Tagged Biden Administration

Becerra Has Long Backed Single-Payer. That Doesn’t Mean It Will Happen if He’s HHS Secretary.

“Becerra supports Bernie’s government takeover of your health care, eliminating your employer-provided coverage.”

TV ad funded by Cotton for Senate, Feb. 22

A digital ad running in Georgia and New Hampshire says Xavier Becerra, President Joe Biden’s nominee for Health and Human Services secretary, supports “Medicare for All.”

“Becerra supports Bernie’s government takeover of your health care, eliminating your employer-provided coverage,” the narrator says.

The ad, funded by the campaign PAC of Sen. Tom Cotton (R-Ark.), is part of a blitz from conservative groups against Becerra’s confirmation. It first aired last week and will continue until the Senate’s confirmation vote. The gritty, foreboding ad includes a range of other attacks, including criticisms of California’s covid-19 response and Becerra’s role in legal cases on reproductive rights.

Another ad, this one funded by Heritage Action for America and airing in the Washington, D.C., market, uses similar talking points, including Becerra’s support for “government-run health care.”

Becerra underwent two Senate hearings last week in which he faced questions about his support for Medicare for All.

“Your long-standing support for single-payer, government-run health care seems hostile to our current system from my perspective,” Sen. Mike Crapo (R-Idaho) said during Wednesday’s Senate Finance Committee hearing. “What assurances can you give to Americans who currently have private insurance, including through Medicare Advantage, and are satisfied with their insurance provider that they will not lose their coverage in the future to some sort of Medicare for All approach or federal takeover of health care?”

Becerra responded that he was asked to serve at the pleasure of Biden, who has made it clear he wants to build on the Affordable Care Act. “That will be my mission,” he said.

Since a vote on Becerra’s nomination could happen this week, we thought it was important to check the claim from this ad and give context to what power HHS secretaries actually have.

We reached out to Cotton’s press team to ask for evidence to support the ad but didn’t hear back. The ad does cite a December New York Times article with the headline “Becerra Supports ‘Medicare for All’ and Could Help States Get There” to back up the claim.

Noah Weinrich, press secretary for Heritage Action for America, did provide evidence of Becerra’s support for Medicare for All. Weinrich sent clips of press interviews, as well as links to House of Representatives Medicare for All bills that Becerra co-sponsored over his years in Congress.

Where Becerra and Biden Stand on Health Care

Xavier Becerra was elected as a Democrat to represent a Los Angeles district in the U.S. House in 1993. He stayed in Congress 24 years. He resigned in 2017 to accept the position of attorney general of California, which was offered to him by then-Gov. Jerry Brown.

As attorney general, Becerra brought more than 100 legal challenges against the Trump administration for various health, environmental and immigration issues. One of his best-known lawsuits was in support of the Affordable Care Act. California took the lead with 18 other states in arguing against overturning the law before the U.S. Supreme Court. That decision is expected by the end of June.

Since Becerra was first elected to Congress, he has been an advocate for single-payer, or universal, health coverage. This type of coverage can take many forms, but by most definitions, it means the federal government would have some role in funding and administering health insurance for the public.

“I do, as I said before, join my colleagues who support the single-payer plan,” Becerra said during a congressional hearing in 1994. “For me, meaningful health care reform means that we must have universal coverage. We must have portability. We must have choice of provider.”

More recently, this approach took on the moniker of Medicare for All, in reference to Sen. Bernie Sanders’ (I-Vt.) health care bill with the same name. Sanders’ bill, first introduced in 2017, was designed to eliminate private health insurance after phasing in government-run health care, funded by raising taxes.

In 2017, Becerra said he would “absolutely” support Sanders’ bill. “I’ve been a supporter of Medicare for All for the 24 years that I was in Congress,” Becerra said during a Fox News interview. “This year, as attorney general, I would fight for that if we had an opportunity to put that forward in the state of California, because I think what we do is we give people that certainty that they’re going to be able to access a doctor or a hospital.”

And in 2019, Becerra told KHN’s Samantha Young he’s “been a single-payer advocate all my life.”

Reviewing Becerra’s statements, it’s clear he does support Medicare for All or similar plans.

But, if confirmed as head of the Department of Health and Human Services, Becerra will be a member of Biden’s Cabinet, and the president dictates policy priorities. During the Democratic presidential primaries, Biden was unwavering in his opposition to Medicare for All, instead throwing his support behind implementing a public option health plan and expanding the ACA. A public option is a government-run health insurance plan that would exist beside private health insurance coverage as a choice in the ACA marketplace.

It’s also important to note that while the ad says Becerra supports Medicare for All, thus “eliminating your employer-provided coverage,” that doesn’t mean your health insurance would be eliminated. Rather, it would be replaced by government-run health insurance.

