>Portions of this article originally appeared in previous articles published on <a href="https://theconversation.com/the-next-attack-on-the-affordable-care-act-may-cost-you-free-preventive-health-care-166087">Sep. 7, 2021</a> and <a href="https://theconversation.com/hiv-prevention-pill-prep-is-now-free-under-most-insurance-plans-but-the-latest-challenge-to-the-affordable-care-act-puts-this-benefit-at-risk-171086">Dec. 1, 2021</a>.</em></p><img src="https://counter.theconversation.com/content/190317/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Shafer has received funding in the past three years from the Commonwealth Fund, Arnold Ventures, Robert Wood Johnson Foundation, Kate B. Reynolds Charitable Trust, Starbucks Coffee Company, and Renova Health.</span></em></p><p class="fine-print"><em><span>Kristefer Stojanovski has received funding in the past from the Robert Wood Johnson Foundation, the National Institute of Minority Health & Health Disparities, the National Institute of Mental Health, and the Fulbright Program</span></em></p>Judge Reed O'Connor ruled in a case that coverage for HIV prevention medicine PrEP violated the religious freedom of the plaintiffs. It is unclear whether the order will extend nationwide.Paul Shafer, Assistant Professor of Health Law, Policy and Management, Boston UniversityKristefer Stojanovski, Research Assistant Professor of Social, Behavioral and Population Sciences, Tulane UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1767772022-02-24T13:53:50Z2022-02-24T13:53:50ZWhen parents get Medicaid, it can benefit the health of their kids too<figure><img src="https://images.theconversation.com/files/446819/original/file-20220216-14-18uvj8q.jpg?ixlib=rb-1.1.0&rect=59%2C81%2C4883%2C3297&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Millions of low-income Americans have gained health insurance through the Affordable Care Act.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/black-mother-with-baby-reading-pill-bottle-royalty-free-image/187137286">Ariel Skelley/DigitalVision via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>Low-income parents who live in <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map">states that expanded their Medicaid programs</a> under the Affordable Care Act are 4.7% more likely to say they are in good health than their peers in states that have declined to take this step, according to new research I co-authored. </p>
<p>In addition, children of low-income parents living in states that have expanded their Medicaid programs have a 2% lower growth in <a href="https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm">body mass index</a>, suggesting improvement in their health as well. Preventing excessive weight gain for school-aged children is a priority due to linkages with <a href="https://doi.org/10.1542/peds.101.3.e5">adult obesity</a> and other <a href="https://doi.org/10.1016/j.ehb.2012.05.003">health concerns</a>.</p>
<p>These are the <a href="https://doi.org/10.1016/j.ehb.2021.101098">main findings from a study</a> <a href="https://scholar.google.com/citations?user=WxA-LzcAAAAJ&hl=en&oi=ao">I conducted</a> with <a href="https://scholar.google.com/citations?hl=en&user=6cbDgj0AAAAJ">Caitlin McPherran Lombardi</a> and <a href="https://scholar.google.com/citations?hl=en&user=wXzyv3oAAAAJ">Lindsey Rose Bullinger</a>.</p>
<p>After combing through <a href="https://nces.ed.gov/ecls/kindergarten2011.asp">nationally representative data</a>, we compared the health of parents and their children in states that had taken advantage of Medicaid expansion under the ACA with those living in states that had not. We also analyzed the changes before and after expansion took effect in the state where these parents lived.</p>
<p>We used statistical analysis to rule out other variables, such as race or ethnicity and marital status, as the source of these differences. We didn’t detect any significant changes in terms of what parents said about their children’s overall health or the use of preventive care. </p>
<h2>Why it matters</h2>
<p>In 2014, <a href="https://doi.org/10.1377/hlthaff.2015.1632">28 states expanded access to Medicaid</a>, a federal health insurance program primarily for low-income and disabled people under 65 that’s administered independently by every state. States that have expanded the program can enroll people with incomes up to 138% of the <a href="https://www.healthcare.gov/glossary/federal-poverty-level-fpl/">federal poverty level</a> – currently <a href="https://www.medicaidplanningassistance.org/federal-poverty-guidelines/">US$38,295 for a family of four</a> – as part of the Affordable Care Act. Since then, <a href="https://www.healthinsurance.org/medicaid/">another 10 states</a> have expanded access. Most recently, Missouri and Oklahoma expanded the program in 2021.</p>
<p>About <a href="https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/">2.2 million uninsured adults under 65</a> who have incomes below the poverty line live in Texas, Florida, North Carolina and the other nine states that have yet to expand access to Medicaid. If they resided elsewhere, they would be able to enroll in the program.</p>
<p>Roughly 60% of the Americans in this situation in 2019 were <a href="https://www.cbpp.org/research/health/closing-medicaid-coverage-gap-would-help-diverse-group-and-narrow-racial">people of color</a>. <a href="https://www.kff.org/health-reform/issue-brief/build-back-better-would-change-the-ways-low-income-people-get-health-insurance/">Legislation that would further increase access</a> to health insurance has stalled in the Senate.</p>
<h2>What other research is being done</h2>
<p><a href="https://doi.org/10.1542/peds.2019-3178">Previous</a> <a href="https://doi.org/10.1016/j.whi.2017.11.005">studies</a> have <a href="https://doi.org/10.1002/pam.21993">shown</a> that Medicaid expansion is leading more low-income parents to get health insurance. Other researchers have also found that concerns about medical costs and health insurance coverage eased <a href="https://doi.org/10.1377/hlthaff.2016.1650">psychological distress</a> among low-income parents. </p>
<p>Children from low-income households were already eligible, prior to 2014, for government-provided heath insurance, <a href="https://www.census.gov/library/stories/2019/09/uninsured-rate-for-children-in-2018.html">either through Medicaid</a> or the <a href="https://www.medicaid.gov/chip/index.html">Children’s Health Insurance Program</a>. Known as CHIP, it’s a joint federal and state program that provides health coverage to kids and pregnant women whose families have low incomes but make too much to qualify for Medicaid.</p>
<p>But <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0347">multiple</a> <a href="https://doi.org/10.1177/0046958020952920">studies</a> have found that increased awareness of public health insurance eligibility among parents led to an uptick in children’s insurance coverage as well in what is known as the “<a href="https://ccf.georgetown.edu/2017/09/15/medicaids-welcome-mat-effect-means-medicaid-expansion-helps-children-get-health-coverage/">welcome-mat effect</a>.” </p>
<p>These studies also echo the findings from prior studies of earlier expansions to Medicaid, which took place in the 1990s and 2000s. That research determined that <a href="https://doi.org/10.1111/1475-6773.00177">uninsurance rates</a> for children fell, and that newly insured low-income parents said they had increased their use of <a href="https://doi.org/10.1016/j.jhealeco.2005.03.007">preventive medical care</a> and reported significant <a href="https://doi.org/10.1111/1475-6773.12432">mental health improvements</a>.</p>
<h2>What’s next</h2>
<p>We are doing additional research regarding the benefits of Medicaid expansion. One study indicates that low-income children in Medicaid-expansion states <a href="https://www.edworkingpapers.com/ai21-406">made more progress in standardized reading tests</a> compared with kids their age in other states.</p>
<p>We’re also finding that low-income parents in states that expanded Medicaid spent about 13% more time reading with their children, and they were 5% more likely to have consistent dinnertime routines than their counterparts in states that haven’t taken this step.</p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-likethis">Sign up for The Conversation’s daily newsletter</a>.]</p><img src="https://counter.theconversation.com/content/176777/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maithreyi Gopalan receives funding from Spencer Foundation and the Population Research Institute that is funded by an infrastructure grant by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. </span></em></p>Social scientists determined that body mass index growth declined for children of low-income parents in states that had expanded their Medicaid programs.Maithreyi Gopalan, Assistant Professor of Education and Public Policy, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1764242022-02-18T13:07:14Z2022-02-18T13:07:14Z1 in 4 Americans are covered by Medicaid or CHIP – a program that insures low-income kids<figure><img src="https://images.theconversation.com/files/447118/original/file-20220217-6550-13ekrf6.jpg?ixlib=rb-1.1.0&rect=319%2C31%2C4865%2C2491&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More than 91% of the country has health insurance now.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/male-nurse-showing-digital-tablet-to-mother-by-royalty-free-image/1309071095">The Good Brigade/DigitalVision via Getty Images</a></span></figcaption></figure><figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/447143/original/file-20220217-19-jhlihf.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/447143/original/file-20220217-19-jhlihf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/447143/original/file-20220217-19-jhlihf.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=255&fit=crop&dpr=1 600w, https://images.theconversation.com/files/447143/original/file-20220217-19-jhlihf.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=255&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/447143/original/file-20220217-19-jhlihf.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=255&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/447143/original/file-20220217-19-jhlihf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=321&fit=crop&dpr=1 754w, https://images.theconversation.com/files/447143/original/file-20220217-19-jhlihf.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=321&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/447143/original/file-20220217-19-jhlihf.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=321&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>As of July 2021, a total of <a href="https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/downloads/july-2021-medicaid-chip-enrollment-trend-snapshot.pdf">83.6 million</a> Americans were insured through either Medicaid or the <a href="https://www.medicaid.gov/chip/index.html">Children’s Health Insurance Program</a>.</p>
<p>That’s almost 1 in 4 Americans, with 76.7 million insured through Medicaid and 6.9 million through CHIP. Both public health insurance programs are funded jointly by the federal and state governments. Medicaid provides health insurance for low-income people, <a href="https://www.census.gov/library/publications/2021/demo/p60-274.html">most of whom are 64 or younger</a>.</p>
<p>CHIP provides health coverage to kids and pregnant women whose families have low incomes but make too much to qualify for Medicaid.</p>
<h2>Affordable Care Act’s impact</h2>
<p>Before states began to expand Medicaid in 2014 as part of the Affordable Care Act, the program was much smaller, <a href="https://www.census.gov/content/dam/Census/library/publications/2015/demo/p60-253.pdf">covering around 55 million people in 2013</a>.</p>
<p>So far, <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map">38 states and the District of Columbia</a> have expanded Medicaid access, with financial support from the federal government. </p>
<p>Prior to the ACA, most states were more restrictive about who could enroll in Medicaid, a program launched following the enactment of landmark legislation President <a href="https://www.medicaid.gov/about-us/program-history/index.html">Lyndon B. Johnson signed into law in 1965</a>. After the ACA, the federal government began to shoulder more of the program’s costs, footing at least <a href="https://www.kff.org/medicaid/issue-brief/new-incentive-for-states-to-adopt-the-aca-medicaid-expansion-implications-for-state-spending">90% of the bill</a> for new enrollees covered through the program’s expansion.</p>
<p>Today, all adults in Medicaid expansion states who are under 65 with annual incomes less than <a href="https://www.medicaidplanningassistance.org/federal-poverty-guidelines/">138% of the federal poverty line</a> are eligible for Medicaid. In 2022, that means someone who is single without dependents and has an income of $18,754 or less qualifies, as does a family of four earning up to $38,295.</p>
<p>Eligibility rules in nonexpansion states vary widely and <a href="https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/">exclude more low-income people</a>.</p>
<p>CHIP was <a href="https://www.medicaid.gov/about-us/program-history/index.html">signed into law in 1997</a>. Like the Medicaid expansion it was optional, yet it was <a href="https://www.macpac.gov/subtopic/history-and-impact-of-chip/">adopted in all states within three years, by 2000</a>.</p>
<p>Unfortunately, <a href="https://www.census.gov/library/stories/2021/09/uninsured-rates-for-children-in-poverty-increased-2018-2020.html">4.3 million</a> children remain uninsured, many of whom are in poverty, live in a nonexpansion state or a state with stricter <a href="https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-childrens-health-insurance-program-basic-health-program-eligibility-levels/index.html">income eligibility standards for CHIP</a>.</p>
<p>Even when children are eligible for Medicaid or CHIP, they may not be enrolled in the program due to their parents’ lack of awareness or their state’s lack of outreach. </p>
<p>The pace of <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/">Medicaid expansion since 2014</a> has been far slower than the CHIP rollout. Twelve states have yet to opt in, as of February 2022, though the <a href="https://www.washingtonpost.com/politics/2022/01/31/south-dakota-is-next-front-medicaid-expansion/">expansion debate continues</a>.</p>
<p>And yet Medicaid’s sharp enrollment growth has reduced the share of uninsured people.</p>
<h2>Fewer uninsured Americans</h2>
<p>About <a href="https://www.census.gov/content/dam/Census/library/visualizations/2021/demo/p60-274/figureB1.pdf">91.4% of Americans had public or private health coverage</a> for at least part of 2020, leaving an estimated 28 million Americans without any health insurance, according to the Census Bureau. <a href="https://www.census.gov/content/dam/Census/library/visualizations/2021/demo/p60-274/figureB1.pdf">In 2013, only 86.7%</a> of the country was insured.</p>
<p>Our state, <a href="https://www.healthinsurance.org/medicaid/missouri">Missouri, expanded Medicaid on Oct. 1, 2021</a>. The state estimates that as <a href="https://missouriindependent.com/2021/01/27/gov-parsons-budget-funds-missouri-medicaid-expansion-without-cuts-to-other-needs/">many as 275,000</a> people are newly eligible, though only about <a href="https://dss.mo.gov/mis/clcounter/">64,000 enrolled in the first five months</a>. Oklahoma expanded Medicaid in July 2021, enrolling more than <a href="https://oklahoma.gov/ohca/about/newsroom/2021/november/more-than-200000-oklahomans-enrolled-in-soonercare-through-medicaid-expansion.html">200,000</a> in its first few months. <a href="https://sdsos.gov/elections-voting/assets/2022ConstitutionalAmendmentDPressRelease.pdf">South Dakota</a> may be next: its voters will decide whether to expand Medicaid in November 2022.</p>
<p>Of the 28.6 million Americans who have enrolled in Medicaid or CHIP since the ACA was rolled out, about 60% obtained coverage <a href="https://www.kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/">prior to the COVID-19 pandemic</a>. </p>
<h2>Response to the COVID-19 pandemic</h2>
<p>In March 2020, the federal government responded to what it correctly anticipated as the sharp growth of Medicaid and CHIP coverage.</p>
<p>At the time, an <a href="https://www.bls.gov/opub/mlr/2021/article/unemployment-rises-in-2020-as-the-country-battles-the-covid-19-pandemic.htm">unemployment surge</a> was stripping millions of workers of their economic stability, including health insurance coverage. Medicaid enrollments tend to rise during bad economic times, as people become eligible due to lower incomes. The pandemic was no different, particularly in 2020.</p>
<p>What’s different this time is that states, which administer Medicaid and CHIP, haven’t been allowed to kick anyone out of the program during this period – even if they would have lost eligibility due to higher earnings.</p>
<p>This restriction will continue as long as the federal government public health emergency declaration remains in effect. To help states with that increased financial burden, the <a href="https://www.kff.org/coronavirus-covid-19/issue-brief/how-much-fiscal-relief-can-states-expect-from-the-temporary-increase-in-the-medicaid-fmap/">federal government increased its share</a> of Medicaid payments to states. </p>
<p>In January 2022, the Biden administration renewed the public health emergency for another three months. The emergency declaration is scheduled to expire on <a href="https://ccf.georgetown.edu/2022/01/14/secretary-becerra-extends-the-phe-what-does-this-mean-for-medicaid-and-the-continuous-enrollment-provision/">April 16</a>. </p>
<p>Soon after this measure expires, millions who have been covered by Medicaid but now make too much money to qualify <a href="https://khn.org/news/article/why-millions-on-medicaid-are-at-risk-of-losing-coverage-in-the-months-ahead/">could lose their eligibility</a>, particularly if they live in states that have not yet expanded Medicaid. </p>
<p>But it’s not clear whether the number of Americans enrolled in these programs will decline sharply. In part, that’s because more people are getting access to Medicaid for the first time due to their states’ participation in its expansion.</p>
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<p class="fine-print"><em><span>Heather Bednarek receives funding from the Missouri Foundation for Health. </span></em></p><p class="fine-print"><em><span>Ellen Barnidge receives funding from Missouri Foundation for Health. </span></em></p>Most states have taken advantage of the opportunity to expand access to Medicaid since 2014 through the Affordable Care Act. That’s helping reduce the number of uninsured people.Heather Bednarek, Associate Professor of Economics, Saint Louis UniversityEllen Barnidge, Associate Professor of Behavioral Science and Health Education; Interim Dean of the College for Public Health and Social Justice, Saint Louis UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1758112022-01-27T13:31:34Z2022-01-27T13:31:34ZThe moderate, pragmatic legacy of Stephen Breyer<figure><img src="https://images.theconversation.com/files/442841/original/file-20220126-26-16nbyan.jpg?ixlib=rb-1.1.0&rect=11%2C11%2C3739%2C2485&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A justice representing a kinder political age?</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/SupremeCourtBreyerRetire/322df6a5f075411fa0d7810abac23943/photo?Query=Stephen%20Breyer&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=473&currentItemNo=37">AP Photo/Steven Senne</a></span></figcaption></figure><p>Stephen Breyer will leave a legacy that reflects the Supreme Court he joined nearly three decades ago – less fractious and less partisan than the bench he is <a href="https://apnews.com/article/stephen-breyer-supreme-court-retirement-2f9c1f5da824e3b1ef25964205131fff">reportedly set to leave</a> at the end of the current term.</p>
<p>When Breyer was <a href="https://clinton.presidentiallibraries.us/items/show/36180">nominated by Democratic President Bill Clinton</a> in 1994, he was not a controversial choice. He was confirmed by an 87-9 vote in the Senate, garnering the support of <a href="https://news.bloomberglaw.com/us-law-week/breyers-strong-bipartisan-confirmation-a-relic-of-the-past">79% of Republicans</a>.</p>
<p>There were few surprises at his relatively uneventful <a href="https://lawreview.uchicago.edu/sites/lawreview.uchicago.edu/files/ConfirmationMessesOldAndNew.pdf">confirmation hearing</a>. By and large, senators knew what they were getting: a moderate liberal who took a pragmatic approach to judging.</p>
<p>For Breyer, this meant a healthy respect for precedent and endeavoring to understand the practical consequences of the court’s cases, including how they affect the general population.</p>
<h2>Breyer’s majority opinions</h2>
<p>Breyer joined a court that had just reaffirmed the right to abortion in 1992’s <a href="https://www.oyez.org/cases/1991/91-744">Planned Parenthood v. Casey</a>, and he consistently upheld the precedent set by that case and Roe v. Wade throughout his tenure. In 2000, he wrote the majority opinion in <a href="https://www.oyez.org/cases/1999/99-830">Stenberg v. Carhart</a>, invalidating a state law that criminalized “partial-birth” abortion. In more recent terms, his opinions in <a href="https://www.oyez.org/cases/2015/15-274">Whole Woman’s Health v. Hellerstedt</a> and <a href="https://www.oyez.org/cases/2019/18-1323">June Medical Services, LLC v. Russo</a>, in 2016 and 2020 respectively, struck down state hospital admission requirements for abortion clinic doctors.</p>
<p>As the court moved in a more conservative direction, particularly after the 2020 death of liberal Justice <a href="https://www.nytimes.com/2020/09/18/us/ruth-bader-ginsburg-dead.html">Ruth Bader Ginsburg</a>, Breyer forged an alliance with Chief Justice John Roberts at the Court’s <a href="https://www.theatlantic.com/ideas/archive/2022/01/stephen-breyer-retirement-supreme-court-biden/619331">pragmatic center</a>.</p>
<p>Together, they led the court to moderate rulings upholding the <a href="https://apnews.com/article/supreme-court-dismisses-obamacare-challenge-67cc2e9604a70b1b329c5f3b4177a688">Affordable Care Act</a> and the free-speech <a href="https://apnews.com/article/supreme-court-cursing-cheerleader-first-amendment-981374cd3adc0e73274d7d33c29a9e0e">rights of students</a>. </p>
<h2>Breyer’s dissents</h2>
<p>Breyer’s moderate, pragmatic approach to judging is also apparent in his dissents. For instance, in 2015’s <a href="https://www.oyez.org/cases/2014/14-7955">Glossip v. Gross</a>, Breyer argued that the death penalty was unconstitutional because it was not consistent with contemporary understandings of what constitutes “cruel and unusual punishment.”</p>
<p>To justify this, he pointed out that states were increasingly abandoning the death penalty, that support for the death penalty among the public was decreasing, and that the vast majority of members of the United Nations had ceased using the death penalty. </p>
<p>Being moderate didn’t mean that Breyer was without strong feelings. In the school integration case of <a href="https://www.oyez.org/cases/2006/05-908">Parents Involved in Community Schools v. Seattle School District No. 1</a>, which came before the court in 2007, Breyer read his dissent from the bench – a rare occurrence that <a href="https://www.minnesotalawreview.org/wp-content/uploads/2012/01/TimJohnson_MLR.pdf">signaled</a> his passion for the issue.</p>
<p>Breyer sharply criticized the majority’s decision to strike down voluntary integration policies aimed at achieving racial diversity in a student body. Lamenting what he viewed as a radical departure from precedent, Breyer wrote, “It is not often in the law that so few have so quickly changed so much.”</p>
<h2>Breyer’s Legacy</h2>
<p>Justice Breyer is a product of the era in which he was confirmed: a conservative America where only moderate Democrats were politically viable.</p>
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<p>Clinton had considered several high-profile <a href="https://www.baltimoresun.com/news/bs-xpm-1994-04-07-1994097137-story.html">liberal politicians</a>, including Maine Senator George Mitchell and then-Interior Secretary Bruce Babbitt, for the Supreme Court seat left vacant after the retirement of Justice Harry Blackmun. But in the end, he opted for a moderate judge who was already on the bench.</p>
