Suhas Gondi, Adam Beckman, Sara Rosenbaum, and Howard Forman outline how in this time of crisis, Congress and the White House can step up to protect the public and promote our collective health
As the US prepares for rapid community spread of covid-19, it must grapple with a hard truth: 10 years after the passage of the Affordable Care Act, 28 million Americans are still uninsured. In the middle of a pandemic, this truth presents real dangers.
The high proportion of uninsured Americans poses threats to both individual wellbeing and public health efforts. At the individual level, the lack of insurance is an obstacle to accessing care (covid-related or not), especially given the high out-of-pocket costs of a visit to the emergency department or even an urgent care center. At a societal level, mitigation, containment, and any effort to successfully “flatten the curve” demand that patients experiencing symptoms seek care.
The Families First Coronavirus Response Act, signed into law on 18 March, provides federal funding through Medicaid for uninsured individuals to have covid-19 testing. Yet this provision does not address the very real barriers that exist for uninsured patients to seek care. Even if the cost of covid-19 testing is waived, they may still be liable for the other costs associated with visiting an emergency room and being evaluated by a physician, both of which produce sizable bills independent of covid-19. The downstream costs associated with covid-19 treatment and recovery are greater still, and could be borne largely by the uninsured patient.
If a patient tests negative for covid-19 and receives care unrelated to the virus, that patient may still be held responsible for the full costs of that care (due to a technical amendment to the law). Since the potential for being stuck with expensive medical bills continues to exist, the barrier to seeking care persists for uninsured individuals—most of whom have learnt that to seek care without health insurance risks financial disaster.
Currently, uninsured Americans have limited options to gain coverage. Insurance exchanges at both state and federal levels are closed until January. As the economy slips into a recession and millions of people become newly unemployed, gaining health insurance through a new job becomes even less likely. A simpler answer exists: provide Medicaid coverage.
On 12 March, a group of public health experts, which included these authors, outlined in a Health Affairs blog the healthcare priorities for legislation on covid-19, including mechanisms to eliminate this access barrier. One of the recommendations we made would accomplish this rapidly and effectively: extend Medicaid eligibility to any uninsured state resident for all medically necessary services in connection with covid-related testing, treatment, and recovery.
Congress can amend Medicaid to add a state option to extend Medicaid in this way, and fund it through federal outlays until the public health emergency ends. Any uninsured resident with income up to 400% of the federal poverty line should be eligible, consistent with the Affordable Care Act’s income cutoff for health insurance subsidies. Importantly, states with Medicaid waivers that limit immediate eligibility, like work requirements, should discontinue these policies during this crisis. By extending more comprehensive coverage to the uninsured, we can ensure that they get the care that they need, advancing both individual health and our collective public health efforts.
Regarding legality, the Breast and Cervical Cancer Prevention and Treatment Act, which authorized states to provide Medicaid coverage to low income, uninsured women diagnosed with breast or cervical cancer, provides a legislative precedent for this strategy.
More broadly, significant historical precedent exists to justify a government driven extension of health insurance in extenuating circumstances. In fact, Medicaid has a long history of functioning as a disaster response tool, including in the HIV/AIDS epidemic in the 1980s, in the aftermath of Hurricane Katrina, and during the contamination crisis in Flint, Michigan.
Medicaid was also leveraged in the wake of the 9/11 attacks in New York. Within a week of the attacks, the governor announced that low income New Yorkers could enroll in Medicaid coverage for four months. The coverage, dubbed Disaster Relief Medicaid, included both medical and mental health services, and only required a one page application. The federal government worked with the state, through a Section 1115 Demonstration Waiver, to cover $670 million in healthcare costs for 350 000 people in the wake of 9/11. More recently, the American Recovery and Reinvestment Act of 2009 offered a 65% subsidy on health insurance premiums through COBRA (health insurance for coverage gaps that occur when someone switches jobs) to workers laid off at the start of the last recession.
Time and again, Congress and the White House have stepped up in times of crisis to ensure the uninsured can access care. The current situation is not markedly different from any of these examples. Millions are at risk of contracting covid-19, healthcare capacity is overrun, and financial markets are in turmoil. In times like these, it is the duty of our policymakers in Washington to take steps to protect the public and promote our collective health. Building on the Families First Coronavirus Response Act with a provision to extend comprehensive Medicaid coverage for all covid-related care—not just for testing—to uninsured individuals is part of that duty.
The authors are part of a national covid-19 policy working group that published recommendations about healthcare provisions needed in covid-19 legislation.
Suhas Gondi is a medical student at Harvard Medical School.
Competing interests: None declared.
Adam Beckman is a medical student at Harvard Medical School.
Competing interests: I have received consulting fees from Aledade, Inc.
Sara Rosenbaum is the Harold and Jane Hirsh professor of health law and policy and founding chair of the Department of Health Policy, Milken Institute School of Public Health, at the George Washington University. She has served as a health policy adviser to six presidential administrations and 19 Congresses.
Competing interests: None declared.
Howard Forman is a professor of public health, radiology, and management at Yale University and is the founding member and lead of the national working group.
Competing interests: None declared.