“The notion that by having Medicare for All you’re going to lose insurance coverage is bizarre,” said Mark A. Peterson, a professor of public policy, political science and law at UCLA. “The whole point of Medicare for All is that everyone has health insurance.”

What an HHS Secretary Can Actually Do

Since Biden doesn’t support Medicare for All, would Becerra’s stance really matter?

No, said Joseph Antos, a health care scholar at the right-leaning American Enterprise Institute.

“He will not be able to, in this role, push the executive branch or the Congress in this direction in any perceptible way,” said Antos. “About all he could really do is use the waiver process and loosen up the various restrictions that the Trump administration tried to impose on states in the Medicaid programs. But that’s not the same thing as single-payer.”

Antos was referring to waivers that states can ask for in order to change how they administer the ACA exchanges or Medicaid.

Larry Levitt, executive vice president for health policy at KFF, said it certainly is possible Becerra could be called upon to consider state waiver proposals to implement single-payer systems. (KHN is an editorially independent program of KFF.)

“He would likely look more favorably on waivers like that than the Trump administration, which was quite clear they wouldn’t consider them. He might also view such waivers more positively than an HHS secretary that has not supported Medicare for All,” Levitt wrote in an email. “However, Becerra would not be making decisions on state waivers of such consequence unilaterally. He would certainly consult with the White House.”

Levitt added that it seems unlikely at this point any state could implement a single-payer system. Vermont dropped its efforts to do so after it became clear how much taxes would increase. California does have significant support for single-payer, but it seems unlikely to be realized in that state.

Plus, establishing a national single-payer system would require the support of both the president and Congress — and neither is ideologically there.

The White House maintains Becerra would be focused solely on Biden’s priorities and not Medicare for All.

Andrew Bates, a transition spokesperson for Biden, said in a statement that “Xavier Becerra will support and work to enact President Biden’s health care agenda — building on the ACA with a public option — as was made clear immediately after he was selected.”

But Heritage Action’s Weinrich took a different view: “The HHS secretary holds considerable policy-making and rule-making power, and Becerra’s long record indicates he would use that power to expand government’s role in health care in any way he can, with the ultimate goal of a single-payer option.”

Rhetoric Around Medicare for All, ‘Radical’ Californians

In the 2018 and 2020 elections, it was common for Republicans to paint Democrats as “socialists.” Sometimes this was illustrated through their support for Medicare for All or simply being from California.

The same rhetoric is being employed here, said Peterson.

“That Biden, by bringing in these officials from California, and the fact that Nancy Pelosi is speaker of the House, they’re arguing it’s just showing the infiltration of the radical socialist California state into the federal government,” he said. “But this is ridiculous, because there are not socialist politics, per se, happening in California, and often the California Democrats in Washington are moderate.”

Ultimately, though, the goal of an ad like this is to lay the groundwork for future campaigns.

“In a Senate that is split 50-50 and that 50th Democrat is a conservative Democrat, there is opportunity and leverage for Republicans to try and stand in the way,” said Peterson. “The less effective the Biden administration can be, the more effective campaigning will be for Republicans.”

Our Ruling

The ad states, “Becerra supports Bernie’s government takeover of your health care, eliminating your employer-provided coverage.”

Becerra’s past remarks illustrate he does support Medicare for All or other programs in which the government would run and fund health insurance.

We rate this claim True.


California Healthline, “With Becerra as HHS Pick, California Plots More Progressive Health Care Agenda,” Dec. 10, 2020

CNBC, “Biden Suggests He Would Veto ‘Medicare for All’ Over Its Price Tag,” March 10, 2020

CNS News, “California AG Would ‘Absolutely’ Support Medicare for All Plan,” Oct. 23, 2017

Congress.gov, S.1804 — Medicare for All Act of 2017, accessed Feb. 24, 2021

C-SPAN, HHS Secretary Nominee Xavier Becerra Testifies Before Senate Finance Committee, Feb. 24, 2021

Email interview with Larry Levitt, executive vice president for health policy at KFF, Feb. 23, 2021

Email statement from Andrew Bates, transition spokesperson for Joe Biden, Feb. 23, 2021

JoeBiden.com, Health Care, accessed Feb. 24, 2021

KHN, “Xavier Becerra in His Own Words: ‘Health Care Is a Right,’” Dec. 7, 2020

KHN, “For California Attorney General Xavier Becerra, Resistance Is Personal,” Feb. 4, 2019

KHN, “What to Know as ACA Heads to Supreme Court — Again,” Nov. 9, 2020

KHN, “Politicians Hop Aboard ‘Medicare-for-All’ Train, Destination Unknown,” Oct. 22, 2018

The New York Times, “Biden Picks Xavier Becerra to Lead Health and Human Services,” Dec. 6, 2020