<p>Breyer’s pragmatic approach allowed him to reach consensus with his more conservative colleagues.</p>
<p>His expected departure reminds America that the era of consensus has largely passed.</p><img src="https://counter.theconversation.com/content/175811/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There was little controversy when President Bill Clinton nominated Stephen Breyer to the bench in 1994. His tenure on the Supreme Court reflects those less partisan times.Paul M. Collins Jr., Professor of Legal Studies and Political Science, UMass AmherstArtemus Ward, Professor of Political Science, Northern Illinois UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1710862021-12-01T13:28:14Z2021-12-01T13:28:14ZHIV prevention pill PrEP is now free under most insurance plans – but the latest challenge to the Affordable Care Act puts this benefit at risk<figure><img src="https://images.theconversation.com/files/434560/original/file-20211129-13-1w51j99.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C700&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The FDA approved the first PrEP drug, Truvada, in 2012.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/FDAHIVDrug/dd94b9ab97d14c6f9ec04661c8e81c86">AP Photo/Jeff Chiu</a></span></figcaption></figure><p>Since the start of the HIV epidemic in 1981, <a href="https://www.kff.org/hivaids/fact-sheet/the-hivaids-epidemic-in-the-united-states-the-basics/">over 700,000 Americans</a> have lost their lives to AIDS. Being infected used to be a death sentence. But now, 40 years later, the U.S. is on the precipice of eradicating HIV.</p>
<p>The U.S. <a href="https://www.cdc.gov/endhiv/index.html">Ending the HIV Epidemic</a> initiative provides a road map to reduce new HIV infections by 90% by 2030. A key preventive strategy in this plan is preexposure prophylaxis, or PrEP, medicine that is <a href="https://www.cdc.gov/hiv/basics/prep/prep-effectiveness.html">almost 100% effective</a> in preventing HIV infection when taken as prescribed.</p>
<p>Today, Medicaid and Medicare <a href="https://www.cdc.gov/hiv/basics/prep/paying-for-prep/index.html">cover PrEP at zero or low cost</a>, and there are assistance programs as a backstop. Just this year, PrEP was designated a <a href="https://www.nbcnews.com/nbc-out/out-health-and-wellness/prep-hiv-prevention-pill-must-now-totally-free-almost-insurance-plans-rcna1470">required preventive service</a> under the Affordable Care Act that almost all insurers must cover at no cost. </p>
<p>But the latest challenge to the ACA has put these gains at risk.</p>
<p>We are public health researchers who study the <a href="https://www.bu.edu/sph/profile/paul-shafer/">ACA’s effects on preventive health usage and costs</a> and <a href="https://sph.tulane.edu/sbps/kristefer-stojanovski-phd-mph">HIV prevention and LGBTQ health</a>. Because PrEP was only recently included as a required preventive service, there is limited evidence on how expanding PrEP coverage has affected access. But given that removing financial barriers has been shown to significantly increase access to <a href="https://labblog.uofmhealth.org/industry-dx/what-happens-when-preventive-care-becomes-free-to-patients">other types of preventive care</a>, eliminating free HIV prevention would be a big step backward in the goal to eradicate HIV.</p>
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<h2>Barriers to PrEP access</h2>
<p>Although the Food and Drug Administration <a href="https://www.fda.gov/media/83586/download">approved the use of PrEP</a> to prevent HIV in 2012, insurance coverage was slow to build and faced regional disparities, primarily in the South. PrEP often required <a href="https://doi.org/10.1001/jamanetworkopen.2020.7445">prior approval</a> before it could be prescribed by a health care provider and is often documented in medical records with stigmatizing terms like “<a href="http://publichealth.lacounty.gov/dhsp/Providers/PrEP-PEPBillingCodes.pdf">high-risk sexual behavior</a>.” Some states also have public insurance policies like restrictive HIV testing requirements that <a href="https://www.kff.org/hivaids/issue-brief/state-medicaid-management-of-prescription-drugs-for-hiv-treatment-and-prevention/">create more barriers to PrEP access</a>.</p>
<p>People who are socially and economically vulnerable face <a href="https://dx.doi.org/10.1007%2Fs12325-020-01295-0">additional access barriers</a>, like limited knowledge and awareness of PrEP, concerns about costs and provider unwillingness to write a prescription. Fear of stigma from the health care system and personal relationships further diminish its use.</p>
<p>People who face higher financial burdens <a href="https://labblog.uofmhealth.org/industry-dx/what-happens-when-preventive-care-becomes-free-to-patients">benefit the most</a> from making preventive care free. For example, low-income Medicare patients showed the <a href="https://doi.org/10.1002/cncr.29494">greatest increase</a> in colorectal cancer screening rates once it was made free compared with higher-income privately insured patients.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=1000&fit=clip"><img alt="Person holding red ribbon." src="https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">PrEP, or preexposure prophylaxis, is highly effective at preventing HIV infection when taken consistently as prescribed.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/man-holding-red-ribbon-for-hiv-illness-awareness-1-royalty-free-image/1185494323">klebercordeiro/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<p>These same trends apply to PrEP. A <a href="https://doi.org/10.1001/jamanetworkopen.2021.22692">recent study</a> in a large California health system found that younger patients, people of color and those with lower incomes face significant disparities in obtaining and continuing PrEP. Removing the financial barrier for PrEP through the ACA was a huge win for HIV prevention and the <a href="https://www.aidsmap.com/news/oct-2021/stark-disparities-seen-all-along-us-prep-continuum">marginalized populations</a> that stand to benefit most.</p>
<h2>The Affordable Care Act and PrEP</h2>
<p>A popular piece of the Affordable Care Act is its requirement that <a href="https://www.kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/">preventive care services</a> be covered at no cost in most commercial health insurance plans. Though it <a href="https://doi.org/10.1016/j.ypmed.2021.106690">doesn’t work perfectly</a>, sometimes leaving patients frustrated by <a href="https://www.washingtonpost.com/national/health-science/getting-charged-for-free-preventive-care/2014/01/17/98fbd1fa-7ec2-11e3-95c6-0a7aa80874bc_story.html">unexpected bills</a>, it has made a huge difference in reducing costs for services like <a href="https://doi.org/10.1001/jamanetworkopen.2021.1248">well-child visits</a> and <a href="https://doi.org/10.1097/MLR.0000000000000610">mammograms</a>, just to name a few. </p>
<p><a href="https://www.law.cornell.edu/cfr/text/29/2590.715-2713">Section 2713</a> of the law lays out a few ways a preventive service can qualify for full coverage. Immunizations, like COVID-19 vaccines, require a recommendation from the <a href="https://www.cdc.gov/vaccines/acip/index.html">Advisory Committee on Immunization Practices</a> of the Centers for Disease Control and Prevention, while women’s health services require approval from the <a href="https://www.hrsa.gov/womens-guidelines/index.html">Health Resources and Services Administration</a>. Most other preventive services require an A or B rating from the <a href="https://uspreventiveservicestaskforce.org/uspstf/home">U.S. Preventive Services Task Force</a>, an independent body of experts trained in research methods, statistics and medicine, and supported by the <a href="https://www.ahrq.gov/cpi/about/otherwebsites/uspstf/index.html">Agency for Healthcare Research and Quality</a>.</p>
<p>The U.S. Preventive Services Task Force assigns <a href="https://www.uspreventiveservicestaskforce.org/uspstf/us-preventive-services-task-force-ratings">letter grades</a> to preventive services through a <a href="https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/uspstf-recommendations-development-process-graphic-overview">five-step review process</a> that evaluates the strength of the <a href="https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis">scientific evidence</a> supporting a service’s net health benefit. An A or B grade indicates “moderate” or “substantial net benefit” supporting the service’s being provided to patients when appropriate. C grades mean there is likely only a small benefit and the service should be considered on a case-by-case basis, while D indicates a recommendation against use. An I grade means there is insufficient evidence to make a recommendation.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Red ribbon hanging from the North Portico of the White House" src="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">PrEP is a key tool to helping the U.S. reach its goal of substantially reducing new HIV infections by 2030.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/ObamaWorldAidsDay/c146dee7e944420482f3e5786d4d2e50">AP Photo/Pablo Martinez Monsivais</a></span>
</figcaption>
</figure>
<p>PrEP received an <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis">A rating</a> in June 2019. This paved the way for both PrEP and related services like clinic visits and lab tests to be covered at no cost for millions of commercially insured Americans.</p>
<p>[<em>More than 140,000 readers get one of The Conversation’s informative newsletters.</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-140K">Join the list today</a>.]</p>
<h2>What is at stake?</h2>
<p>This preventive health benefit has become the latest front in the seemingly unending <a href="https://www.theatlantic.com/ideas/archive/2021/06/next-major-challenge-affordable-care-act/619159/">legal battle</a> over the ACA. The plaintiffs in <a href="https://www.vox.com/2021/4/2/22360341/obamacare-lawsuit-supreme-court-little-sisters-kelley-becerra-reed-oconnor-nondelegation">Kelley v. Becerra</a> are arguing for the inclusion of religious and moral objections that would directly affect contraception and PrEP coverage. Kelley v. Becerra, which is currently <a href="https://www.healthaffairs.org/do/10.1377/hblog20211109.807537/full/">pending at a Texas district court</a> with Judge Reed O'Connor, may also strike out Section 2713 of the ACA altogether, eliminating other free preventive services. A decision is expected early next year.</p>
<p>The case rests on <a href="https://theconversation.com/the-next-attack-on-the-affordable-care-act-may-cost-you-free-preventive-health-care-166087">two legal technicalities</a> that have nothing to do with whether PrEP or contraception deserves to be considered on equal footing with cancer screenings and childhood immunizations. It focuses on whether Congress needed to be more specific about what services could be covered under the law, and whether the power to select covered services could be delegated to groups like the U.S. Preventive Services Task Force.</p>
<p>There are well <a href="https://doi.org/10.1016/j.annepidem.2018.05.003">over a million people</a> in the U.S. who could benefit from PrEP. But if Kelley v. Becerra eliminates free preventive care, over <a href="https://dx.doi.org/10.1016%2Fj.annepidem.2018.06.009">170,000 current PrEP users</a> and a million others who need it could be severely affected. Access to PrEP for Americans with commercial insurance – <a href="https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202108-508.pdf">nearly two-thirds of the population</a> under age 65 – was made easier with the removal of financial barriers. Now those barriers are at risk of being put back in place.</p>
<p>A future without HIV is possible and within reach for the U.S. But widely accessible PrEP is a big part of how the nation can get there. Losing preventive coverage through Kelley v. Becerra would be a huge setback to the goal of ending the HIV epidemic in the U.S.</p><img src="https://counter.theconversation.com/content/171086/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Shafer has received funding in the past three years from the Commonwealth Fund, Kate B. Reynolds Charitable Trust, Robert Wood Johnson Foundation, Horowitz Foundation for Social Policy, Starbucks Coffee Company, and Renova Health. He also previously worked in the Center for Evidence and Practice Improvement at the Agency for Healthcare Research and Quality, which provides support to the US Preventive Services Task Force.</span></em></p><p class="fine-print"><em><span>Kristefer Stojanovski has been supported by funding from the Robert Wood Johnson Foundation, the National Institutes of Health, and the Centers for Disease Control and Prevention.</span></em></p>World AIDS Day on Dec. 1 this year comes at a time when a key step to removing financial barriers to PrEP access in the U.S. faces legal challenges.Paul Shafer, Assistant Professor of Health Law, Policy and Management, Boston UniversityKristefer Stojanovski, Research Assistant Professor of Social, Behavioral and Population Sciences, Tulane UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1652962021-09-17T12:15:34Z2021-09-17T12:15:34ZHow to make comparing prices of an MRI or colonoscopy as easy as shopping for a new laptop<figure><img src="https://images.theconversation.com/files/421698/original/file-20210916-13-wms9l2.jpg?ixlib=rb-1.1.0&rect=1031%2C782%2C4900%2C3166&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new rule is intended to let patients comparison shop for hospital services.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/photos/shopping-cart-first-aid?agreements=pa:119486&family=creative&license=rf&phrase=shopping%20cart%20first%20aid&sort=best">Black Lollipop/iStock via Getty Images</a></span></figcaption></figure><p>Health researchers <a href="https://doi.org/10.1377/hlthaff.22.3.89">have long argued</a> that the key to reining in <a href="https://nurse.plus/become-a-nurse/soaring-cost-of-health-care/">surging health care costs</a> is to tackle the high prices of services, and one potential way to do this is to provide patients with price transparency. </p>
<p>That is, if people know how much a procedure such as a colonoscopy or MRI will cost, they’re more likely to <a href="https://theconversation.com/us/search?q=hospital+price+transparency">shop around for a better price</a>, just as they do for a wide variety of consumer products. This could, theoretically, increase competition among health care providers and result in lower overall prices for everybody.</p>
<p>A <a href="https://www.cms.gov/hospital-price-transparency">new federal regulation that took effect in January 2021</a> is supposed to do just that by requiring hospitals to post prices of all their services and procedures. But <a href="https://www.rwjf.org/en/library/research/2021/09/new-health-care-transparency-requirements-recommendations-for-optimizing-pricing-data-to-reduce-system-costs.html">researchers</a>, <a href="https://www.healthaffairs.org/do/10.1377/hblog20210311.899634/full/">including us</a>, <a href="https://www.healthsystemtracker.org/brief/early-results-from-federal-price-transparency-rule-show-difficultly-in-estimating-the-cost-of-care">have found</a> that the vast majority of hospitals haven’t been complying with the rule. </p>
<p>This <a href="https://www.cms.gov/newsroom/press-releases/cms-proposes-rule-increase-price-transparency-access-care-safety-health-equity">prompted the Biden administration to crack down</a> in July by increasing fines for noncompliance.</p>
<p>As <a href="https://scholar.google.com/citations?user=mq6SungAAAAJ&hl=en&oi=ao">health</a> <a href="https://scholar.google.com/citations?user=fykU7h4AAAAJ&hl=en&oi=ao">policy analysts</a>, we agree that hospitals need to do more in order for the new regulation to succeed. But the regulation itself needs to be fixed if comparing the price of an appendectomy is ever going to be as easy as shopping for a computer. </p>
<h2>Hospital pricing is murky</h2>
<p>The Centers for Disease Control and Prevention estimates that <a href="https://www.cdc.gov/nchs/fastats/health-expenditures.htm">almost 33 cents of every dollar</a> spent on health care in the U.S. goes to hospitals – and that’s excluding what your doctor bills you separately. </p>
<p>But hospital pricing isn’t just expensive. It’s also murky. </p>
<p>Typically, patients don’t pay hospital bills themselves. Rather, health insurance companies pay most of the bills for patients’ care at agreed-upon amounts that are the <a href="https://www.nytimes.com/interactive/2021/08/22/upshot/hospital-prices.html">result of hospital-insurer negotiations</a>. Different insurers negotiate different rates with different hospitals, which can cause the price of a single procedure to vary widely. </p>
<p>For example, Beaumont Hospital-Royal Oak in Royal Oak, Michigan, <a href="https://www.nytimes.com/interactive/2021/08/22/upshot/hospital-prices.html">bills Blue Cross $728 for a colonoscopy</a>, but makes Humana pay $1,801. The University of Mississippi Medical Center, based in Jackson, Mississippi, charges Cigna $1,463 for the same procedure, while Aetna pays $2,144. </p>
<p>Numbers like these led lawmakers to demand greater price transparency when <a href="https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/increasing-transparency02162012a">they crafted the Affordable Care Act in 2009</a>. But it took a long time for regulators to come up with the rule and resolve legal challenges. And finally on Jan. 1, 2021, the Centers for Medicare & Medicaid Services’ <a href="https://www.cms.gov/hospital-price-transparency">price transparency regulation</a> took effect.</p>
<p>Put simply, the regulation requires almost all hospitals in the U.S. – <a href="https://www.govinfo.gov/content/pkg/FR-2019-11-27/pdf/2019-24931.pdf">about 6,000</a> – to disclose the prices they charge to insurers for every item and service they provide in <a href="https://www.federalregister.gov/documents/2019/11/27/2019-24931/medicare-and-medicaid-programs-cy-2020-hospital-outpatient-pps-policy-changes-and-payment-rates-and#p-1010">machine-readable data files</a>.</p>
<p>Instead of a profusion of confidential, negotiated rates determining the cost of care behind the scenes, patients are supposed to now have information at their fingertips to determine, ahead of time, their cost of care at a given hospital.</p>
<p>This should, in theory, allow them to choose the lowest-cost location for their care. And self-insured companies and insurers themselves could use the same information to <a href="http://www.doi.org/10.1377/hblog20191003.778513">bargain more aggressively</a> with hospitals. </p>
<p>While the jury is still out on whether transparency alone can meaningfully slow the <a href="https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly">soaring cost of health care in the U.S.</a>, there is some evidence that it can work.</p>
<p>New Hampshire created a hospital price transparency tool in 2005 that <a href="https://doi.org/10.1162/rest_a_00765">resulted in modest cost savings</a>, according to a 2019 study. </p>
<p>But any potential policy effect hinges on hospitals actually posting their prices – which, for the most part, they have not.</p>
<h2>Hospitals flouting the rule</h2>
<p>Several hospital associations <a href="https://www.aha.org/system/files/media/file/2019/12/hospital-groups-lawsuit-over-illegal-rule-mandating-public-disclosure-individually-negotiated-rates-12-4-19.pdf%20.pdf">sued the government</a> in 2019, calling the new rule unconstitutional. </p>
<p>But even after <a href="https://www.cadc.uscourts.gov/internet/opinions.nsf/CCDF215AFCAF25F98525864D005716BC/$file/20-5193-1877500.pdf">losing their final appeal</a> in December 2020, most hospitals have simply ignored the rule or posted very limited data. </p>
<p>We found that some hospitals post no data file at all. Others have posted a data file, but without all the <a href="https://www.cms.gov/hospital-price-transparency/hospitals">required elements</a> – such as cash discounts and prices negotiated with specific insurers. Others posted data files with the correct elements, but only for a handful of items and services. Finally, still others post data files that contain <a href="https://www.healthsystemtracker.org/brief/early-results-from-federal-price-transparency-rule-show-difficultly-in-estimating-the-cost-of-care/">discrepancies</a>, are not downloadable or <a href="https://www.wsj.com/articles/hospitals-hide-pricing-data-from-search-results-11616405402">are very difficult to find on their websites</a>. </p>
<p>The number of hospitals that fully comply with all aspects of the regulation is very small: less than 6%, according to <a href="https://static1.squarespace.com/static/60065b8fc8cd610112ab89a7/t/60f1c225e1a54c0e42272fbf/1626456614723/PatientRightsAdvocate.org+Semi-Annual+Hospital+Compliance+Report.pdf">one recent study</a>. </p>
<p>After the White House <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2021/07/09/fact-sheet-executive-order-on-promoting-competition-in-the-american-economy">said it would step up enforcement</a> of the rule, the Centers for Medicare & Medicaid Services began sending out <a href="https://www.fiercehealthcare.com/hospitals/cms-sent-out-its-first-wave-warnings-to-hospitals-noncompliant-its-new-price-transparency">warning letters to noncompliant hospitals</a>, and it is currently conducting a <a href="https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-12-18-mlnc-se">compliance audit</a>. Additionally, the maximum penalty for noncompliance <a href="https://www.cms.gov/newsroom/press-releases/cms-proposes-rule-increase-price-transparency-access-care-safety-health-equity">was recently increased from $300 per day to $5,500 per day</a> for large hospitals. </p>
<h2>Patients need an app for that</h2>
<p>But even if the hospitals were in full compliance, it wouldn’t matter without a way for consumers to actually compare prices. </p>
<p>The current regulations do not require standardization of the files that hospitals post. As a result, the files that we examined use a wide variety of formats, names and terms that are incompatible. </p>
<p>For price transparency to work, the data needs to be clean, standardized and simple to use so that one can easily compare prices across procedures, payers and hospitals – and even over time. A good example is how the Affordable Care Act established insurance marketplaces, which <a href="https://www.commonwealthfund.org/blog/2021/state-efforts-standardize-marketplace-health-plans">standardized and simplified</a> health insurance plans.</p>
<p>But even if the data were standardized and comparable, it wouldn’t be much use to patients unless there’s a website or app that they can use to see how much two nearby hospitals charge for a specific procedure. </p>
<p>The jury is still out on whether price transparency will lead to a reduction in hospital prices, but it’ll never work unless there’s greater compliance and an easy way for patients and others to efficiently use the data. </p>
<p>[<em>Get the best of The Conversation, every weekend.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklybest">Sign up for our weekly newsletter</a>.]</p><img src="https://counter.theconversation.com/content/165296/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Morgane Mouslim receives funding from the University of Maryland Baltimore County. </span></em></p><p class="fine-print"><em><span>Morgan Henderson does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Health researchers hope a new regulation requiring hospitals to post their prices will tame soaring health care costs, but compliance and standardization are hurdles.Morgan Henderson, Senior Data Scientist, University of Maryland, Baltimore CountyMorgane Mouslim, Policy Analyst, University of Maryland, Baltimore CountyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1660872021-09-07T12:48:49Z2021-09-07T12:48:49ZThe next attack on the Affordable Care Act may cost you free preventive health care<figure><img src="https://images.theconversation.com/files/419146/original/file-20210902-23-1rk6juj.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1998%2C1488&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A provision of the Affordable Care Act makes it easier for patients to receive preventive care.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/doctor-listening-to-heartbeat-of-patient-royalty-free-image/633707477">Jose Luis Pelaez Inc/Digital Vision via Getty Images</a></span></figcaption></figure><p>Many Americans breathed a sigh of relief when the Supreme Court left the Affordable Care Act (ACA) in place following its <a href="https://www.supremecourt.gov/opinions/20pdf/19-840_6jfm.pdf">third major legal challenge</a> in June 2021. This decision left <a href="https://source.wustl.edu/2017/02/americans-divided-on-obamacare-repeal-poll-finds/">widely supported policies</a> in place, like ensuring coverage <a href="https://www.healthcare.gov/coverage/pre-existing-conditions/">regardless of preexisting conditions</a>, coverage for <a href="https://www.healthcare.gov/young-adults/children-under-26/">dependents up to age 26</a> on their parents’ plan and removal of <a href="https://www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits/">annual and lifetime benefit limits</a>.</p>
<p>But the hits keep coming. One of the most popular benefits offered by the ACA, <a href="https://www.kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/">free preventive care</a> through many employer-based and marketplace insurance plans, is under attack by another legal domino, <a href="https://www.vox.com/2021/4/2/22360341/obamacare-lawsuit-supreme-court-little-sisters-kelley-becerra-reed-oconnor-nondelegation">Kelley v. Becerra</a>. As University of Michigan law professor Nicholas Bagley sees it, “[t]his time, the law’s opponents <a href="https://www.theatlantic.com/ideas/archive/2021/06/next-major-challenge-affordable-care-act/619159/">stand a good chance of succeeding</a>.”</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1405860623372754945"}"></div></p>
<p>We are <a href="https://scholar.google.com/citations?user=bDT820kAAAAJ&hl=en">public health</a> and <a href="https://scholar.google.com/citations?user=Ks-_ZlIAAAAJ&hl=en">economics</a> researchers at Boston University who have been studying how preventive care is covered by the ACA and what this means for patients. With this policy now in jeopardy, health care in the U.S. stands to take a big step backward. </p>
<h2>What did the ACA do for preventive health?</h2>
<p>The Affordable Care Act tried to achieve the twin ideals of <a href="https://www.healthcare.gov/glossary/affordable-care-act/">making health care more accessible while reducing health care spending</a>. It <a href="https://www.healthcare.gov/glossary/marketplace/">created marketplaces</a> for individuals to purchase health insurance and <a href="https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/">expanded Medicaid</a> to increase coverage for more low-income people.</p>
<p>One way it has tried to reach both goals is to prioritize <a href="https://www.kff.org/health-reform/report/preventive-services-tracker/">preventive services</a> that maximize patient health and minimize cost, like cancer screenings, vaccinations and access to contraception. Eliminating financial barriers to health screenings increases the likelihood that common but costly chronic conditions, such as heart disease, will be <a href="https://doi.org/10.1377/hlthaff.2008.0701">diagnosed early on</a>.</p>
<p><a href="https://www.law.cornell.edu/cfr/text/29/2590.715-2713">Section 2713</a> of the ACA requires insurers to offer <a href="https://www.healthcare.gov/coverage/preventive-care-benefits/">full coverage of preventive services</a> that are endorsed by three federal groups: the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices and the Health Resources and Services Administration. This means that eligible preventive services ordered by your doctor won’t cost you anything out of pocket. For example, <a href="https://www.congress.gov/bill/116th-congress/house-bill/748/">the CARES Act</a> used this provision to ensure COVID-19 vaccines would be free for many Americans.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Healthcare provider examining child in exam room." src="https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Affordable Care Act significantly reduced the costs of well-child visits since it was instated.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/girl-having-checkup-in-doctors-office-royalty-free-image/153337724">John Fedele/The Image Bank via Getty Images</a></span>
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<p>Removing the financial barrier has drastically reduced the average cost of a range of preventive services. Our study found that the costs of <a href="https://doi.org/10.1001/jamanetworkopen.2021.1248">well-child visits</a> and <a href="https://doi.org/10.1097/MLR.0000000000000610">mammograms</a> were reduced by 56% and 74%, respectively, from 2006 to 2018. We also found that the ACA reduced the share of children’s preventive checkups that included out-of-pocket costs <a href="https://doi.org/10.1001/jamanetworkopen.2021.1248">from over 50% in 2010 to under 15% in 2018</a>. </p>
<h2>Residual costs for preventive services remain</h2>
<p>Despite these reductions in costs, there are limitations to this benefit. For example, it <a href="https://www.carecredit.com/well-u/health-wellness/what-is-covered-in-preventive-care-what-isnt/">doesn’t cover follow-up tests or treatments</a>. This means that if a routine mammogram or colonoscopy reveals something that requires further care, patients may have to pay for the initial screening test, too. And some patients still <a href="https://www.washingtonpost.com/national/health-science/getting-charged-for-free-preventive-care/2014/01/17/98fbd1fa-7ec2-11e3-95c6-0a7aa80874bc_story.html">receive unexpected bills</a> for preventive care that should have been covered. This can happen, for example, when providers submit incorrect billing codes to insurers, which have <a href="https://www.consumerreports.org/health-insurance/what-to-do-when-your-insurer-wont-cover-free-preventive-care/">specific and often idiosyncratic preventive care guidelines</a>. </p>
<p>We also studied the <a href="https://doi.org/10.1016/j.ypmed.2021.106690">residual out-of-pocket costs</a> that privately insured Americans had after using eligible preventive services in 2018. We found that these patients paid between $75 million to $219 million per year combined for services that should have been free for them. Unexpected preventive care bills were most likely to hit patients living in rural areas or the South, as well as those seeking women’s services such as contraception and other reproductive health care. Among patients attempting to get a free wellness visit from their doctor, nearly 1 in 5 were later asked to pay for it.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Medical bills stacked on top of each other with a credit card nestled between forms." src="https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418998/original/file-20210901-17-1llknsw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Lack of standardized billing and policy compliance has led to unexpected bills.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/medical-bills-royalty-free-image/184284259">DNY59/E+ via Getty Images</a></span>
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<p>Nevertheless, the preventive health provision of the ACA has resulted in <a href="https://doi.org/10.1001/jamanetworkopen.2021.1248">significant reductions in patient costs</a> for many essential and popular services. And <a href="https://labblog.uofmhealth.org/industry-dx/what-happens-when-preventive-care-becomes-free-to-patients">removing financial barriers</a> is a key way to encourage patients to use preventive services intended to protect their health.</p>
<h2>The threat of Kelley v. Becerra</h2>
<p>The plaintiffs who brought the <a href="https://khn.org/news/article/lawsuit-targets-health-law-no-charge-coverage-of-preventive-exams-like-mammograms/">latest legal challenge</a> to the ACA, Kelley v. Becerra, object to covering contraception and preexposure prophylaxis (PrEP) for HIV on religious and moral grounds. The case is currently awaiting decision in a district court in Texas, but seems to be headed to the Supreme Court.</p>
<p>The case rests on <a href="https://www.theatlantic.com/ideas/archive/2021/06/next-major-challenge-affordable-care-act/619159/">two legal issues</a>: 1) violation of the nondelegation doctrine, and 2) the appointments clause of the Constitution. The <a href="https://ballotpedia.org/Nondelegation_doctrine">nondelegation doctrine</a> is a rarely used legal argument that requires Congress to specify how their powers should be used. It essentially argues that Congress was too vague by not specifying which preventive services would be included in Section 2713 up front. The <a href="https://constitution.congress.gov/browse/essay/artII_S2_C2_2_1_4/">appointments clause</a> specifies that the people using government powers must be “officers of the United States.” In this case, it is unclear whether those in the federal groups that determine eligible preventive care services qualify.</p>
<p>Texas District Judge Reed O’Connor has indicated so far that he <a href="https://www.latimes.com/business/story/2021-06-21/obamacare-legal-threat-remains">takes a kind view</a> toward the plaintiff’s case. He could rule that this provision of the ACA is unconstitutional and put the case on a path to the Supreme Court. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Demonstrator holds a sign saying " src="https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/419002/original/file-20210902-19-azgfs0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The Affordable Care Act has faced many legal challenges over the years.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/SupremeCourtHealthCare/af7a18ea1fc84b39af301fa84aec0672">AP Photo/Alex Brandon</a></span>
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<h2>Patients stand to lose more than just money</h2>
<p>If Section 2713 were repealed, insurers would have the freedom to reimpose patient cost-sharing for preventive care. In the short run, this could increase the financial strain that patients face when seeking preventive care and discourage them from doing so. In the long run, this could result in increased rates of preventable and expensive-to-treat chronic conditions. And because Section 2713 is what allows free COVID-19 vaccines for those with private health insurance, some patients <a href="https://acasignups.net/21/06/20/updated-well-was-fun-while-it-lasted-next-big-aca-lawsuit-coming-down-pike">may have to pay</a> for their vaccines and future boosters if the provision is axed.</p>
<p>[<em>Over 100,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p>
<p>The ACA has been instrumental in expanding access to preventive care for millions of Americans. While the ACA’s preventive health coverage provision isn’t perfect, a lot of progress that has been made toward lower-cost, higher-value care may be erased if Section 2713 is repealed.</p>
<p><a href="https://labblog.uofmhealth.org/industry-dx/what-happens-when-preventive-care-becomes-free-to-patients">Lower-income patients</a> will stand to lose the most. And it could make ending the COVID-19 pandemic that much harder.</p><img src="https://counter.theconversation.com/content/166087/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Shafer has received funding in the past three years from the Commonwealth Fund, Kate B. Reynolds Charitable Trust, Robert Wood Johnson Foundation, Horowitz Foundation for Social Policy, Starbucks Coffee Company, and Renova Health.</span></em></p><p class="fine-print"><em><span>Alex Hoagland does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Affordable Care Act has allowed many preventive health services, including cancer screenings and vaccines, to be free of charge. But legal challenges may lead to costly repercussions for patients.Paul Shafer, Assistant Professor, Health Law, Policy, and Management, Boston UniversityAlex Hoagland, PhD Candidate in Health Economics, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1659592021-08-18T12:11:15Z2021-08-18T12:11:15ZCan health insurance companies charge the unvaccinated higher premiums? What about life insurers? 5 questions answered<figure><img src="https://images.theconversation.com/files/416367/original/file-20210816-15-7tqby.jpg?ixlib=rb-1.1.0&rect=571%2C200%2C4378%2C2953&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Laws restrict the ways insurers can use vaccination status to affect coverage or premiums.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakCaliforniaSchools/1a48e81ef35d4521a2e956195aa618eb/photo?Query=Vaccine%20AND%20shot&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=3632&currentItemNo=36">AP Photo/Marcio Jose Sanchez</a></span></figcaption></figure><p><em>The current COVID-19 wave in the U.S. is mostly affecting unvaccinated Americans, who <a href="https://www.cnn.com/2021/07/31/health/fully-vaccinated-people-breakthrough-hospitalization-death/index.html">represent more than 95% of current cases of hospitalization and death</a>.</em></p>
<p><em>Given the average cost of a COVID-19 hospitalization in 2020 <a href="https://doi.org/10.1101/2021.05.26.21257879">ran about US$42,200 per patient</a>, will the unvaccinated be asked to bear more of the cost of treatment, in terms of insurance, as well?</em></p>
<p><em>We asked economists <a href="https://scholar.google.com/citations?user=fjl_qjwAAAAJ&hl=en&oi=ao">Kosali Simon</a> and <a href="https://scholar-google-com.proxy.library.cornell.edu/citations?user=S9Fo9fgAAAAJ&hl=en">Sharon Tennyson</a> to explain the rules governing how health and life insurers can discriminate among customers based on vaccination status and other health-related reasons.</em> </p>
<h2>1. Can insurers charge the unvaccinated more?</h2>
<p>This is a really interesting question and depends on the type of insurance. </p>
<p>Life insurance companies have the freedom to charge different premiums based on risk factors that predict mortality. Purchasing a life insurance policy often entails a health status check or medical exam, and asking for vaccination status is not banned. </p>
<p>Health insurers are a different story. A <a href="https://doi.org/10.1016/j.jpubeco.2004.07.003">slew of state and federal regulations</a> in the last three decades <a href="http://www.doi.org/10.1257/000282802760015720">have heavily restricted</a> their ability to use health factors in issuing or pricing polices. In 1996, the Health Insurance Portability and Accountability Act <a href="https://www.hhs.gov/hipaa/index.html">began prohibiting</a> the use of health status in any group health insurance policy. And the Affordable Care Act, passed in 2014, <a href="https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs5">prevents insurers</a> from pricing plans according to health – with one exception: smoking status.</p>
<h2>2. Are premiums or coverage being affected yet?</h2>
<p>Fortune recently reported that while <a href="https://www.yahoo.com/now/unvaccinated-still-able-life-insurance-150000872.html/">several of the biggest U.S. life insurance companies aren’t yet asking customers</a> for their vaccination status, a few insurers told the magazine they are doing so for people at high risk. It wasn’t clear from the article whether this is affecting premiums.</p>
<p>A recent study comparing life insurance policies from 2014 through February 2021 found that <a href="https://doi.org/10.1111/jori.12344">premiums and coverage didn’t change a lot</a> during the pandemic. The study did find some evidence that policy terms for the oldest individuals and those with high-risk health conditions did worsen. </p>
<p>The authors of the study suggested that the rapid development of vaccines may be why life insurance markets haven’t yet shown a dramatic response to COVID-19, but their work does not distinguish the vaccinated from the unvaccinated.</p>
<p>It’s important to note that no matter what, premiums and coverage on existing life insurance plans won’t change, so a death due to COVID-19 will definitely be covered. In general, denial of life insurance claims is rare and <a href="https://content.naic.org/sites/default/files/inline-files/JIR-ZA-36-10-EL.pdf">occurs only for specific documented reasons</a>.</p>
<h2>3. So smokers may pay higher premiums?</h2>
<p>In life insurance, smokers definitely pay higher premiums, as do people who are obese. </p>
<p>ValuePenguin, a unit of LendingTree that provides research and analysis, <a href="https://www.valuepenguin.com/life-insurance-smokers">found that smokers typically pay</a> over three times more for life insurance than non-smokers. </p>
<p>The site also found that <a href="https://www.valuepenguin.com/life-insurance-overweight-obese">obesity increases premiums</a> by about 150% – or more if the person also has medical conditions associated with being overweight.</p>
<p>As for health insurance pricing, the Affordable Care Act <a href="https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Market-Rating-Reforms">allows insurers to increase premiums</a> by up to 50% for smokers. The difference between what smokers and non-smokers pay may actually be higher because the former <a href="http://www.doi.org/10.1377/hlthaff.2020.00015">can’t use a key government subsidy</a> to pay for the smoker surcharge. </p>
<p>The ACA makes no similar exception for obesity.</p>
<h2>4. How about discounts for the vaccinated?</h2>
<p>There is a tool health insurers – including self-insured employers – have to lower premiums to those who are vaccinated: wellness incentives. </p>
<p>Just as insurers and companies offer discounts for things like trying to lose weight or stop smoking, <a href="https://www.kff.org/coronavirus-covid-19/fact-sheet/what-can-employers-do-to-require-or-encourage-workers-to-get-a-covid-19-vaccine">they are also permitted</a> to reduce the health insurance premiums that vaccinated employees pay.</p>
<p>In 2019, the average maximum incentive <a href="https://www.kff.org/private-insurance/issue-brief/trends-in-workplace-wellness-programs-and-evolving-federal-standards">offered by employers</a> for workers to participate in wellness activities was $783 per year.</p>
<p>Some employers are already incentivizing COVID-19 vaccinations this way. For example, Missouri State University <a href="https://www.missouristate.edu/Human/wellness-incentive.htm">offers a $20-a-month discount</a> on health insurance premiums for employees who got a COVID-19 jab. <a href="https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/employers-ponder-health-plan-premium-surcharges-for-the-unvaccinated.aspx">Others are considering similar discounts</a>. </p>
<p>And so, even though insurers can’t charge the unvaccinated higher premiums, people who refuse to get a shot can end up paying more than their vaccinated colleagues. </p>
<h2>5. Do insurers consider other vaccine or flu shots in rates?</h2>
<p>To the best of our knowledge, insurers haven’t specifically used vaccination status or getting a flu shot in setting premiums. </p>
<p>As part of having access to your medical records, life insurers might get to know whether you received vaccinations, but there are no systems in place to verify each year whether you got your flu shot. Health insurers can’t ask about vaccine status for the reasons listed above.</p>
<p>Employers can offer incentives to get a flu shot through their wellness programs.</p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>.]</p><img src="https://counter.theconversation.com/content/165959/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kosali Simon's research has received funding from U.S. National Institutes for Health; she currently serves on the U.S. Congressional Budget Office Panel of Health Advisors and serves on the board of the non-profit Health Care Cost Institute; none of these affiliations are perceived as presenting a conflict of interest but are related to the topic of health care financing. </span></em></p><p class="fine-print"><em><span>Sharon Tennyson has engaged in research and expert testimony funded by property-liability insurance companies and their affiliates but has no professional associations with life insurance companies or organizations. She is a Senior Associate Editor of the Journal of Risk and Insurance, in which the Harris, Yelowitz and Courtmanche article is published.</span></em></p>Two economists explain what insurers can and can’t do to factor vaccination status into their coverage and rates.Kosali Simon, Professor of Health Economics, Indiana UniversitySharon Tennyson, Professor of Public Policy and Economics, Cornell UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1629822021-06-21T12:20:19Z2021-06-21T12:20:19ZWhat’s next for health care reform after the Supreme Court rejects ACA’s most recent challenge<figure><img src="https://images.theconversation.com/files/407334/original/file-20210620-26-fwakz2.jpg?ixlib=rb-1.1.0&rect=0%2C37%2C5056%2C3322&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Supreme Court has pushed back three challenges to the Affordable Care Act.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/SupremeCourtHealthCare/af7a18ea1fc84b39af301fa84aec0672/photo?Query=Obamacare%20Supreme%20Court&mediaType=photo,graphic&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=273&currentItemNo=9">AP Photo/Alex Brandon</a></span></figcaption></figure><p>The U.S. Supreme Court upheld the Affordable Care Act for the third time on June 17, 2021, this time in a case called <a href="https://www.oyez.org/cases/2020/19-840">California v. Texas</a>. With seven justices holding that the states and individual plaintiffs <a href="https://www.nytimes.com/2021/06/18/us/politics/supreme-court-conservatives-liberals.html">lacked standing to sue</a> because they failed to show that they had suffered a <a href="https://www.nytimes.com/2021/06/17/us/obamacare-supreme-court.html">direct injury</a>, the Court delivered its strongest defense of the law to date. The key parts of the previous decisions had been <a href="https://www.nytimes.com/2012/06/29/us/supreme-court-lets-health-law-largely-stand.html">5-4</a> and <a href="https://www.nytimes.com/2015/06/26/us/obamacare-supreme-court.html">6-3</a>, respectively.</p>
<p>This result was not unpredicted. Indeed, <a href="https://theconversation.com/while-the-supreme-court-deliberates-on-the-affordable-care-act-congress-and-the-white-house-may-act-149891">as I wrote in November</a>, legal experts called the arguments brought by the states and individual plaintiffs challenging the ACA “<a href="https://reason.com/volokh/2020/11/10/thoughts-on-todays-oral-argument-in-california-v-texas-the-obamacare-severability-case/">weak</a>” and “<a href="https://www.theatlantic.com/ideas/archive/2019/07/texas-v-us-rise-know-nothing-judge/593959/">ridiculous</a>.” </p>
<p>And, <a href="https://theconversation.com/while-the-supreme-court-deliberates-on-the-affordable-care-act-congress-and-the-white-house-may-act-149891">as I noted at the time</a>, the oral arguments suggested that the Court’s key swing votes were <a href="https://news.bloomberglaw.com/us-law-week/supreme-court-shaped-by-trump-poised-to-hear-challenge-to-aca">largely skeptical</a> of the challengers’ legal arguments. What was more potentially surprising about the 7-2 final result were the votes of Justices Clarence Thomas and Amy Coney Barrett, as they joined Chief Justice John Roberts, and Justices Stephen Breyer, Elena Kagan, Brett Kavanaugh and Sonia Sotomayor in voting to deny the challenge. </p>
<p>Specifically, the litigation centered around whether the individual mandate penalty – the fine an individual must pay for not carrying health insurance – was made unconstitutional when Congress <a href="https://www.nytimes.com/2017/12/18/us/politics/tax-cut-obamacare-individual-mandate-repeal.html">“zeroed out” the monetary penalty in 2017</a>. Two individual plaintiffs and a group of states led by Texas argued that they were injured as a result of the now-unenforceable mandate, and that the mandate – now, arguably, no longer a tax because it was not revenue-generating – could no longer be upheld as constitutional. But the Court found that the challengers had failed to state a cognizable injury and thus, <a href="https://www.usatoday.com/story/news/politics/2021/06/17/supreme-court-rejects-obamacare-challenge-brought-texas/4153925001/">lacked standing</a>.</p>