The New York Times, “Becerra Supports ‘Medicare for All,’ and Could Help States Get There,” Dec. 10, 2020

Office of Attorney General of California, Attorney General Xavier Becerra, accessed Feb. 24, 2021

Phone interview with Anthony Wright, executive director of Health Access, Feb. 23 and 24, 2021

Phone interview with Mark A. Peterson, professor of public policy, political science and law at UCLA, Feb. 24, 2021

Phone interview with Joseph Antos, Wilson H. Taylor Scholar in Health Care and Retirement Policy, American Enterprise Institute, Feb. 24, 2021

Politico, “A Trio of Conservative Groups Tries to Torpedo Two Top Biden Nominees,” Feb. 18, 2021

Twitter, @ddiamond tweet, Dec. 6, 2020

TomCotton.com, “Senator Cotton Launches Ads in Georgia and New Hampshire Targeting Xavier Becerra,” Feb. 22, 2021

U.S. House of Representatives History, Art & Archives, Becerra, Xavier, accessed Feb. 24, 2021

YouTube, “Becerra Can’t Be Trusted — New Hampshire,” accessed Feb. 24, 2021

YouTube, “Becerra — Not the Right Choice,” accessed Feb. 24, 2021

KHN’s ‘What the Health?’: Staffing Up at HHS

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More than a month into President Joe Biden’s term, nominees to fill some of the top posts at the Department of Health and Human Services are finally getting confirmation hearings in the Senate, starting with the nominee for secretary, California Attorney General Xavier Becerra. Barring something unexpected, it appears that Becerra, along with the surgeon general nominee, Vivek Murthy, and the nominee for assistant secretary for health, Rachel Levine, will all be confirmed, despite criticisms raised by some Republicans.

Meanwhile, the Supreme Court agreed to hear a case challenging the Trump administration’s rules for the federal family planning program that effectively evicted Planned Parenthood from participation. And the Biden administration asked the court to cancel oral arguments scheduled for late March about work requirements approved by the Trump administration for adult Medicaid recipients in some states.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Margot Sanger-Katz of The New York Times and Tami Luhby of CNN.

Among the takeaways from this week’s podcast:

  • Republican complaints that Becerra may not be qualified for the job of HHS secretary because he’s not a medical doctor were surprising to many. Since HHS was separated from the Department of Education, there have been 12 secretaries and only three have been physicians.
  • Democrats seem confident that Becerra weathered Republican criticism about his qualifications and his support for reproductive rights and that he will be confirmed.
  • The Republican arguments about Becerra’s positions on abortion may signal a shift away from the GOP’s emphasis on repealing the Affordable Care Act and back to traditional issues that galvanize conservative voters.
  • The people Biden has chosen to work on health policy by and large have strong backgrounds in management and many were in the Obama administration working on the implementation of the ACA. They are likely coming in with a mission to make changes and do so quickly.
  • The Biden administration is expected to seek to reverse the Title X rule at issue in a case just accepted by the Supreme Court before the justices hear the matter. But even if the administration can do that, conservatives may still ask the court to proceed.
  • The covid relief bill moving through Congress includes several measures that would make health insurance plans sold on the ACA marketplace more affordable, but those changes would last only two years. ACA advocates reason it would be hard, however, for future lawmakers to take those benefits away.

Also this week, Rovner interviews HuffPost’s Jonathan Cohn, whose new book, “The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage,” is out this week.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The Washington Post’s “The Joy of Vax: The People Giving the Shots Are Seeing Hope, and It’s Contagious,” by Maura Judkis

Margot Sanger-Katz: Covid19-projections.com’s “Path to Normality: 2021 Outlook of COVID-19 in the US,” by Youyang Gu

Tami Luhby: The Guardian and KHN’s “’It Doesn’t Feel Worth It’: Covid Is Pushing New York’s EMTs to the Brink,” by Martha Pskowski

Alice Miranda Ollstein: KHN’s “Covid Vaccine Websites Violate Disability Laws, Create Inequity for the Blind,” by Lauren Weber and Hannah Recht

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Biden’s Straight-Talking CDC Director Has Long Used Data to Save Lives

In early December, Dr. Katy Stephenson was watching TV with her family and scrolling through Twitter when she saw a tweet that made her shout.

“I said ‘Oh, my God!’” she recalled. “Super loud. My kids jumped up. My husband looked over. He said, ‘What’s wrong, what’s wrong, is everything OK?’ I was like, ‘No, no, it’s the opposite. It’s amazing. This is amazing!’”

Dr. Rochelle Walensky had just been tapped to lead the Centers for Disease Control and Prevention.

Stephenson is an infectious diseases specialist and vaccine scientist at Beth Israel Deaconess Medical Center in Boston. So the news had special meaning for her and the many jubilant colleagues tweeting their joy. They’d been helping one another through the brutal pandemic year, she said, while feeling they had little to no help from the federal government.