<p>The decision’s biggest fireworks came from Justice Samuel Alito, whose <a href="https://supreme.justia.com/cases/federal/us/593/19-840/#tab-opinion-4440774">strongly worded dissent</a> was joined by Justice Neil Gorsuch. Alito found that the challengers did experience the type of injury required, agreeing with the argument that an unenforceable individual mandate penalty – <a href="https://www.nytimes.com/2012/06/29/us/supreme-court-lets-health-law-largely-stand.html">upheld as a constitutional tax in National Federation of Independent Businesses v. Sebelius</a> – was no longer justifiable, finding it both unconstitutional and not severable, or able to be excised, from the rest of the law. Alito’s opinion, which would have struck down the entire ACA, was cutting in its criticism, perhaps reminding Court watchers of the <a href="https://www.nytimes.com/2016/02/16/arts/recalling-scalia-a-literary-stylist-who-scorned-jiggery-pokery.html">sharp dissents of the late Justice Antonin Scalia</a>.</p>
<p>Indeed, even though this legal challenge was weaker than previous ones, the ACA still did hang in the balance – with <a href="https://www.nytimes.com/article/supreme-court-obamacare-case.html">21 million people at direct risk of losing their health insurance</a>, and millions <a href="https://www.nytimes.com/article/supreme-court-obamacare-case.html">more at risk of losing protection</a> against preexisting condition discrimination.</p>
<p>As a <a href="https://law.utk.edu/directory/zack-buck/">health law professor</a> who <a href="https://papers.ssrn.com/sol3/cf_dev/AbsByAuth.cfm?per_id=1713816">studies and writes about the ACA and health reform</a>, I think it is worthwhile to look ahead to what comes next now that the newest challenge has been laid to rest.</p>
<figure class="align-center ">
<img alt="President Barack Obama is surrounded by onlookers as he signs a document. Joe Biden, Nancy Pelosi and a young Black boy in a vest and tie are part of the crowd." src="https://images.theconversation.com/files/407336/original/file-20210620-35539-mzb63.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/407336/original/file-20210620-35539-mzb63.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=327&fit=crop&dpr=1 600w, https://images.theconversation.com/files/407336/original/file-20210620-35539-mzb63.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=327&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/407336/original/file-20210620-35539-mzb63.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=327&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/407336/original/file-20210620-35539-mzb63.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=411&fit=crop&dpr=1 754w, https://images.theconversation.com/files/407336/original/file-20210620-35539-mzb63.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=411&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/407336/original/file-20210620-35539-mzb63.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=411&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">President Barack Obama signs the Affordable Care Act in 2010.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/HealthOverhaulLawsuit/e33c3840d72f4ade8b1cb0e077471cf7/photo?Query=Obama%20signs%20Affordable%20Care%20Act&mediaType=photo,graphic&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=251&currentItemNo=3">AP Photo/J. Scott Applewhite</a></span>
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<h2>An inflection point</h2>
<p>The summer of 2021 seems to present a very different political environment for the ACA. Now <a href="https://www.nytimes.com/2010/03/24/health/policy/24health.html">more than 11 years after President Obama signed the ACA</a>, the law has experienced its most <a href="https://www.kff.org/interactive/kff-health-tracking-poll-the-publics-views-on-the-aca/#?response=Favorable--Unfavorable&aRange=all">extensive period of sustained public support</a>, according to the Kaiser Family Foundation, a nonprofit organization focusing on national health policy issues.</p>
<p>The first challenge to the ACA to reach the Supreme Court, <a href="https://www.oyez.org/cases/2011/11-393">National Federation of Independent Businesses v. Sebelius</a>, was filed in 2010, with a decision in 2012. The complaint that would become <a href="https://www.oyez.org/cases/2014/14-114">King v. Burwell</a> was filed in 2013, with a favorable decision for the ACA in 2015. This most recent challenge was filed in the spring of 2018. </p>
<p>But the germination of these legal challenges took place during a very different political era for the ACA. Indeed, until 2017, the ACA <a href="https://www.kff.org/interactive/kff-health-tracking-poll-the-publics-views-on-the-aca/#?response=Favorable--Unfavorable&aRange=all">struggled to gain public support</a>. But since early 2017, more Americans have supported the law than have opposed it, and the trendlines are unmistakable. As of May 2021, <a href="https://www.kff.org/interactive/kff-health-tracking-poll-the-publics-views-on-the-aca/#?response=Favorable--Unfavorable&aRange=all">53% of Americans supported the ACA and 35% opposed it</a>.</p>
<p>In short, it remains an open question as to whether there is the political will to continue to seek a judicial remedy to destroy a law that seems to be increasingly popular. One would think that the law may finally be here to stay. But given the frequency with which opponents of the ACA have resorted to the courts, one can never be sure.</p>
<h2>To the states</h2>
<p>Instead, it seems like the focus of health reform over the remainder of the first half of President Joe Biden’s term will be on whether the administration can finally persuade the <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/">12 remaining “holdout” states</a> to expand their Medicaid programs, granting health care access to millions more Americans. Two other states — Missouri and Oklahoma — <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/">have voted to expand Medicaid but have not yet implemented</a> Medicaid expansion.</p>
<p>The biggest prize is Texas, which, according to a study, could cover up to <a href="https://www.commonwealthfund.org/publications/issue-briefs/2019/aug/medicaid-expansion-texas-potential-economic-employment-implications">1.2 million</a> uninsured individuals through Medicaid expansion. But the Texas House <a href="https://www.texastribune.org/2021/04/22/texas-house-medicaid-expansion-uninsured/">rejected an expansion effort</a> earlier this year. Additionally, with expansion, Florida could cover <a href="https://www.commonwealthfund.org/blog/2019/medicaid-expansion-florida-budget-buster-or-deal-century">more than 800,000 people</a>, and Georgia, <a href="https://www.augustachronicle.com/story/news/2021/05/20/study-medicaid-expansion-georgia-could-bring-thousands-jobs/5163389001/">more than 600,000</a>. </p>
<p>Through <a href="https://www.usatoday.com/story/news/politics/2021/03/02/covid-stimulus-package-includes-major-expansion-obamacare/4560965001/">the COVID-19 relief bill</a>, the Biden administration sweetened the deal for states to expand their Medicaid programs <a href="https://www.nbcnews.com/politics/politics-news/changed-hearts-minds-biden-s-funding-offer-shifts-medicaid-expansion-n1262229">by increasing federal funding</a>. While it seems that those efforts may have initially <a href="https://www.nbcnews.com/politics/politics-news/changed-hearts-minds-biden-s-funding-offer-shifts-medicaid-expansion-n1262229">resulted in some shifts</a> in these states, and in others the efforts have drawn a “<a href="https://news.yahoo.com/thanks-no-thanks-states-wary-100019175.html">mixed response</a>,” no state has yet moved to expand the program as a result.</p>
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<h2>An equipoise?</h2>
<p>At the same time, it would appear that some of the more progressive health reform goals — such as “Medicare for All,” or even a government-run public option — are <a href="https://www.nbcnews.com/politics/joe-biden/health-insurance-public-option-might-be-fizzling-left-ok-n1269571">not part of the Biden agenda</a>. According to reporting in early June 2021, the federal public option “<a href="https://www.nbcnews.com/politics/joe-biden/health-insurance-public-option-might-be-fizzling-left-ok-n1269571">has fallen off the national radar and will be difficult to revive without a major push by the White House</a>.” Nonetheless, Nevada, Colorado and Washington state have now established <a href="https://www.vox.com/policy-and-politics/22535267/public-option-health-insurance-nevada-colorado-washington">their own public options</a>.</p>
<p>Instead, the Biden administration is working to <a href="https://blog.petrieflom.law.harvard.edu/2021/05/13/biden-private-health-insurance/">bolster and broaden the ACA’s subsidies for private insurance</a>, which is having positive effects on the number of Americans <a href="https://www.modernhealthcare.com/insurance/more-half-million-americans-gain-coverage-under-biden">covered under the ACA</a>.</p>
<p>All of this seems to suggest a health reform equipoise at the moment. Perhaps the ACA’s most turbulent decade is behind us, and, instead, policymakers will be working to bolster its coverage and plug its holes. Nonetheless, if we’ve learned one thing over the last 11 years of following American health care reform efforts, it is that what happens next is often hard to predict.</p><img src="https://counter.theconversation.com/content/162982/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Zack Buck does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Support for the Affordable Care Act is at an all-time high.Zack Buck, Associate Professor of Law, University of TennesseeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1575652021-05-12T12:46:06Z2021-05-12T12:46:06ZHow America’s partisan divide over pandemic responses played out in the states<figure><img src="https://images.theconversation.com/files/399863/original/file-20210510-5469-z092na.jpg?ixlib=rb-1.1.0&rect=3%2C79%2C1016%2C553&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The COVID-19 pandemic seems to have widened the partisan divide between Democrats and Republicans on health care.
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/">John M. Lund Photography/Getty Images</a></span></figcaption></figure><p>Throughout the COVID-19 pandemic, a <a href="https://theconversation.com/democratic-governors-are-quicker-in-responding-to-the-coronavirus-than-republicans-135599">partisan divide</a> has existed over the appropriate government response to the public health crisis. Democrats have been more likely to favor stricter policies such as prolonged economic shutdowns, limits on gathering in groups and mask mandates. Republicans overall have favored less stringent policies.</p>
<p>As political scientists and public health scholars, we’ve been studying political responses to the pandemic and their impacts. In research <a href="https://doi.org/10.3138/cpp.2020-101">published in the summer of 2020</a>, we found that “sub-governments,” which in the U.S. means state governments, tended to have a bigger impact on the direction of pandemic policies than the federal government. Now, as data on last year’s case and death rates emerge, we’re looking at whether the political party in the governor’s office became a good predictor of public health outcomes as COVID-19 moved across the country.</p>
<p>Looking at states’ COVID-19 case and death rates, <a href="https://doi.org/10.1377/hlthaff.2020.00608">researchers</a> are <a href="https://doi.org/10.1126/science.abd9338">finding the more stringent policies</a> typical of Democratic governors led to lower rates of infections and deaths, compared to the the pandemic responses of the average Republican governor. In preparation for future pandemics, it may be worth considering how to address the impact that a state government’s partisan leanings can have on the scope and severity of a public health crises. </p>
<h2>Comparing responses by Democratic and Republican governors</h2>
<p>To compare and chart our state-by-state <a href="https://www.binghamton.edu/political-science/covid-response/">COVID-19 policy stringency data</a>, we’ve developed our “<a href="https://www.nowpublishers.com/article/Details/PIP-0023">Protective Policy Index</a>.” To calculate this index, we took into account the types of policies state governments adopted over the course of the pandemic, such as school closings, lockdowns and mandatory mask mandates. We combined the adopted measures for each state over time to calculate the index. Higher values of the index indicate states adopted more stringent measures. </p>
<p>When we charted the policy responses of Democratic and Republican governors between May 1 and July 31, 2020, they revealed that heading into May, states led by Democrats generally took more stringent measures than those led by Republicans. Over the next eight weeks or so, as Democratic-led states began to slowly reopen, they continued to maintain more stringent measures on average than Republican-led states. By July, Democratic governors began to roll back their reopenings amid some signs of a new pandemic wave, while Republican-led states largely maintained the same level of stringency.</p>
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<p>With that information established, we could begin to explore whether there was a relationship between COVID-19 policy stringency in different states, and their rates of pandemic cases and deaths. </p>
<p>According to a <a href="https://www.cnn.com/2021/03/10/politics/covid-cases-deaths-red-blue-states-late-2020/index.html">study released in March</a>, both case and death rates were higher on average in states led by Republican governors during the second half of 2020. The first map represents rates of COVID-19 cases between June 1 and July 31, 2020 <a href="https://covid.cdc.gov/covid-data-tracker/#datatracker-home">as reported by the CDC</a>. The second map represents <a href="https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm">CDC</a> estimates of excess mortality rates – the number of deaths above the average norm – between June 1 and August 31, 2020. The taller spikes indicate higher case and death rates. </p>
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<p>Next, to study the relationship between the stringency of a state’s pandemic responses and its rates of COVID-19 cases and deaths, we mapped each state’s rating on the Protective Policy Index to the same CDC data. The results show that more stringent policies were generally associated with fewer cases and deaths.</p>
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<p>All of these findings, in conjunction with those of our own research, suggest that amid the current deep divide in U.S. politics, it’s possible to forecast public health outcomes based on whether a state is led by a Republican or a Democrat. For large chunks of time in 2020, states led by Republicans overall had higher average case and death rates from COVID-19, in part due to their state governments adopting less stringent policies to quell the virus. It is important to note, however, that not all states fit perfectly into this pattern. For example, Vermont Gov. Phil Scott, a Republican, adopted relatively stricter measures and this likely led to <a href="https://abcnews.go.com/US/vermont-model-country-responding-coronavirus-pandemic/story?id=73057030">better health outcomes</a>. </p>
<h2>America’s polarized health care politics</h2>
<p>The differences we discovered between red and blue states in our analysis did not surprise our team. After all, a partisan divide over health care in the U.S. existed before COVID-19. During President Bill Clinton’s administration in the 1990s, there was a clear and growing partisan divide over health care reform. During President Barack Obama’s administration, Democrats supported the <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.01444?casa_token=LyZhJhFUIMgAAAAA%3AwRNanEY1lsb1qQg_4-Thc6TEvYLom3ud5GkbmUGXG6RtYilakaS65vM7DNfRLHmYZ3b4JbL6015i">Affordable Care Act</a> and <a href="https://read.dukeupress.edu/jhppl/article-abstract/36/6/1021/13463/Red-State-Blue-State-Flu-State-Media-Self">the federal government’s response to the H1N1 virus</a>, while nearly all Republicans opposed both measures. </p>
<p>We already know that partisan divisions over health care in the U.S. can worsen public health. For example, <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.01436?casa_token=FzafestjpRoAAAAA%3A9D_WTo5gythAS7jZkYHwwQ1sqtsLoJj8yhkJcnk6hLj9DhQJQ-SGcElo96bjS0R_pE23qSxTmHzJ">despite the evidence</a> that the ACA has had a positive effect on individual health care outcomes, <a href="https://read.dukeupress.edu/jhppl/article/42/5/985/131420/How-the-ACA-Addressed-Health-Equity-and-What">Republicans</a> have consistently fought against it. Republican-led states that chose not to adopt Medicaid expansion have not <a href="https://doi.org/10.1002/pam.21961">experienced</a> all the positive <a href="https://doi.org/10.1016/j.jhealeco.2020.102333">benefits</a> of the Affordable Care Act. </p>
<p>For example, states such as Texas, Florida, Georgia and Mississippi that <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/">have not expanded Medicaid</a> have the <a href="https://www.census.gov/library/stories/2019/11/state-by-state-health-insurance-coverage-2018.html">largest relative percentage of uninsured residents</a> in the country. In some Republican-led states that did opt for Medicaid expansion, it was adopted with new restrictions. This has ultimately <a href="https://dx.doi.org/10.2105%2FAJPH.2016.303192">led to worse outcomes</a>.</p>
<p>These long-established partisan divisions have also influenced <a href="https://doi.org/10.1017/S0008423920000463">Americans’ polarized views</a> of the government’s proper role in addressing the pandemic. <a href="https://theconversation.com/poor-us-pandemic-response-will-reverberate-in-health-care-politics-for-years-health-scholars-warn-148963">This divide</a> grew so wide during 2020 that at some points it was as if <a href="https://theconversation.com/the-partisan-pandemic-do-we-now-live-in-alternative-realities-140290">people were living in alternate realities</a> based on their partisan leanings. At times an American’s political affiliation indicated whether or not they would acknowledge even that a pandemic was really happening.</p>
<h2>Where we go from here</h2>
<p>Now that mass vaccination against COVID-19 is underway across the country, Americans have hope that life will soon get “back to normal.” But until enough people are vaccinated to halt the spread of the virus, public health officials are warning that <a href="https://www.reuters.com/world/us/new-us-covid-cases-fall-sharply-last-week-deaths-lowest-since-october-2021-04-26/">we are not quite there yet</a>. They are encouraging states to maintain some restrictions that slow the spread of the virus, especially considering that there are <a href="https://graphics.reuters.com/HEALTH-CORONAVIRUS/USA-TRENDS/dgkvlgkrkpb/index.html">more contagious variants</a> spreading across the country.</p>
<p>Overwhelming evidence suggests that differences between Republican and Democratic officials on health policy have had life-or-death consequences during the pandemic. But recent history suggests that in the next public health crisis, governments across the U.S. may once again focus more on politics than on policies grounded in the best available science. Experience also suggests that even when this leads to bad health outcomes, Americans aren’t likely to rethink the partisan divide over health care.</p>
<p><em>Editor’s note: The maps in this article have been updated to correct the case count and death rate for the state of New York.</em></p><img src="https://counter.theconversation.com/content/157565/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>States led by Republican governors generally had higher COVID-19 case and death rates in 2020.Julie VanDusky, Assistant Professor of Political Science, Boise State UniversityOlga Shvetsova, Professor of Political Science and Economics, Binghamton University, State University of New YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1587302021-04-29T12:47:05Z2021-04-29T12:47:05ZState lawsuits over stimulus tax rule face uphill battle<figure><img src="https://images.theconversation.com/files/396369/original/file-20210421-13-oozbx7.jpg?ixlib=rb-1.1.0&rect=35%2C106%2C7805%2C5037&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Vice President Kamala Harris speaks at an American Rescue Plan virtual briefing on March 11, 2021 in Washington, D.C.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/vice-president-kamala-harris-speaks-at-an-american-rescue-news-photo/1306551744?adppopup=true">Tasos Katopodis/Getty Images</a></span></figcaption></figure><p>States were told by the federal government that they can’t use pandemic relief funds passed by Congress in March to lower taxes. In response, 16 states have filed lawsuits challenging the constitutionality of that <a href="https://www.nytimes.com/2021/03/17/us/politics/stimulus-states-lawsuit-tax-cuts.html">restriction</a> in the <a href="https://home.treasury.gov/news/featured-stories/fact-sheet-the-american-rescue-plan-will-deliver-immediate-economic-relief-to-families">US$1.9 trillion legislation</a>, known as the American Rescue Plan Act of 2021.</p>
<p>The rescue plan makes $350 billion available to state and local governments over the next four years to cover costs associated with COVID-19. It guarantees every state at least $500 million, but more can be provided based on unemployment numbers and poverty rates.</p>
<p>The law, however, forbids states from using this money “to either directly or indirectly offset a reduction in net tax revenue” over those four years. In other words, rescue plan money cannot pay for state tax cuts.</p>
<p>That restriction prompted the lawsuits, which are pending in Ohio, Arizona, Missouri and Alabama federal courts.</p>
<p>The states claim that the rescue plan’s policies <a href="https://constitutioncenter.org/interactive-constitution/interpretation/amendment-x/interps/129">violate the 10th Amendment</a>, which helps define the relationship between the federal government and the states. </p>
<p>Historically, the Supreme Court has interpreted this provision to prevent the federal government from directing state policy rather than to limit what the feds can do themselves.</p>
<p>The rescue plan might run afoul of the 10th Amendment if it dictated what laws state legislatures must or must not adopt. That would mean states could use the federal money to offset tax cuts. </p>
<p>But as a <a href="https://case.edu/law/our-school/faculty-directory/jonathan-l-entin">constitutional law professor</a> who has written extensively about federal powers, I think it’s unlikely that the rescue plan violates the 10th Amendment. That’s because it does not order states to do anything. </p>
<h2>Supreme Court precedent</h2>
<p>In 1992, the Supreme Court declared that a federal law ordering states to pass legislation for the <a href="https://www.oyez.org/cases/1991/91-543">safe disposal of nuclear waste</a> violated the 10th Amendment. And in 2018 the high court struck down the Professional and Amateur Sports Protection Act, which <a href="https://www.oyez.org/cases/2017/16-476">forbade states from authorizing sports betting</a>.</p>
<p>But the rescue plan does not explicitly require or forbid states to enact legislation, as the nuclear waste and sports gambling laws did.</p>
<p>It offers states a deal: If you want federal money, you can’t use it to subsidize tax cuts. States get to choose whether they prefer tax cuts or federal funding. So I believe the 10th Amendment challenge will likely fail.</p>
<p>The plaintiff states rely more heavily on a claim that the tax provision imposes an unconstitutional condition on receipt of their funds. They have two main arguments.</p>
<p>The states assert that the law forbids them from cutting taxes, even though it does not.</p>
<p>They rely on the Supreme Court’s decision to overturn a provision of the Affordable Care Act that <a href="https://www.oyez.org/cases/2011/11-393">withheld all federal Medicaid funding from states</a> that refused to expand the health coverage program. </p>
<p>This was a real penalty: The feds were already providing more than half of all Medicaid money and would pay virtually all of the additional costs of expanding the program. States that refused to expand Medicaid <a href="https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2012/06/28/court-lets-states-opt-out-of-medicaid-expansion">would get no federal Medicaid money at all</a>, leaving them much worse off than they were before.</p>
<p>But the rescue plan does not put the states in a worse position.</p>
<p>The rescue plan seeks only to make sure that the federal spending goes to cover the costs of the pandemic. It imposes a condition on federal spending, something that the Supreme Court has consistently approved.</p>
<h2>Funds for pandemic expenses</h2>
<p>The rescue plan tax provision more closely resembles a law that <a href="https://www.csmonitor.com/1986/1016/adrink.html">withheld federal highway money</a> from states that had a drinking age below 21. <a href="https://www.oyez.org/cases/1986/86-260">The Supreme Court upheld that law</a> in 1987.</p>
<p>The Supreme Court recognized that a condition could be unconstitutionally coercive. But it dismissed that concern because states would lose only 5% of their highway money if they failed to raise their drinking age. Every state except South Dakota complied with the condition. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/396371/original/file-20210421-19-z3vb3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Harris explains how the Covid relief package will help small businesses." src="https://images.theconversation.com/files/396371/original/file-20210421-19-z3vb3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/396371/original/file-20210421-19-z3vb3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/396371/original/file-20210421-19-z3vb3b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/396371/original/file-20210421-19-z3vb3b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/396371/original/file-20210421-19-z3vb3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=496&fit=crop&dpr=1 754w, https://images.theconversation.com/files/396371/original/file-20210421-19-z3vb3b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=496&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/396371/original/file-20210421-19-z3vb3b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=496&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Vice President Harris embarked on a three-state tour in March to highlight how the American Rescue Plan Act of 2021 will help small businesses in driving the American economic recovery.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/vice-president-kamala-harris-right-and-the-second-gentleman-news-photo/1307483418?adppopup=true">Helen H. Richardson/MediaNews Group/The Denver Post via Getty Images</a></span>
</figcaption>
</figure>
<p>The same principle should apply here. The rescue plan withholds federal relief if the funds offset state tax cuts. The feds need not provide any relief, but it can make sure that the relief it does provide is used to <a href="https://apnews.com/article/joe-biden-personal-taxes-legislation-coronavirus-pandemic-unemployment-insurance-104c5477a7879abd4117abfea25c30d5">defray pandemic expenses</a>. </p>
<p>The plaintiff states also maintain that the broad scope of the rescue plan’s tax provision – which covers “direct or indirect” reductions in net tax revenue, such as by lowering tax rates or providing tax rebates – makes its coverage ambiguous. That, states claim, violates the requirement that conditions on federal spending be “clearly stated.”</p>
<p>But at least one state, Missouri, concedes that the provision simply forbids applying stimulus money “to offset a specific tax reduction of a similar amount.” That concession could hurt the states in court.</p>
<p>And Treasury Secretary Janet Yellen has authority to promulgate regulations to clarify any ambiguity. She recently <a href="https://home.treasury.gov/news/press-releases/jy0113">issued guidance under the law</a>, stating that changes to state tax laws that take account of recent changes to federal tax law will not be treated as tax cuts under the rescue plan.</p>
<p>[<em>The Conversation’s Politics + Society editors pick need-to-know stories.</em> <a href="https://theconversation.com/us/newsletters/politics-weekly-74/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=politics-need-to-know">Sign up for Politics Weekly</a>.]</p>
<h2>Other payment methods</h2>
<p>Suppose, however, that the rescue plan does have a broader sweep.</p>
<p>States still could provide economic help to their residents and keep all of their COVID-19 money. They could do so by using ARPA money to pay people directly instead of reducing their taxes.</p>
<p>Maybe states should be careful not to label those payments as rebates, which might run afoul of the restriction. But they could avoid that problem by calling them, in <a href="https://www.congress.gov/bill/117th-congress/house-bill/1319/text">the rescue plan’s words</a>, “assistance to households, small businesses, and nonprofits” and “aid to impacted industries.”</p>
<p>However these cases get resolved, we should view them as the latest round in the political battle between the states and the federal government over contentious federal policy.</p>
<p>Legal doctrines might evolve, but in many respects these lawsuits are really performances: They allow state officials to score <a href="https://www.latimes.com/california/story/2020-08-28/california-100-lawsuits-trump-administration">political points with their constituents</a>, <a href="https://www.washingtonpost.com/news/the-fix/wp/2016/05/27/why-texas-likes-to-sue-the-federal-government-a-lot/">whether or not their legal arguments ultimately prevail</a>.</p><img src="https://counter.theconversation.com/content/158730/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Entin does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>States claim the stimulus law assaults state sovereignty by barring local governments from using aid money to cut taxes. But the Supreme Court has consistently approved conditions on federal spending.Jonathan Entin, Professor Emeritus of Law and Adjunct Professor of Political Science, Case Western Reserve UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1572162021-03-25T12:24:48Z2021-03-25T12:24:48ZWhat the American Rescue Plan says about President Biden’s health care priorities – and what they mean for you<figure><img src="https://images.theconversation.com/files/391310/original/file-20210324-17-piq131.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5932%2C3886&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">On the campaign trail Oct. 28, 2020, in Wilmington, Delaware, Joe Biden talks about the need to build up the Affordable Care Act.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/democratic-presidential-nominee-joe-biden-delivers-remarks-news-photo/1229328585?adppopup=true">Drew Angerer/Getty Images</a></span></figcaption></figure><p>As millions of Americans receive COVID-19 vaccines, the Affordable Care Act just got a booster shot of its own. </p>
<p>After <a href="https://www.nytimes.com/2021/03/22/us/politics/biden-obamacare-anniversary.html">11 years</a> of existential threat and months after an <a href="https://www.npr.org/2020/11/10/933462515/supreme-court-appears-likely-to-uphold-obamacare">argument before the Supreme Court</a>, the ACA has been strengthened under President Joe Biden’s American Rescue Plan, the US$1.9 trillion economic relief package. This means greater access to health insurance at lower costs for millions of Americans.</p>
<p>The ARP is the most noteworthy expansion of health insurance benefits since the passage of the landmark legislation in 2010. Specifically, it <a href="https://www.nytimes.com/2021/02/27/upshot/biden-health-plan-obamacare.html">contains</a> an <a href="https://www.hhs.gov/about/news/2021/03/12/fact-sheet-american-rescue-plan-reduces-health-care-costs-expands-access-insurance-coverage.html">important extension of financial assistance</a> to Americans who purchase health insurance on the ACA’s private insurance exchanges.</p>
<p>As a <a href="https://law.utk.edu/directory/zack-buck/">health law professor</a> who <a href="https://papers.ssrn.com/sol3/cf_dev/AbsByAuth.cfm?per_id=1713816">focuses on health care finance and delivery</a>, I see this as a key moment to gain insight into President Biden’s preferred policy choices as he seeks to improve health care access and financing in the United States.</p>
<h2>The original policy architecture</h2>
<p>In addition to outlawing preexisting condition discrimination, providing the funding to expand Medicaid programs across the country, and encouraging Medicare spending reforms, the ACA constructed private marketplaces, known as <a href="https://www.healthcare.gov">exchanges</a>. People who did not receive health insurance from their jobs, or who were not part of Medicare, Medicaid, or any other public plan, could purchase highly regulated health insurance plans with the help of federal tax subsidies known as <a href="https://www.irs.gov/affordable-care-act/individuals-and-families/the-premium-tax-credit-the-basics">premium tax credits</a>. </p>
<p>These tax subsidies were vital to the reforms; without them, policymakers knew that fewer people would enroll, particularly because the exchange insurance plans were unaffordable for many Americans.</p>
<p>As designed, these tax credits were available to Americans making between 100% and 400% of the <a href="https://aspe.hhs.gov/poverty-guidelines">federal poverty level</a>. In 2021, the <a href="https://aspe.hhs.gov/poverty-guidelines">poverty level</a> for an individual is just under $13,000 of annual income; for a family of four, it is $26,500.</p>
<p>For many of these Americans who qualified for tax subsidy assistance to purchase health insurance, this financial assistance was indispensable. The subsidies are robust: <a href="https://www.healthinsurance.org/obamacare/subsidy-calculator/">About 85%</a> of Americans have qualified for a subsidy on the exchange, and, of those, the average subsidy pays for <a href="https://www.healthinsurance.org/obamacare/subsidy-calculator/">about 85%</a> of the overall health insurance premium for the beneficiary.</p>
<p>In 2020, the average premium was <a href="https://www.healthinsurance.org/obamacare/subsidy-calculator/">$576</a>, and the average subsidy was <a href="https://www.healthinsurance.org/obamacare/subsidy-calculator/">$492</a>, meaning that the average beneficiary paid $84 in monthly premiums.</p>
<figure class="align-center ">
<img alt="Protesters carrying signs that call for Medicaid expansion." src="https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Protesters in Miami urge state officials to expand Florida’s Medicaid program.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/deborah-dion-and-other-protesters-gather-in-the-office-of-news-photo/181320209?adppopup=true">Joe Readie/Getty Images</a></span>
</figcaption>
</figure>
<h2>An unexpected problem</h2>
<p>While the subsidy was quite generous for these income groups, many Americans with incomes just above or just below the cutoffs faced unaffordable premiums. Without federal help, individuals could face thousands of dollars in health insurance premiums per year.</p>
<p>One of the ACA’s main thrusts was to protect the poorest Americans, or those making less than 100% of the poverty level. As the law was written, this would happen through an expansion of Medicaid, the federal-state program that provides health care coverage to the poor. </p>
<p>The law contemplated that many would qualify for newly expanded Medicaid; these individuals would not need access to the new private insurance exchange. Of course, this was altered when the Supreme Court in 2012 ruled that the Medicaid expansion contemplated by the ACA <a href="https://www.kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-decision/">could not be mandatory</a>.</p>
<p>Following the 2012 decision, most states expanded their programs, but <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/">12 states</a> have continued to refuse to expand their Medicaid programs, mainly because of concerns about costs. As a result, those under the federal poverty level living in those states that have not expanded Medicaid have fallen into a <a href="https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/">coverage gap</a>. They have been unable to access Medicaid coverage in their states and unable to access tax credits to purchase subsidy-assisted exchange plans. </p>
<p>At the other end of the income spectrum, people making more than 400% of the poverty level faced increasing premiums. This was a particular problem for many Americans nearing age 65, especially those who were independent contractors, business owners or early retirees. And as insurance premiums increased, these Americans could <a href="https://khn.org/news/overlooked-by-aca-many-people-paying-full-price-for-insurance-getting-slammed/">not depend on any subsidy cushion to assist</a>, requiring either the purchase of extremely expensive health plans or the decision to go without health insurance.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ldkQAbz31KY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">President Joe Biden announces extension for enrolling for insurance through the ACA.</span></figcaption>
</figure>
<h2>The new rules</h2>
<p>But the ARP broadens subsidies for every income group. Almost everyone is now eligible for credits that limit their health insurance premiums to no more than 8.5% of their household income. </p>
<p>Specifically, according to the <a href="https://www.cbo.gov/system/files/2021-02/hwaysandmeansreconciliation.pdf">Congressional Budget Office</a>, people with incomes just over 400 percent of the poverty level “who are older or enrolled in family policies or in insurance rating areas with especially high premiums would experience the greatest reduction in net premiums.” </p>
<p>Additionally, for those lower on the income scale, the new tax credit structure grows to relieve the burden of any premium for individuals making between 100% and 150% of the poverty level (<a href="https://www.cbo.gov/system/files/2021-02/hwaysandmeansreconciliation.pdf">this reduces the premiums from the limit of 2.07% to 4.14% currently</a>). </p>
<p>These changes should make plans much more affordable for many exchange customers, better facilitating their ability to acquire health insurance. Already, <a href="https://www.nytimes.com/2021/03/22/us/politics/biden-obamacare-anniversary.html">more than 200,000 additional Americans</a> have signed up for plans during the current special enrollment period. And President Biden announced on March 23 that <a href="https://www.wsj.com/articles/biden-administration-extends-enrollment-period-for-affordable-care-act-11616533263">the enrollment period will be extended until Aug. 15</a>.</p>
<p>To address the coverage gap in holdout states, the ARP bolsters funding in an attempt to sweeten the deal for Medicaid expansion. This has <a href="https://nymag.com/intelligencer/2021/03/stimulus-spurs-new-push-for-red-state-medicaid-expansion.html">led to renewed consideration</a> and <a href="https://www.usnews.com/news/best-states/wyoming/articles/2021-03-24/wyoming-house-passes-medicaid-expansion-bill-on-32-28-vote">garnered additional support</a> for Medicaid expansion in these states.</p>
<figure class="align-center ">
<img alt="A woman wearing a hat that says " src="https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Debate has swirled for years over whether the U.S. should switch to a single-payer system.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/healthcare-reform-activist-wears-a-hat-as-she-protests-news-photo/88051954?adppopup=true">Justin Sullivan/Getty Images</a></span>
</figcaption>
</figure>
<h2>The policy choice</h2>
<p>In addition to providing tangible benefits to those buying health insurance on the private health insurance exchange, the move by President Biden illustrates his commitment to bolstering the ACA. Indeed, for his first big move on health policy, Biden is strengthening private insurance. </p>
<p>This is a far cry from the more dramatic reforms sought by some advocates, such as “<a href="https://www.nbcnews.com/politics/elections/what-medicare-all-how-would-it-work-n1014256">Medicare for All</a>” proposals, or extensions to traditional Medicare, or even more moderate but still disruptive reforms like a public option. Instead of deconstructing private insurance, Biden is making it more durable. </p>
<p>This signals a continuation of the status quo from the Obama administration, and not a dramatic shift in how the federal government conceives of health care insurance in this country. A world in which the ACA provides more financial insulation for more Americans may be a world in which dramatic cost-controlling reforms seem less likely. And while these welcomed changes will limit the health care expenditures for which many Americans are responsible, the large-scale, endemic causes of the high cost of American health care are likely to remain in place. </p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/157216/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Zack Buck does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Stimulus checks received a lot of attention during debates about the stimulus package, but it may be expansion of health insurance that will have the longest-lasting effect on Americans.Zack Buck, Associate Professor of Law, University of TennesseeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1536142021-03-02T13:24:24Z2021-03-02T13:24:24ZCOVID-19 revealed how sick the US health care delivery system really is<figure><img src="https://images.theconversation.com/files/380135/original/file-20210122-17-1q4kx0c.jpg?ixlib=rb-1.1.0&rect=8%2C62%2C5982%2C3925&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many U.S. hospitals and clinics are behind when it comes to sharing information.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/men-point-to-digital-tablets-with-virtual-screen-royalty-free-image/1257966144?adppopup=true">Teera Konakan/Moment via Getty Images</a></span></figcaption></figure><p>If you got the COVID-19 shot, you likely received a little paper card that shows you’ve been vaccinated. Make sure you keep that card in a safe place. There is no coordinated way to share information about who has been vaccinated and who has not.</p>
<p>That is just one of the glaring flaws that COVID-19 has revealed about the U.S. health care system: It does not <a href="https://www.healthit.gov/topic/interoperability/">share health information</a> well. Coordination between public health agencies and medical providers <a href="https://www.healthit.gov/topic/health-it-health-care-settings/public-health/">is lacking</a>. Technical and regulatory restrictions <a href="https://doi.org/10.31478/201810a">impede use</a> of digital technologies. To put it bluntly, our health care delivery system is failing patients. <a href="https://www.healthaffairs.org/do/10.1377/hblog20200721.330502/full/">Prolonged disputes</a> about the Affordable Care Act and rising health care costs have done little to help; the problems go beyond insurance and access.</p>
<p>I have spent most of my career within the domain of information technology and IT-based innovation and systems engineering. As a <a href="https://scholar.google.com/citations?user=pQuX8m0AAAAJ&hl=en.">professor of health informatics</a>, I have focused on health care transformation. For two years, I served on the Health Innovation Committee at <a href="https://www.himss.org/">HIMSS</a>, the preeminent global health information and technology organization. In short, I have studied these problems for decades, and I can tell you that most of them aren’t about medicine or technology. Rather, they are about the inability of our delivery system to meet the evolving needs of patients.</p>
<h2>We need a high-performance system</h2>
<p>In reality, the U.S. health care sector is not a system at all. Instead, it is an underperforming conglomerate of <a href="https://www.nap.edu/catalog/11378/building-a-better-delivery-system-a-new-engineeringhealth-care-partnership/">independent entities</a>: hospitals, clinics, community health and urgent care centers, individual practitioners, small group practices, pharmacy and retail outlets, and more, most of which compete for profits and in some cases pay sky-high salaries to executives.</p>
<figure class="align-center ">
<img alt="A nurse making a computerized medical report." src="https://images.theconversation.com/files/380139/original/file-20210122-19-18dl21h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/380139/original/file-20210122-19-18dl21h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380139/original/file-20210122-19-18dl21h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380139/original/file-20210122-19-18dl21h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380139/original/file-20210122-19-18dl21h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380139/original/file-20210122-19-18dl21h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380139/original/file-20210122-19-18dl21h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The U.S. transition to a high-performing health care delivery system has been a slow one.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/side-view-of-female-nurse-making-medical-report-in-royalty-free-image/1188432112?adppopup=true">Maskot via Getty Images</a></span>
</figcaption>
</figure>
<p>These entities often function in silos. Errors, gaps, duplication of services and poor patient outcomes <a href="https://www.annfammed.org/content/7/2/100">are often the result</a>. </p>
<p>Here’s an example: A heart surgery patient, still on oxygen and in intensive care just two days earlier, is referred to her primary care physician for follow-up, and to a rehabilitation center for therapy. Neither her doctor nor the facility knows the patient was even hospitalized, nor do they have access to her records or medication list. </p>
<h2>Shopping for doctors</h2>
<p>For patients, this might mean a <a href="https://www.annfammed.org/content/7/2/100">disjointed set of services</a> that don’t offer a coordinated plan of care or even a timely or comprehensive diagnosis of their health problems. Patients with chronic conditions often see more than 10 different doctors <a href="https://www.rand.org/content/dam/rand/pubs/tools/TL200/TL221/RAND_TL221.pdf">during dozens of office visits per year</a>.</p>
<p>The specialist may not even be aware when the patient does not return. Patient information is seldom shared; specialists are often associated with different medical systems that don’t share records. And even when they try, accurately matching patient IDs in different systems can be problematic. </p>
<p>The challenge now is to transform the status quo into a high-performance system, a true 21st-century health care delivery system. Bringing systems engineering and information technologies to medical practice can help make that happen, but doing that requires a holistic approach. </p>
<p>Let’s start with electronic health records. More than 20 years ago, the <a href="https://www.nap.edu/read/12709/chapter/2">Institute of Medicine</a> called for the transition from paper to digital health records. This would allow patients to easily share lab, imaging and other test results with different providers. Nearly a decade went by before action occurred on the recommendation. In 2009, the <a href="https://www.asha.org/practice/reimbursement/hipaa/hitech-act/#:%7E:text=The%20Health%20Information%20Technology%20for,(EHR)%20systems%20among%20providers.">HITECH Act</a> was passed, which provided US$30 billion of incentives for the transition. </p>
<p>Yet now, 12 years down the road, we’re still a long way from a patient’s electronic health records becoming universally available at the point of care. Connectivity across systems and networks remains fragmented, and a lack of trust between organizations, along with anti-competitive behavior, results in an unwillingness to share patient information. </p>
<figure class="align-center ">
<img alt="A patient talks to a doctor on her digital tablet." src="https://images.theconversation.com/files/380141/original/file-20210122-13-1ox81wj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/380141/original/file-20210122-13-1ox81wj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380141/original/file-20210122-13-1ox81wj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380141/original/file-20210122-13-1ox81wj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380141/original/file-20210122-13-1ox81wj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380141/original/file-20210122-13-1ox81wj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380141/original/file-20210122-13-1ox81wj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Although telemedicine conferences have become popular during the pandemic, the technology is still not.
up to speed for many patients.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/she-doesnt-need-a-prescription-for-this-tablet-royalty-free-image/1062130130?adppopup=true">AJ_Watt/E+ via Getty Images</a></span>
</figcaption>
</figure>
<h2>Unsafe medical treatment</h2>
<p><a href="https://www.pewtrusts.org/-/media/assets/2018/09/healthit_enhancedpatientmatching_report_final.pdf">One failure</a> of the system is an inability to accurately identify and match patient records. Few standards exist for collecting patient information. With hundreds of vendors and thousands of hospitals, doctor’s offices, pharmacies and other facilities participating in the process, variation is huge. Is John Doe at 250 Park Ridge Drive the same as John E. Doe at 250 Parkridge? </p>
<p>In 2017, the American Hospital Association estimated 45% of large hospitals <a href="https://www.aha.org/news/headline/2019-09-06-aha-urges-senate-appropriators-allow-funding-unique-patient-identifier/">reported difficulties in correctly identifying patients</a> across information technology systems. This means, on occasions at least, clinicians are making decisions that lead to increased chances of misdiagnosis, unsafe medical treatment and duplicate testing.</p>
<p>During a public health emergency like COVID-19, accurate ID’s of patients is one of the most <a href="http://patientidnow.org/wp-content/uploads/2020/09/Patient-ID-Now-Provides-Testimony-on-Coronavirus-Response-Efforts.pdf">difficult operational issues that a hospital faces</a>. Accurate COVID-19 test results <a href="http://patientidnow.org/wp-content/uploads/2020/11/Senate-Appropriations-Statement-11.10.20.pdf">are hampered</a> when specimens, sent to public health labs, are accompanied by patient misidentification and inadequate demographic data. Results can be sent to the wrong patient, or at best, get backlogged. </p>
<p>These mistakes also are costly. More than one-third of all denied claims <a href="https://www.ponemon.org/">result directly</a> from inaccurate patient identification or information that’s wrong or incomplete. This costs the average U.S. health care facility <a href="http://promos.hcpro.com/pdf/2016-national-report-misidentification-report.pdf">$1.2 million per year</a>. </p>
<h2>Congress needs to act</h2>
<p>For nearly two decades, the Department of Health and Human Services has been restricted from spending federal dollars to adopt a unique health identifier for patients. To remedy the problem, the U.S. House of Representatives in July 2020 unanimously adopted an amendment allowing HHS to evaluate patient identification solutions that still protect patient privacy. But the Senate chose not to address the issue. Still, many health care leaders are advocating for the new Congress to take action. Health care proponents are hopeful the new Senate majority leader will be more receptive to addressing the issue.</p>
<p>A bright spot in all of this is that many health care systems saw the advantages of telemedicine during the pandemic. It’s convenient for patients, it saves money and it meets the needs of patients who have <a href="https://doi.org/10.1177/0025817220926926">difficulty traveling</a>. Telemedicine could be just the beginning; with an ever-growing array of mobile health devices, physicians can monitor a patient at home, rather than in an institution. More must be done, however. Throughout the pandemic, some patients, with a lack of broadband access or poor Wi-Fi, <a href="https://www.pewresearch.org/internet/2020/04/30/53-of-americans-say-the-internet-has-been-essential-during-the-covid-19-outbreak/">had something less</a> than a rich and uninterrupted visit. </p>
<p>Health IT advocates have long envisioned a health care system that seamlessly uses connected care to improve patient outcomes while costing less. When the pandemic subsides, the waivers and policies temporarily adopted will require not a sudden termination, but a transition to such a system. </p>
<p>Over the past year, doctors, nurses and health care systems have learned lessons out of necessity. Instead of abandoning our new knowledge, I believe we need to double down on a modern, stable and value-based health delivery system with equity for all. And at its heart must be one certainty: that accurate and comprehensive patient records are always available at the point of care.</p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/153614/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth A. Regan receives funding from the National Science Foundation. She is affiliated with the Health Information Management Systems Society (HIMSS) and its local South Carolina chapter.</span></em></p>With outdated delivery systems at many hospitals and clinics, mistakes can lead to costly duplication of services and poor patient outcomes. But there are ways to fix the current system.Elizabeth A. Regan, Dept. Chair Integrated Information Technology and Professor of Health Informatics, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1538162021-02-11T13:15:27Z2021-02-11T13:15:27ZPublic option in Biden plan could change the face of US health care<figure><img src="https://images.theconversation.com/files/383109/original/file-20210208-23-tr2oo5.jpg?ixlib=rb-1.1.0&rect=17%2C8%2C2977%2C1733&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">President Biden's proposed changes in health care include more than revamping our COVID-19 response.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/making-a-doctors-appointment-royalty-free-image/1140741451?adppopup=true">Aja Koska via Getty Images</a></span></figcaption></figure><p>President Joe Biden <a href="https://www.federalregister.gov/presidential-documents/executive-orders/joe-biden/2021">issued 10 executive orders</a> to fight COVID-19 on his first day in office on Jan. 20, 2021. </p>
<p>Among those orders: Speed up vaccine production, expand testing, support the safe reopening of schools and reduce racial and ethnic disparities in care and treatment.</p>
<p><a href="https://scholar.google.com/citations?user=s7A-LdEAAAAJ&hl=en">As a physician and health care researcher and administrator</a> at the University of Virginia, I agree that the biggest issue facing President Biden is stopping the coronavirus. But there is far more to America’s health problems than COVID-19. Biden promised sweeping reforms to the health care system; what follows is perhaps the top 10.</p>
<h2>For starters, a short list</h2>
<p><a href="https://joebiden.com/healthcare/">Biden’s platform</a> included health care policies that would have tremendous impact on every American, among them:</p>
<ol>
<li><p>Give Americans a new choice on health insurance – specifically, a <a href="https://www.nytimes.com/2019/02/19/upshot/medicare-for-all-health-terms-sanders.html">public option</a> that allows working-age adults - and not just the elderly - to buy into a public insurance plan rather than a private plan like Medicare. If adopted, those eligible could purchase insurance directly from the federal government, likely through the federal marketplace, similar to the existing Affordable Care Act marketplace.</p></li>
<li><p>Extend coverage to working Americans further by increasing the value of tax credits to lower premiums, by increasing the amount that enrollees can deduct from their income tax to purchase health insurance coverage on an exchange. </p></li>
<li><p>Expand coverage to low-income Americans. In 14 states, governors and state legislatures have <a href="https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?">refused to take up</a> the Affordable Care Act’s expansion of Medicaid eligibility - thereby denying Medicaid to an estimated <a href="https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/">4.9 million adults</a>. </p></li>
<li><p>Stop <a href="https://theconversation.com/surprise-medical-bills-increase-costs-for-everyone-not-just-for-the-people-who-get-them-146476">surprise billing</a>. That’s when an insured patient receives a bill from a provider they may not have even seen, such as an anesthesiologist who is out of network. </p></li>
<li><p>Tackle market concentration across the health care system. The Biden administration has pledged to aggressively use its existing antitrust authority to address this problem. </p></li>
<li><p>Partner with the health care workforce to lower costs and improve health outcomes. </p></li>
<li><p><a href="https://www.ssa.gov/OP_Home/ssact/title18/1860D-11.htm">Repeal the exception</a> that allows drug companies to avoid negotiating its prices with Medicare. </p></li>
<li><p>Limit manufacturers from setting abusively high launch prices for drugs that face no competition. Also limit price increases for all brand, biotech and generic drugs to the rate of inflation.</p></li>
<li><p>Allow consumers to buy <a href="https://theconversation.com/why-the-us-has-higher-drug-prices-than-other-countries-111256">prescription drugs from other countries</a>.</p></li>
<li><p>End the tax break that <a href="https://www.brown.senate.gov/newsroom/press/release/brown-introduces-legislation-to-close-big-pharma-advertising-tax-loophole">drug companies receive for advertising</a>. </p></li>
</ol>
<figure class="align-center ">
<img alt="Demonstrators protesting for" src="https://images.theconversation.com/files/382349/original/file-20210203-23-u62bfh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/382349/original/file-20210203-23-u62bfh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/382349/original/file-20210203-23-u62bfh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/382349/original/file-20210203-23-u62bfh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/382349/original/file-20210203-23-u62bfh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/382349/original/file-20210203-23-u62bfh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/382349/original/file-20210203-23-u62bfh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Even with the ACA in effect, tens of millions of Americans are still uninsured or underinsured.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/about-500-protesters-chanting-kill-the-bill-dont-kill-us-news-photo/1229041615?adppopup=true">Erik McGregor/LightRocket via Getty Images</a></span>
</figcaption>
</figure>
<h2>More about the public option</h2>
<p>Among the 10 initiatives, the public option alone would <a href="https://www.hartfordbusiness.com/article/lembo-a-public-option-is-good-for-business">change the face of U.S. health care</a>. By essentially price-setting and thereby benchmarking payments for the great majority of health services, the government would become the Sam’s Club of health care, which would drive prices down.</p>
<p>Currently, insurance payments to physicians and hospitals are often expressed in terms of “Medicare plus” (or “minus,” in the case of Medicaid). The Medicare rate <a href="https://www.mgma.com/data/data-stories/almost-three-fourths-of-practices-report-their-com">serves as the benchmark</a> on which private commercial insurers base their negotiated fee schedules. But with the government more heavily involved in directly paying for health services, the “Sam’s Club” effect will push prices down. Compared to commercial insurance, individual consumer costs <a href="https://www.rand.org/pubs/research_briefs/RB10120.html">would likely be dramatically lower</a> for those choosing the public option. </p>
<p>That’s why it’s not hard to imagine that many Americans, perhaps a significant majority, would choose the public option over other insurance, including employer-based health plans with their ever-increasing <a href="https://www.kff.org/interactive/premiums-and-worker-contributions-among-workers-covered-by-employer-sponsored-coverage-1999-2020/#/?coverageGroup=family">shift of costs to employees</a>. With that scenario, it’s true the public option might encourage commercial insurers and perhaps health systems to further coalesce to protect their market shares and spread risk. This may or may not result in additional price disparity as nongovernmental insurers feel compelled to optimize their margins.</p>
<figure class="align-center ">
<img alt="Franklin D. Roosevelt in 1932." src="https://images.theconversation.com/files/382351/original/file-20210203-19-3sla81.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/382351/original/file-20210203-19-3sla81.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=479&fit=crop&dpr=1 600w, https://images.theconversation.com/files/382351/original/file-20210203-19-3sla81.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=479&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/382351/original/file-20210203-19-3sla81.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=479&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/382351/original/file-20210203-19-3sla81.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=602&fit=crop&dpr=1 754w, https://images.theconversation.com/files/382351/original/file-20210203-19-3sla81.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=602&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/382351/original/file-20210203-19-3sla81.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=602&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">On the 1932 campaign trail, soon-to-be President Franklin D. Roosevelt touts his New Deal.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/the-new-deal-franklin-delano-roosevelt-32nd-president-of-news-photo/113490483?adppopup=true">Universal History Archive/Getty Images</a></span>
</figcaption>
</figure>
<h2>History repeating itself</h2>
<p>Since Reconstruction, U.S. domestic policy has been a study in contradiction and compromise, characterized by policies and politics that, on their surface, were intended to help the nation heal from war, lift Americans out of poverty and unite the nation. </p>
<p>The New Deal, the GI Bill, the Social Security Act and the establishment of the Federal Housing Administration were implemented in a way that was almost criminally obtuse in their failure to anticipate the adverse impacts they would have on Black Americans. “Black neighborhoods” didn’t so much happen; instead, they were deliberately engineered through New Deal policies in the 1930s and the ironically named Fair Housing Act enacted in the 1960s, which was supposed to fix the post-World War II housing shortage. State and regional housing authorities <a href="https://wwnorton.com/books/The-Color-of-Law/">did precisely that - for white Americans</a>. </p>
<p>So what does this have to do with a potential Biden-led public option, which would also represent a major expansion of the U.S. social safety net? </p>
<p>The Confederacy justified slavery as an issue of “states’ rights” and federal overreach. From Reconstruction on, major federal policy changes <a href="https://millercenter.org/president/fdroosevelt/the-american-franchise">have required compromise with Southern states</a> to secure enough votes for passage. </p>
<p>In most cases - this applies to the GI Bill, the Social Security Act and the Federal Housing Administration - the compromise took the form of allowing Southern states to control the implementation of these policies. Southern Veterans Affairs offices, housing authorities and Social Security offices, adhering to the specific language of the law, <a href="https://www.history.com/news/gi-bill-black-wwii-veterans-benefits">were highly effective in disenfranchising Black Americans</a>. Northern states were much less likely to do so, although <a href="https://www.nationalbcc.org/news/beyond-the-rhetoric/2791-the-black-vote-volunteer-slavery">by no means was this ubiquitous</a>.</p>
<p>Which brings us back to number three on President Biden’s list. Nearly 5 million Americans <a href="https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?">are denied access to Medicaid</a> by governors and state legislatures. </p>
<p>The message: Legislative language isn’t all that matters. To truly end the centuries-long health disparities among Americans, an essential step is not only to scrutinize how public policy is designed, but to hold our leaders accountable for how its implemented. As the aforementioned policies demonstrate, good intentions on paper, when left to state governments, are routinely applied inequitably in America, particularly in certain states. The implementation of the ACA is a current example, wherein former Confederate states and those led by the most conservative legislatures <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/%20https://www.usnews.com/news/the-report/articles/2015/12/04/opposing-medicaid-expansion">have resisted the expansion of Medicaid, often citing “states’ rights</a>.” </p>
<p>[<em>The Conversation’s science, health and technology editors pick their favorite stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-favorite">Weekly on Wednesdays</a>.]</p>
<p>While I admittedly cannot prove causality, the correlation between the <a href="https://doi.org/10.1001/jama.2019.16932">list of states with the shortest life expectancies</a>, <a href="https://www.spreadsheetweb.com/project/life-expectancy-by-state-and-race-in-the-us/">the states with the worst disparities in life expectancy for Black people</a> and states that have not expanded Medicaid is high. I would argue that it is too high to be coincidental. Federal policy that would mitigate and has mitigated health disparities has once again been subverted by individual states’ choices in how (or how not to) to implement it, much as the New Deal was. </p>
<p>There is a way to fix this. A public option, underwritten by the federal government, would enable individuals to circumvent those state governments who have prevented them from accessing health care and other services. By calling out the specific states, if not by name, at least by clear implication (“In 14 states, governors and state legislatures have refused to uptake the Affordable Care Act’s expansion of Medicaid eligibility - point 3 in Biden’s plan”), the Biden administration would be proactive in addressing the gaps in care not yet filled by the ACA via the public option. Doing this could effectively put an end to yet one more harmful “states’ rights” argument and marry federal health policy with equitable implementation. Seems a worthy objective to me.</p><img src="https://counter.theconversation.com/content/153816/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Williams does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The president is calling for sweeping changes in health care policy. Tens of millions of Americans could be affected.Michael Williams, Associate Professor of Surgery and Public Policy and Former Director of the UVA Center for Health Policy, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1542132021-02-08T18:24:07Z2021-02-08T18:24:07ZFact check US: Can progressive and centrist Democrats finally agree on health care reform?<p>The Democrats are back in the driving seat. Some are demanding a complete overhaul of the health care system, specifically from progressive Senator Sanders. Sanders has just been named to the strategic position of Senate Budget Committee Chairman. Does this mean that the left and center of the Democratic Party will finally agree on a more comprehensive health insurance system?</p>
<p>Senator <a href="https://www.politico.com/news/2021/01/12/bernie-sanders-big-budget-plans-458461">Bernie Sanders</a> is already promoting his campaign for a universal, public health insurance model with a vengeance: </p>
<blockquote>
<p>“I am a very strong advocate of Medicare for All. I introduced legislation in the Senate. I think, at the end of the day, the American people understand that our current health care system is so dysfunctional, so cruel, so wasteful, so expensive that we need to do what every other major country on Earth does, and get health care to all people. What we will be doing is working within the context of what Biden wants.” </p>
</blockquote>
<p>Sanders’ statement comes as no surprise. As a senator from the progressive state of Vermont, he has been fighting for years to implement a public health care system in the United States similar to models in Europe. This has long been a core aim of <a href="http://www.pressesdesciencespo.fr/fr/book/?gcoi=27246100830610">progressives in Wisconsin</a>, from the days of Roosevelt’s New Deal to the debate around Bill Clinton’s proposed health care reform in 1993. That was when progressive Democrats started to advocate for single-payer health care – that all essential health care be covered by a single public system, rather than private insurers.</p>
<h2>Seeking a fairer health care system while the pandemic rages</h2>
<p>For many in the United States, the debate remains the same – it’s still a case of choosing between a “grand illusion” of universal care and a <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2019.305315">“feasible solution”</a>. However, the Covid-19 pandemic, which has caused nearly 450,000 deaths so far, has pushed supporters of public health care to speak out more forcefully, right when the Biden administration is taking over. </p>
<p>So what can we expect from the new president? As part of the moderate wing of the Democratic Party, Joe Biden was not supportive of Medicare for All during the primaries. He stated that he was in favor of improving the Affordable Care Act (ACA), Barack Obama’s health care reform, which gave coverage to <a href="https://www.cbpp.org/research/health/chart-book-accomplishments-of-affordable-care-act">20 million Americans</a> who previously had none. Under the act, popularly known as Obamacare, Americans are encouraged to get private health insurance, with public assistance for those who could not afford to do so. Two longstanding public programs with narrow criteria complete the system: Medicare (for those over 65 years old) and Medicaid (for minors and single women).</p>
<p>Biden was in favor of increasing public funding so that all citizens could afford insurance, essentially an Affordable Care Act 2.0. The high public cost of Medicare for All as well as the number of Americans who are relatively satisfied with the current employer-based system meant that the Delaware senator considered larger reform out of the question.</p>
<p>However, with Kamala Harris as his running mate and now vice-president, and an eye on getting progressive Democrats on board, Biden has shifted to the left. One such move was proposing a more substantial reform of Obamacare, introducing a “public option”. Harris had earlier come out in favor of an “open” version of Medicare for All, with the option to take out supplementary private health insurance. The two compromised on a solution with both private and public insurance. However, this kind of reform requires budget legislation that cannot be passed by a simple majority (which the Democrats have in the Senate). They would need a supermajority of 60 votes to get it through, and avoid Republican obstruction (a.k.a., the <a href="https://theconversation.com/fact-check-us-lobstruction-parlementaire-lun-des-obstacles-majeurs-a-venir-pour-joe-biden-153902">filibuster</a>).</p>
<p>What’s more, with the absolute priority currently given to the fight against the Covid-19 pandemic, it’s unclear whether Biden will take an extra step toward the far-reaching reform sought by progressive Democrats. Looking at the make-up of Biden’s new administration, one cannot precisely assess the importance that this issue could have on the upcoming political agenda. Out of the <a href="https://www.washingtonpost.com/politics/interactive/2020/biden-appointee-tracker/">19 executive positions</a> in the Department of Health awaiting appointments, and approval by the Senate, only one has been confirmed – Dr. Francis Collins, the new director of the National Institute of Health. Nominations of Xavier Becerra as the secretary, as well as the deputy and assistant secretary candidates, are awaiting confirmation. </p>
<p>By comparison, the 2008–09 Obama administration was set up as a sort of task force, with a number of veterans from the Clinton administration. These advisers, many of whom held positions in the White House and Department of Health, backed the consensus-based health-insurance reform bill. There is nothing of the sort in the current administration.</p>
<h2>A bare majority for Democrats in Congress</h2>
<p>President Biden’s main priority is to fight the Covid-19 pandemic, hence his promise for <a href="https://www.forbes.com/sites/roberthart/2021/12/29/biden-promises-100-million-covid-19-vaccinations-in-first-100-days-warning-that-trumps-approach-would-take-years/?sh=6efbc5892a97">“100 days, 100 million vaccinations”</a>. This is also his reasoning behind the recruiting of his chief of staff, Ron Klain, who as part of the Obama administration was responsible for managing the US response to the Ebola epidemic. </p>
<p>Responding to Covid-19 also allows for the triumphant return of experts to the White House, who were both badly treated and side-lined by the Trump administration. Biden’s choice of the ten members of his task force shows a change in tack. And the nomination of Jeff Zients, an economist and a former Obama advisor, to coordinate the federal vaccination program reaffirms this choice. Zients was the one who fixed the rollout of the ACA’s federal health insurance marketplace website.</p>
<p>Assessing the Biden administration’s opportunities for substantial US health care reform requires a careful reading of the recent election results. Despite Trump’s baseless claims, Biden comfortably won, but there wasn’t a “blue wave” in Congress. The Democrats actually lost seats in the House of Representatives and have only the barest majority in the Senate, with Harris as the tiebreaker vote. Any major Medicare for All–type reform bill will inevitably be subject to criticism from the Republicans who warn against so-called “socialized medicine” while dismissing the benefits of universal care. The Biden administration has also committed $1.9 billion to fight the impacts of Covid-19, with more planned.</p>
<p>All this means that it is likely that Biden will choose to improve the ACA, introducing measures by passing budget legislation or budget balancing, which would only require a relative majority in the Senate (50 votes).</p>
<p>As vice-president, Harris will likely will leave her health care reform agenda for a later date. Committing to such a reform without having 60 Democratic votes in the Senate would be a major political risk for the 2022 midterm elections. And there are certainly other issues to tackle, such as securing minority rights or providing a stable situation for the 11 million undocumented immigrants or the 700,000 “dreamers” (children of migrants born in the United States). These political battles are just as deeply felt as Medicare for All and certainly much less risky for Harris, who no doubt hopes to embody the future of the Democratic Party in the post-Biden era.</p>
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<p><em>The Fact check US section received support from <a href="https://craignewmarkphilanthropies.org/">Craig Newmark Philanthropies</a>, an American foundation fighting against disinformation.</em></p>
<p><em>Translated from the French by Rosie Marsland for <a href="http://www.fastforword.fr/en">Fast ForWord</a>.</em></p><img src="https://counter.theconversation.com/content/154213/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Les auteurs ne travaillent pas, ne conseillent pas, ne possèdent pas de parts, ne reçoivent pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'ont déclaré aucune autre affiliation que leur organisme de recherche.</span></em></p>From Vice-President Kamala Harris to Senator Bernie Sanders, voices were raised during the campaign for a more accessible US health care system. What can we expect from the Biden administration?William Genieys, Directeur de recherche CNRS au CEE, Sciences Po Larry Brown, Professeur invité au Laboratoire interdisciplinaire d'évaluation des politiques publiques (LIEPP), Sciences Po, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1536472021-01-21T18:53:32Z2021-01-21T18:53:32ZVital Signs: Biden’s economic centrism isn’t exciting, but right for these divisive times<p>In an age of hyperpartisan politics, the Biden presidency offers a welcome centrism that might help bridge the divides.</p>
<p>But it is also Biden’s economic centrism that offers a chance to cut through what has become an increasingly polarised approach to economic policy.</p>
<p>On the Republican side of politics, there is strong support for neoliberal economic policies – that is, economic policies that don’t just emphasise the importance of markets but represent a kind of free-market fanaticism. Ronald Reagan aptly expressed this view in his <a href="https://www.reaganfoundation.org/ronald-reagan/reagan-quotes-speeches/inaugural-address-1/">1981 inaugural speech</a>, in which he said “government is not the solution to our problem, government is the problem”.</p>
<p>On the Democratic side, the centrism of the Bill Clinton era (1993- 2001) has given way to much more left-wing policies. Indeed the democratic socialism of Bernie Sanders and Alexandria Ocasio-Cortez have been in the ascendancy for several years.</p>
<p>If you have any doubt about this, consider two facts. </p>
<p>First, Sanders came very close to being the Democratic Party’s presidential nominee in 2016. Second, the 2020 Democratic presidential primaries were dominated by candidates with similar views – such as Senator Elizabeth Warren.</p>
<p>Biden, of course, ran on a much more centrist economic platform. </p>
<p>This was perhaps best captured by his approach to health care – seeking to build on Obamacare (the Affordable Care Act) and insure more people, rather than adopt the “<a href="https://berniesanders.com/issues/medicare-for-all/">Medicare for All</a>” policy advocated by Sanders and Warren.</p>
<p>In a whole range of areas Biden and his nominees for important cabinet posts have signalled the new administration’s economic policies will be responsive to the demands of the left but still be sensitive to the concerns of the right. </p>
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Read more:
<a href="https://theconversation.com/whos-who-in-joe-bidens-cabinet-152252">Who’s who in Joe Biden’s cabinet</a>
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<h2>Big spending, but within limits</h2>
<p>One of the most important things the administration will do in its early days is to orchestrate a large spending package to help deal with the fallout of the coronavirus pandemic. </p>
<p>This will include spending on the vaccine roll-out, helping schools reopen, extending unemployment insurance and cheques to households.</p>
<p>So the spending package is likely to be huge. But the administration is not going to spend with complete abandon and without acknowledging constraints.</p>
<p>As Biden’s pick for Treasury Secretary, Janet Yellen, said in her <a href="https://www.rev.com/blog/transcripts/janet-yellen-opening-statement-transcript-at-confirmation-hearing">confirmation hearing</a>:</p>
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<p>Neither the president elect, nor I, proposed this release relief package without an appreciation for the country’s debt burden. But right now, with interest rates at historic lows, the smartest thing we can do is act big. In the long run, I believe the benefits will far outweigh the costs, especially if we care about helping people who’ve been struggling for a very long time.</p>
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Read more:
<a href="https://theconversation.com/vital-signs-janet-yellen-the-very-model-of-a-modern-madam-secretary-150836">Vital Signs: Janet Yellen, the very model of a modern Madam Secretary</a>
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<h2>Treading cautiously on health care</h2>
<p>Sanders and others’ “Medicare for All” plan involves single-payer (i.e. the government) universal coverage and <a href="https://www.bloomberg.com/news/articles/2019-07-05/harris-keeps-tripping-up-on-her-medicare-for-all-fuzziness">ending private health insurance</a>. This would be similar to the approach in Scandinavia, Canada and Britain.</p>
<p>Biden has strongly resisted this on two fronts. </p>
<p>One, it would be incredibly expensive, <a href="https://www.cnbc.com/2020/03/10/biden-says-he-wouldd-veto-medicare-for-all-as-coronavirus-focuses-attention-on-health.html">costing</a> US$30-40 trillion over a decade. Two, it would involve more than 150 million Americans losing their current insurance.</p>
<p>Instead, Biden wants to expand the Affordable Care Act with more incentives to push towards truly universal coverage. This is something Mitt Romney (the Republicans’ 2012 presidential candidate) might easily have proposed. Don’t forget that as governor of Massachusetts (from 2003 to 2007) he enacted a plan almost identical the Affordable Care Act – an idea championed by the conservative <a href="https://www.forbes.com/sites/johngoodman/2016/02/15/where-did-the-idea-of-obamacare-come-from-a-defense-of-the-heritage-foundation/?sh=1afbc76c4170">Heritage Foundation</a>.</p>
<h2>Likewise with tax reform</h2>
<p>Biden’s tax plan certainly involves raising taxes but not to anywhere near the levels called for by the democratic socialist wing of his party. Nor will he embrace a wealth tax like Warren championed. Under her plan, people with assets of more than US$50 million would be taxed 2% of that amount a year (and 3% for more than US$1 billion).</p>
<p>But he does plan to raise the top income tax rate (on income more than US$400,000) from <a href="https://taxfoundation.org/joe-biden-tax-plan-2020/">37% to 39.6%</a>. He will raise the flat 21% corporate tax rate introduced by Trump to 28%.</p>
<p>US companies will need to pay a minimum tax of 21% on foreign income – addressing the issue of companies avoiding taxes through legal set-ups in low-tax overseas jurisdictions (such as <a href="https://itep.org/fact-sheet-apple-and-tax-avoidance/">Apple in Ireland</a>). </p>
<p>Biden will even introduce a tax penalty on companies that move jobs overseas if their products are sold in the US.</p>
<p>This is not a package any Republican administration would be likely to introduce. On the other hand, it falls dramatically short of what Sanders, Warren and Ocasio-Cortez want.</p>
<h2>Responsive but responsible</h2>
<p>The Biden economic plan is responsive to the current – almost shocking – state of the US economy. His health care and tax policies are sensitive to concerns about inequality.</p>
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Read more:
<a href="https://theconversation.com/joe-biden-sends-a-clear-message-to-the-watching-world-americas-back-153698">Joe Biden sends a clear message to the watching world – America’s back</a>
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<p>His approach acknowledges, rightly, that with interest rates at historic lows there is room for considerably more spending than in the past, despite already huge deficits. But it also acknowledges there are limits to what the government can or should do. </p>
<p>In that sense it is something even conservative Republicans ought to be able to live with – and common ground is something the US desperately needs to find.</p><img src="https://counter.theconversation.com/content/153647/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Holden does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Joe Biden’s middling economic policies are a chance to cut through the bitter polarisation of US politics.Richard Holden, Professor of Economics, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1494262020-12-09T13:17:46Z2020-12-09T13:17:46Z4 ways to close the COVID-19 racial health gap<figure><img src="https://images.theconversation.com/files/373699/original/file-20201208-21-1otkx6m.jpg?ixlib=rb-1.1.0&rect=12%2C0%2C8634%2C5691&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">New strategies are needed to help people of color battle the COVID-19 virus.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/mixed-race-african-american-teenager-teen-girl-royalty-free-image/1265049144?adppopup=true">dmbaker via Getty Images</a></span></figcaption></figure><p>The COVID-19 pandemic has exposed the reality that health in the U.S. has glaring <a href="https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html">racial inequities</a>. Since March, people of color have been <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6942e1.htm">more likely to get sick and more likely to die</a> from COVID-19 infection because they have been living and working in <a href="http://dx.doi.org/10.1037/tra0000889">social conditions</a> that worsen their physical health and mental health. </p>
<p>These conditions are rooted in structural inequalities that are also responsible for the <a href="https://doi.org/10.1007/s42399-020-00363-4">severity and progression of COVID-19</a>. While the issues are complex, research has suggested some ways to repair the broken system. Now, at the dawn of a new administration, more effective strategies that look at the realities of these affected communities can be implemented. </p>
<p>As <a href="https://www.semel.ucla.edu/hhmb/team/tamra-loeb-phd">research psychologists</a> <a href="https://www.semel.ucla.edu/cctmhd/team/dorothy-chin">who study</a> the <a href="https://doi.org/10.2105/AJPH.92.4.660">social influences</a> of health and mental health among marginalized groups and help design <a href="https://doi.org/10.1016/j.pcad.2020.02.014">interventions</a> for COVID-affected communities, we offer a four-pronged approach in mounting an effective response.</p>
<h2>Focus on community, rather than individual, risk</h2>
<p>Risk for COVID-19 has primarily been framed as <a href="https://doi.org/10.1080/01634372.2020.1779161">individual risk</a>, such as being over 60, having a preexisting illness or performing front-line work. Research suggests that to close the racial gaps in health, we need to shift our thinking <a href="https://doi.org/10.1377/hblog20200319.757883">away from personal risk to a community orientation</a>. </p>
<p>Community risk is the set of factors that collectively put a group of people at risk. One such factor is <a href="https://www.apa.org/about/governance/president/deep-poverty-initiative?_ga=2.99317470.1377691203.1604934305-1793871760.1586287394&_gac=1.124472056.1601667945.CjwKCAjwn9v7BRBqEiwAbq1Ey1v7ddmG7T85_j7u7mDPbrDw_pzvjnwW0q1qfsz9MxbQMDhOS2vorRoCr7cQAvD_BwE">deep poverty</a>. Deep poverty, describing those with <a href="https://www.apa.org/monitor/2019/07-08/ce-corner-poverty">household incomes at less than 50% of the poverty level</a>, is linked with <a href="https://www.apa.org/monitor/2019/07-08/ce-corner-poverty">poor physical health and mental health</a> and lack of resources. </p>
<p>COVID-19 has laid bare the effects of deep poverty in communities of color, with government mandates that do not square with the <a href="https://www.usnews.com/news/healthiest-communities/articles/2020-03-19/coronavirus-could-crush-the-poor-and-homeless-advocates-warn">realities of underresourced communities</a>. How does one socially distance in an <a href="https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html">overcrowded</a> living situation? How can children <a href="https://www.marketplace.org/2020/08/18/back-to-school-may-block-back-to-work-for-many-parents/">learn remotely from home when parents have to go to work</a>? Policymakers need to understand and better address risk profiles that reflect communities’ <a href="https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health">environmental conditions</a> and specific vulnerabilities. </p>
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<h2>Use culturally relevant messages</h2>
<p>One reason that Asian countries have succeeded in curbing the spread of COVID-19 is the widespread acceptance of mask-wearing, consistent with <a href="https://www.voanews.com/covid-19-pandemic/how-cultural-differences-help-asian-countries-beat-covid-19-while-us-struggles">collectivistic cultures</a>. Mask-wearing is seen as polite social behavior that protects others, so recommendations to wear masks graft onto an existing social value. </p>
<p>Among those in the white mainstream culture in the United States, the message of mask-wearing may <a href="https://www.brookings.edu/blog/up-front/2020/08/31/american-individualism-is-an-obstacle-to-wider-mask-wearing-in-the-us/">conflict</a> with the individualistic ethos. Black men, however, may limit mask-wearing out of fears that it will incur <a href="https://www.statnews.com/2020/06/03/which-deamany-black-men-fear-wearing-mask-more-than-coronavirus/">police attention</a>. In Latino communities where family is a top priority, “protect your family” may be an effective message. Identifying culturally consistent messaging is important for COVID-19 prevention, testing and treatment efforts.</p>
<p>Also exemplary of cultural differences are the varying responses to a COVID-19 vaccine. An overwhelming <a href="https://abc7.com/covid-vaccine-covid-19-poll-black-women-rally-for-raction-action/7285315/">93% of Black Americans in Los Angeles County</a> said they would not take the vaccine when it becomes available. Black and Indigenous Americans have long been subjected to <a href="https://doi.org/10.2105/AJPH.2008.152181">unethical medical experimentation and outright deception and fraud</a>. Coupled with <a href="https://www.usatoday.com/story/news/health/2020/04/19/coronavirus-vaccine-black-americans-prevention/5146777002/">racism in the health care system and a lack of physicians of color</a>, many may question whether the vaccine is a safe option. </p>
<p>For Black and Indigenous Americans to accept the safety and value of a newly developed vaccine, <a href="https://www.centerforhealthsecurity.org/our-work/pubs_archive/pubs-pdfs/2020/200709-The-Publics-Role-in-COVID-19-Vaccination.pdf">trusted community partners</a> such as familiar neighborhood clinics and local social activists need to present reliable data coming from community-validated sources.</p>
<p>Prevention, testing and treatment messages must be tailored to populations most affected by COVID-19 to determine the best way to allocate <a href="https://www.latimes.com/california/story/2020-07-17/gavin-newsom-contact-tracing-testing-coronavirus-covid-19-reopening-california">limited resouces</a>. Public health messaging should consider communities’ <a href="https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html">sociodemographic factors</a>, such as <a href="https://doi.org/10.3389/fsoc.2020.00047">poverty</a>, <a href="https://www.cbpp.org/research/poverty-and-inequality/tracking-the-covid-19-recessions-effects-on-food-housing-and">housing</a>, <a href="https://covid19.ca.gov/discrimination/">discrimination</a>, <a href="https://www.usnews.com/news/healthiest-communities/articles/2020-04-16/language-access-problems-a-barrier-during-covid-19-pandemic">language barriers</a>, <a href="https://doi.org/10.7326/M20-1491">loss or lack of health insurance</a>, <a href="https://www.theatlantic.com/health/archive/2020/06/sick-leave-covid-time-off/612361/">jobs without paid sick leave</a> and lack of <a href="https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/access-to-foods-that-support-healthy-eating-patterns">access to healthy foods</a>. </p>
<p>Researchers have called for <a href="http://dx.doi.org/10.1037/tra0000796">culturally sensitive health care</a> and interventions designed to meet the needs of vulnerable populations. Without this approach, messages encouraging COVID-19 prevention, testing, treatment and ultimately acceptance of the vaccine will have limited success. </p>
<figure class="align-center ">
<img alt="Providers must screen for patients who have a history of trauma." src="https://images.theconversation.com/files/372094/original/file-20201130-19-1he1mpm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/372094/original/file-20201130-19-1he1mpm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/372094/original/file-20201130-19-1he1mpm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/372094/original/file-20201130-19-1he1mpm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/372094/original/file-20201130-19-1he1mpm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/372094/original/file-20201130-19-1he1mpm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/372094/original/file-20201130-19-1he1mpm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Providers must be trained to help patients with a history of trauma, including those affected by racial discrimination.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/mid-adult-woman-is-upset-and-uncomfortable-with-royalty-free-image/1225603812?adppopup=true">SDI Productions via Getty Images</a></span>
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<h2>Identify barriers to health care</h2>
<p>There are many interrelated barriers to health care access. Many Latino and Latina people face language barriers in <a href="https://www.psychiatry.org/psychiatrists/cultural-competency/education/mental-health-facts">communicating with providers</a>, which can result in being <a href="https://www.psychiatry.org/psychiatrists/cultural-competency/education/mental-health-facts">undertreated</a>. Health care systems need to incorporate integrated care for cumulative <a href="https://doi.org/10.1016/j.pcad.2020.02.014">histories of trauma</a>, which are high in communities of color. Trauma, including experiences of racism and <a href="https://doi.org/10.1037/ort0000481">discrimination</a>, <a href="https://doi.org/10.1037/a0039077">increase mental health risks</a>, pose <a href="https://doi.org/10.1016/j.pcad.2020.02.014">barriers to health care access and treatment adherence</a> and increase risks for <a href="https://doi.org/10.1037/tra0000334">physical symptoms</a> and <a href="https://doi.org/10.1016/j.pcad.2020.02.014">chronic disease</a>. </p>
<p><a href="https://doi.org/10.1037/pas0000069">Brief screening questionnaires</a> that can be quickly administered in primary care settings have been <a href="https://doi.org/10.1037/a0039077">developed for use</a> with diverse populations and can identify those at risk for mental and <a href="https://doi.org/10.1037/tra0000334">physical health problems</a>. However, <a href="https://newsroom.ucla.edu/releases/ucla-studies-identify-predictors-of-depression-and-ptsd-among-african-americans-and-latinos">providers must be trained</a> to ask about histories of trauma and its <a href="https://doi.org/10.1037/tra0000334">bodily manifestations</a> to minimize barriers to COVID-19 testing and treatment. <a href="http://dx.doi.org/10.1037/tra0000796">Researchers and mental health professionals</a> must not only be trained to address COVID-19-related trauma but understand its effects on underresourced communities that have long been affected by adversity, poor mental health and chronic disease. </p>
<h2>Recognize and remedy traumatic effects of racial discrimination</h2>
<p>Research shows that <a href="https://doi.org/10.1037/ort0000481">social rejection</a> based on race is related to post-traumatic stress and depression symptoms. Mental health problems caused by COVID-19 can be exacerbated by experiences of discrimination, linking <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375320/">racism</a> and COVID-19. Police shootings of unarmed Black citizens can have a devastating effect on <a href="https://doi.org/10.1037/ort0000481">entire communities</a>, increasing anxiety, depression, number of sick days taken and school absences. </p>
<p>The experience of racial discrimination over a person’s lifetime is an aspect of <a href="https://doi.org/10.2105/AJPH.2016.303121">cumulative trauma</a> that has reverberating repercussions for health and mental health. <a href="https://doi.org/10.1016/j.pcad.2020.02.014">Intervention programs</a> that contextualize <a href="https://doi.org/10.1177/1532708616634839">discrimination in historical terms</a> can mitigate the negative effects. Unconscious biases of <a href="https://doi.org/10.1177/1532708616634839">Black inferiority</a> perpetuate racism and discrimination; interventions designed to address these biases are critical to promote social justice and health equity. </p>
<p>With the establishment of a new <a href="https://www.statnews.com/2020/11/09/biden-transition-team-unveils-members-of-covid-19-task-force/">coronavirus task force</a>, the incoming Biden administration has taken a critical first step in turning back COVID-19 in the U.S. We believe what needs to follow is a program that aims to close the racial gap brought to light by the pandemic. </p>
<p>Based on our experience and studies, we think the evidence suggests that this program must look at communities as a whole and their cultural values and experiences and remove barriers to health care. It should affirm the existence of and remedy the effects of widespread racism and discrimination. While this approach is ambitious, it is necessary. By adopting it, the Biden presidency can halt, and begin to close, the widening racial gap in health due to COVID-19.</p><img src="https://counter.theconversation.com/content/149426/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tamra Burns Loeb receives funding provided by the UCLA David Geffen School of Medicine COVID-19 Research Award Program (HE-06) and the National Heart, Lung, and Blood Institute (U01HL142109). </span></em></p><p class="fine-print"><em><span>Dorothy Chin receives funding from the National Heart, Lung, and Blood Institute (U01HL142109).</span></em></p>In the U.S., people of color are more likely to die of COVID-19 than whites. The new administration can change this.Tamra Burns Loeb, Adjunct Associate Professor - Interim; UCLA Center for Culture, Trauma, and Mental Health Disparities, University of California, Los AngelesDorothy Chin, Associate Research Psychologist, University of California, Los AngelesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1497982020-11-16T13:23:53Z2020-11-16T13:23:53Z7 things President-elect Biden can achieve on health care<figure><img src="https://images.theconversation.com/files/368796/original/file-20201111-21-wnhiau.jpg?ixlib=rb-1.1.0&rect=26%2C0%2C2955%2C2020&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Biden administration can make significant changes in health care for Americans.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/president-elect-joe-biden-removes-his-mask-to-address-the-news-photo/1284977695?adppopup=true">Joe Raedle via Getty Images</a></span></figcaption></figure><p>President-elect Joe Biden has plenty of work ahead of him; reining in <a href="https://doi.org/10.1002/wmh3.371">the out-of-control pandemic</a> tops the list, and beyond that, there are significant challenges on health care in general. </p>
<p>Unquestionably, the incoming administration also faces limitations. Twelve years ago, Barack Obama had a <a href="https://doi.org/10.1111/j.1541-0072.2012.00446.x">filibuster-proof majority</a> in the U.S. Senate. This time, that will not be the case, and many progressive dreams, like “Medicare for All,” are far out of reach. Even Biden’s modest goal to expand the Affordable Care Act <a href="https://www.milkenreview.org/articles/much-ado-about">via a public option</a> will likely fall on Mitch McConnell’s deaf ears.</p>
<p>As a <a href="https://publicpolicy.psu.edu/people/sfh5482">professor of public policy</a> analyzing the political landscape, I believe big, transformational reforms are unlikely in the next few years, particularly given the contentious aftermath to the presidential election. But Biden and Vice President-elect Kamala Harris can make changes in seven smaller but important policy issues that will improve the lives of millions of Americans. Some of these the Biden administration can achieve on its own via regulations and other administrative actions. Others require bipartisan cooperation, but Republicans might come on board if it suits them politically.</p>
<figure class="align-center ">
<img alt="The Affordable Care Act was passed on March 23, 2010." src="https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Affordable Care Act, championed by then-President Barack Obama, was passed on March 23, 2010.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/president-barack-obama-leaves-after-speaking-in-a-rally-news-photo/152692518?adppopup=true">Jewel Samad via Getty Images</a></span>
</figcaption>
</figure>
<h2>1. Taking Executive Action</h2>
<p>To shore up the Affordable Care Act, Biden has a number of administrative policy tools that reverse course on many actions taken <a href="https://doi.org/10.1111/psj.12385">by the Trump administration</a>. In some instances, he can take executive action; he will not need Congress to cooperate. </p>
<p>To lower the uninsured rate, Biden can expand enrollment periods for the ACA marketplaces. He can also refocus on <a href="https://theconversation.com/trump-isnt-letting-obamacare-die-hes-trying-to-kill-it-81373">advertising, outreach and enrollment</a> efforts. The Trump administration virtually eliminated this type of funding with <a href="https://doi.org/10.1377/hlthaff.2015.0215">significant implications for enrollment</a>. He can also move to strike regulations that <a href="https://doi.org/10.1215/03616878-8543250">weaken the marketplace</a>. Dozens more seemingly small technical changes to regulations can cumulatively have a considerable impact. </p>
<h2>2. Expanding Medicaid coverage</h2>
<p>The ACA was passed with the intent that states would broaden coverage for the uninsured by expanding Medicaid; <a href="https://doi.org/10.1215/03616878-2882219">most Republican states balked</a>. Biden may have a way around that; he can encourage states to expand their Medicaid programs via <a href="https://www.medicaid.gov/medicaid/section-1115-demonstrations/about-section-1115-demonstrations/index.html">the Section 1115 waivers</a>. With those waivers, states may temporarily disregard certain Medicaid requirements to test innovations. </p>
<p><a href="https://doi.org/10.1111/psj.12385">Under President Obama</a>, some Republican states traded Medicaid expansion for smaller premiums or health-behavior incentives. Now work incentives and potentially work requirements may be <a href="https://doi.org/10.1215/03616878-8802198">on the table</a>.
While these requirements certainly make individual enrollment harder for some, compromise may be necessary to bring Medicaid coverage to the remaining holdout states, all Republican.</p>
<h2>3. Tackling the opioid epidemic</h2>
<p>The opioid crisis has worsened because of <a href="https://www.npr.org/sections/health-shots/2018/03/06/590923149/jump-in-overdoses-shows-opioid-epidemic-has-worsened">the coronavirus outbreak</a>. While the Trump administration has made <a href="https://www.whitehouse.gov/opioids/">some efforts to address the issue</a>, those with addiction and substance use disorder need much more. Refocusing the attention of the government on opioids during the pandemic is crucial. Otherwise, things will get even worse. </p>
<p>Biden should secure additional bipartisan funding from Congress for states hit hardest by opioids, <a href="https://theconversation.com/how-killing-the-aca-could-lead-to-more-opioid-deaths-in-west-virginia-and-other-trump-states-79991">like West Virginia</a>. Once again, many of those states are red. Yet bipartisanship will be key to establishing a comprehensive national strategy is crucial here.</p>
<figure class="align-center ">
<img alt="Every year, Americans are haunted by surprise medical bills." src="https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Surprise medical bills haunt millions of Americans every year.</span>
<span class="attribution"><span class="source">Damir Khabirov via Getty Images</span></span>
</figcaption>
</figure>
<h2>4. Improving access to organ transplants</h2>
<p>Organ transplants don’t get much attention, but the U.S. has suffered a <a href="https://www.milkenreview.org/articles/thinking-the-unthinkable">severe shortage</a> of available organs for decades. Every day, 13 Americans die waiting for a kidney, and <a href="https://www.organdonor.gov/statistics-stories/statistics.html">four more die</a> waiting for other organs. COVID-19 has further worsened the shortage. </p>
<p>The Trump administration <a href="https://www.hhs.gov/about/news/2019/12/17/trump-administration-proposes-new-rules-increase-accountability-availability-organ-supply.html">made advances</a> on this issue through regulations. These include increasing support for living organ donors. Biden should build on this progress. He could change the current approach to donations, which relies solely on altruism, by increasing financial support for donors. The <a href="https://www.congress.gov/bill/116th-congress/house-bill/7900/">Organ Donation Clarification Act</a>, from Democratic U.S. Rep. Matt Cartwright of Pennsylvania, is now languishing in Congress, but it could serve as a major step in this direction.</p>
<h2>5. Ending surprise medical bills</h2>
<p>The Trump administration talked about it, but never managed to eliminate <a href="https://theconversation.com/why-thousands-are-getting-hit-with-unexpected-medical-bills-117955">surprise billing</a>. Those are medical bills patients aren’t expecting, often because a provider is not part of their network. </p>
<p><a href="https://www.kff.org/health-costs/poll-finding/data-note-public-worries-about-and-experience-with-surprise-medical-bills/">Americans are overwhelmingly outraged</a> by surprise bills and want a solution. Both parties in Congress have worked on the issue for years, yet hospitals, physicians and insurers <a href="https://khn.org/news/when-your-doctor-is-also-a-lobbyist-inside-the-war-over-surprise-medical-bills/">have lobbied</a> to keep them untouched.</p>
<p>Some limited progress is likely through regulation. But it will take statutory change to establish meaningful protections for all Americans. Strong presidential and congressional leadership could make a difference here, but even then, it won’t be easy.</p>
<h2>6. Reining in prescription drug prices</h2>
<p>The U.S. pays substantially higher prices than the rest of the developed world for prescription drugs. This is primarily due to <a href="https://www.penguinrandomhouse.com/books/318776/an-american-sickness-by-elisabeth-rosenthal/9780143110859/">limited competition among drug companies and a patent system susceptible to gaming</a>. Moreover, our regulatory apparatus has focused <a href="https://www.penguinrandomhouse.com/books/318776/an-american-sickness-by-elisabeth-rosenthal/9780143110859/">largely on drug safety</a> while deemphasizing cost-effectiveness for new and existing drugs. </p>
<p>The Trump administration’s recent proposal to fix the problem <a href="https://theconversation.com/why-the-us-has-higher-drug-prices-than-other-countries-111256">were limited</a>. Congress should follow the German example, which reins in prices <a href="https://theconversation.com/why-the-us-has-higher-drug-prices-than-other-countries-111256">by 30 percentage points</a> as compared with the U.S. and focuses on rewarding effective drugs. Pharmaceutical companies will vigorously fight to maintain their profits, but given the universal public disdain for high drug prices, a committed bipartisan coalition may bring some relief.</p>
<h2>7. Expanding children’s health coverage</h2>
<p>The years under Trump saw <a href="https://www.cnn.com/2020/10/09/politics/uninsured-children-increase-2019/index.html">increases</a> in the number of children without health insurance. Today, <a href="https://ccf.georgetown.edu/2019/10/29/the-number-of-uninsured-children-in-on-the-rise-acs/">more than 4 million American children</a> are without insurance. This occurred even before the job losses caused by the pandemic. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>Bipartisanship has worked in the past to improve access for children both through <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">Medicaid</a> and the <a href="https://theconversation.com/time-to-stop-using-9-million-children-as-a-bargaining-chip-90293">Children’s Health Insurance Program (CHIP)</a>. Now Biden can strengthen both programs. Investments into <a href="https://doi.org/10.1016/j.jadohealth.2020.09.005">school-based health</a> also seems prudent. And while bipartisanship on the issue <a href="https://theconversation.com/clock-running-out-on-health-program-for-9-million-kids-84404">has grown less prominent</a>, there might be enough Republicans in Congress willing to join Democrats and expand coverage and benefits.</p><img src="https://counter.theconversation.com/content/149798/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder is Fellow in the Interdisciplinary Research Leaders Program, a national leadership development program supported by the Robert Wood Johnson Foundation to equip teams of researchers and community partners in applying research to solve real community problems.</span></em></p>From expanding children’s coverage to reducing surprise bills, Biden and lawmakers may be able to broaden health care access.Simon F. Haeder, Assistant Professor of Public Policy, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1498912020-11-12T18:54:41Z2020-11-12T18:54:41ZWhile the Supreme Court deliberates on the Affordable Care Act, Congress and the White House may act<figure><img src="https://images.theconversation.com/files/369114/original/file-20201112-19-fsz4la.jpg?ixlib=rb-1.1.0&rect=0%2C85%2C4757%2C2990&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Demonstrators hold up pro-Affordable Care Act signs outside the U.S. Supreme Court as it hears oral arguments that challenge the Affordable Care Act in Washington on Tuesday, Nov. 10, 2020. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/demonstrators-hold-up-pro-affordable-care-act-signs-outside-news-photo/1229565178?adppopup=true">Caroline Brehman/CQ-Roll Call, Inc via Getty Images</a></span></figcaption></figure><p><a href="https://www.washingtonpost.com/politics/2020/11/10/scotus-hearing-aca-live-updates/">For the third time in a decade</a>, the U.S. Supreme Court has heard oral arguments on the constitutionality of the Affordable Care Act. The case of California v. Texas, heard on Nov. 10, is its most recent major legal challenge. </p>
<p>Taking place eight days after Justice Amy Coney Barrett’s <a href="https://www.nytimes.com/2020/11/02/us/politics/amy-coney-barrett-supreme-court.html">first Supreme Court case</a> and seven days after the 2020 election, Tuesday’s hearing <a href="https://www.nytimes.com/2020/11/02/us/politics/amy-coney-barrett-supreme-court.html">focused on</a> the ACA’s individual mandate, the requirement that most people need to have health insurance. After Congress “<a href="https://www.nytimes.com/2017/12/18/us/politics/tax-cut-obamacare-individual-mandate-repeal.html">zeroed out</a>” the mandate’s penalty in 2017, the challengers are arguing that the mandate is no longer constitutional under Congress’ tax-and-spend authority and must be struck down. </p>
<p>In the case, the court considered whether the individual plaintiffs and the challenging states had standing to sue, whether the “zeroed-out” individual mandate provision was constitutional and whether, if unconstitutional, that provision was severable from the rest of the law. It will likely be spring, and could be early summer, before we hear of the court’s decision.</p>
<p>As a <a href="https://law.utk.edu/directory/zack-buck/">health law professor</a> who <a href="https://papers.ssrn.com/sol3/cf_dev/AbsByAuth.cfm?per_id=1713816">focuses on health care finance and delivery</a>, I think it is important to ask, in addition to the legal arguments and tea-leaf reading of California v. Texas, what is next for the law and American health care policy?</p>
<h2>Reading tea leaves from the oral arguments</h2>
<p>Health care policy and legal experts are closely watching because the advancing litigation has mounted yet another existential threat against the ACA. This challenge was made more menacing when the Trump administration made clear that it was <a href="https://www.nytimes.com/2020/06/26/us/politics/obamacare-trump-administration-supreme-court.html">pushing for the invalidation of the entire law</a> – not just the individual mandate – in a June 2020 brief. </p>
<p>Yet different scholars, those both supportive and unsupportive of the ACA, have noted that the challengers’ legal arguments are “<a href="https://reason.com/volokh/2018/06/11/the-clever-red-state-lawsuit-against-the/">unworthy</a>,” “<a href="https://reason.com/volokh/2020/11/10/thoughts-on-todays-oral-argument-in-california-v-texas-the-obamacare-severability-case/">very weak</a>” and “<a href="https://www.theatlantic.com/ideas/archive/2019/07/texas-v-us-rise-know-nothing-judge/593959/">ridiculous</a>.”</p>
<p>During the hearing Nov. 10, it appeared that Chief Justice Roberts and Justice Kavanaugh, two very important potential swing votes, <a href="https://news.bloomberglaw.com/us-law-week/supreme-court-shaped-by-trump-poised-to-hear-challenge-to-aca">were skeptical</a> of the challengers’ legal arguments, particularly on the issue of severability, which allows for courts, if striking down part of a law, to “sever” and excise the unconstitutional part, leaving the rest of the law intact. </p>
<p>If the court were to find the ACA severable, then even a holding that the individual mandate was unconstitutional would not invalidate the entire law. <a href="https://www.politico.com/news/2020/11/10/supreme-court-obamacare-kavanaugh-435711">Arguments these two justices made</a> during their questioning of the litigants seemed to suggest this exact point. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1326563958023741447"}"></div></p>
<h2>Life, and enrollment, go on</h2>
<p>Regardless of the decision, it is likely months away. Previous ACA-related decisions have been handed down near the very end of the court’s term in late June, and there is no reason to think that this time will be different. That means that, over the next few months, the risk of judicial disruption to the inner workings of the ACA is minimal. </p>
<p>And, importantly, ACA open enrollment <a href="https://www.healthinsurance.org/open-enrollment/">has begun</a>. This is the period during which individuals can sign up for qualified health plans on healthcare.gov for 2021 coverage. The period runs through Dec. 15, 2020. </p>
<p>During last year’s open enrollment period, <a href="https://www.healthaffairs.org/do/10.1377/hblog20200402.109653/full/">11.41 million consumers</a> selected ACA-compliant marketplace insurance plans, which was <a href="https://www.healthaffairs.org/do/10.1377/hblog20200402.109653/full/">down 0.3% from 11.44 million consumers</a> for 2019. According to the Kaiser Family Foundation, both of these numbers are down from the high of <a href="https://www.kff.org/health-reform/state-indicator/marketplace-enrollment/?currentTimeframe=4&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">12.68 enrollees in 2016</a>.</p>
<p>Most consequentially, the ACA will still largely be subject to political wrangling. The incoming Biden administration has indicated a desire to <a href="https://www.washingtonpost.com/health/biden-health-insurance-plan/2020/11/10/10570b3e-22b3-11eb-8672-c281c7a2c96e_story.html">build on the Affordable Care Act</a>. But this is where things get tricky.</p>
<figure class="align-center ">
<img alt="Rev. Raphael Warnock and John Ossoff talk on a campaign stop." src="https://images.theconversation.com/files/369147/original/file-20201112-23-1cd5b55.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/369147/original/file-20201112-23-1cd5b55.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/369147/original/file-20201112-23-1cd5b55.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/369147/original/file-20201112-23-1cd5b55.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/369147/original/file-20201112-23-1cd5b55.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/369147/original/file-20201112-23-1cd5b55.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/369147/original/file-20201112-23-1cd5b55.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Democrats Rev. Raphael Warnock, left, and John Ossoff are in runoffs for two very important Georgia Senate seats that could affect health care access for the entire country.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/Election2020SenateGeorgia/4959f8912e12473088ded8057c6b45f3/photo?Query=warnock%20and%20ossoff&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=9&currentItemNo=4">Brynn Anderson/AP Photo</a></span>
</figcaption>
</figure>
<h2>Georgia on everyone’s mind</h2>
<p>Whether the Biden administration can make bigger structural changes, like adding a public option to the ACA (which is part of President-elect Biden’s <a href="https://joebiden.com/healthcare/">health care plan</a>), is likely to be a heavy lift. With Senate races in Alaska and North Carolina now being projected, Republicans are likely to occupy <a href="https://thehill.com/homenews/campaign/523484-sullivan-wins-reelection-in-alaska-senate-race">50 seats</a> in the Senate, compared to the <a href="https://www.nytimes.com/2020/11/10/us/politics/senate-results.html">48 seats</a> occupied by the Democratic caucus (including the two independent senators who caucus with Democrats), with two races outstanding. </p>
<p>This means that the two Georgia runoffs, between Jon Ossoff and Sen. David Perdue and between Rev. Dr. Raphael Warnock and Sen. Kelly Loeffler, will determine control of the Senate. Should these seats be won by Ossoff and Warnock in January, Democrats would control a chamber that is split 50-50 thanks to the <a href="https://www.newsweek.com/how-georgia-could-give-democrats-control-senate-kamala-harris-vp-1544998">tiebreaking vote provided by Vice President-elect Kamala Harris</a>. This would give President-elect Biden a better chance to push for structural legislative reform to the ACA, like a public option, assuming he can hold all 50 votes. Indeed, the future of American health care policy runs right through Georgia.</p>
<p>Importantly, this outcome would also give Biden and the Democratic-controlled Congress the ability to pass a “<a href="https://www.vox.com/21549641/obamacare-supreme-court-case-amy-coney-barrett-california-texas-biden-departmentalism">legislative fix</a>,” which could largely moot California v. Texas. This could include <a href="https://www.nytimes.com/2020/11/08/us/obamacare-aca-supreme-court.html">repealing the individual mandate from the ACA</a>. As a result, the Georgia Senate races are all the more consequential if the Supreme Court strikes down the ACA.</p>
<h2>Administrative fixes</h2>
<p>Whether or not the Senate falls into Democratic control, the Biden administration can still use executive authority once in office to make changes to the ACA, just as President Trump has done. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>This could include bolstering enrollment periods and support for ACA-compliant insurance plans to <a href="https://www.nytimes.com/2017/10/09/us/politics/obamacare-trump-cuts-open-enrollment.html">reverse Trump cuts</a>, changing the <a href="https://www.govinfo.gov/content/pkg/FR-2018-10-24/pdf/2018-23182.pdf">guidance and approval standards for state waivers</a> under the ACA and reinterpreting anti-discrimination provisions within the ACA to reinstate protections that were <a href="https://www.nytimes.com/2020/06/12/us/politics/trump-transgender-rights.html">ended by the Trump administration</a>, just to name a few.</p>
<p>Though the arguments are over, the battle over the future of the ACA will continue to be waged – both within the executive branch in Washington and in the political arena in Georgia – even while we await the decision from the Supreme Court on its most recent existential threat.</p><img src="https://counter.theconversation.com/content/149891/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Zack Buck does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The ACA’s third date with the Supreme Court was Nov. 10, and it will be months before a decision. In the meantime, however, Congress and the new president can do things to bolster the law.Zack Buck, Associate Professor of Law, University of TennesseeLicensed as Creative Commons – attribution, no derivatives.