“It was so baffling,” she said. “It wasn’t even just that we didn’t know what the government was doing. It was that sometimes it felt like sabotage. Like the federal government was actively trying to mess things up.”

But through it all, as the long months became a year, Walensky had been out front, Stephenson said, sticking to the science and telling the truth.

When Walensky stepped up to lead the CDC, she promised to keep telling the truth — even when it’s bad news. She told a JAMA Network podcast last month that she’ll welcome straight talk from the scientists at the CDC as well.

“They have been diminished,” she said. “I think they’ve been muzzled — that science hasn’t been heard. This top-tier agency, world-renowned, hasn’t really been appreciated over the last four years and really markedly over the last year, so I have to fix that.”

Walensky, 51, has long been a doctor on a mission — first, to fight AIDS around the world, and now, to shore up the CDC and get the United States through the pandemic. Beyond unmuzzling her agency’s staff, she vows to tackle many other challenges, pushing particularly hard on vaccine distribution and rebuilding the public health system.

Walensky’s family has a tradition of service, including a grandfather who served in World War II and rose to be a brigadier general. And she likens the call she got from the Biden administration to a hospital alarm that goes off when a patient is in cardiac arrest.

“I got called during a code,” she told JAMA. “And when you get called during a code, your job is to be there to help.”

At Massachusetts General Hospital, where Walensky was the chief of infectious diseases, some of her many admirers now have T-shirts that read “Answer the Code” with her initials, RPW, beneath.

The shirts are part of an outpouring of affection in Boston biomedical circles and far beyond that greeted Walensky’s appointment — including a flood of floral bouquets that her husband and three sons helped accept after word of her new job got out.

“At one point, one of my sons said, ‘You know, Dad, we should just open a florist shop at this point,” said Dr. Loren Walensky, the CDC director’s husband.

He studies and treats children’s blood cancers at Boston Children’s Hospital and the Dana-Farber Cancer Institute. And now he could be called the “first gentleman” of the CDC.

He calls Rochelle his “Wonder Woman” and still remembers when he first saw her 30 years ago, in the cafeteria of the Johns Hopkins University School of Medicine, where they were both students.

“She stood out,” he said. “And one of the reasons why she stood out is because she stands tall. Rochelle is 6 feet tall.”

She also had extraordinary energy and discipline, even then, he remembered: “Most of us would roll out of bed and stumble into the lecture hall as our first activity of the day and, for Rochelle, she was already up and running and bright-eyed and bushy-tailed for hours before any of us ever saw the light of day.”

After medical school, Rochelle Walensky trained in a hospital medical unit so tough it was compared to the Marines. It was the mid-’90s, and the AIDS epidemic was raging. She saw many people die. And then, a few years later, she saw the advent of HIV treatments that could save patients — if those patients could get access to testing and care.

Loren Walensky recalls coming home one day to find her sitting at the kitchen table working on extremely complex math. She was starting to broaden her focus from patient care to bigger-picture questions about the increased equity in health care that more funding and optimal treatment choices could bring.

“And it was like a switch went off,” he said, “and she just had this natural gift for this style of testing — whether if you did X, would Y happen, and if you did X with a little more money, then how would that affect Y? And all of these if-thens.”

She started doing more research, including studies of ways to get more patients tested and treated for AIDS, even in the poorest countries. One of her most prominent papers calculated that HIV drugs had given American patients at least 3 million more years of life.

She worked with Dr. Ken Freedberg, a leading expert on how money is best spent in medicine.

“You can’t do everything,” Freedberg said, “and even if you could, you can’t do everything at once. So what Rochelle is particularly good at is understanding data about treatments and public health and costs, and putting those three sets of data together to understand, ‘Well, what do we do? And what do we do now?’”

So, if Walensky had a Wonder Woman superpower, it was using data to inform decisions and save lives. That analytic skill has come in handy over the past year, as she has helped lead the pandemic response for her Boston hospital and for the state of Massachusetts.

She has weighed in often — and publicly — about coronavirus policy and medicine, speaking to journalists with a seemingly natural candor that has contrasted with the stiffer style of some federal officials. In April, when a huge surge of covid cases hit, she acknowledged the pain.

“We are experiencing incredibly sad days,” she said in a spring interview. “But we sort of face every day with the hope and the vision that what we will be faced with, we can tackle.”

And in November, she offered a sobering reality check from the front lines about current covid medical treatments: “When I think about the armamentarium of true drugs that we have that benefit people with this disease, it’s pretty sparse,” she said.

Walensky published research on key pandemic topics, such as college testing and antibody treatments. And she weighed in often publicly — on Twitter, in newspapers and on radio and TV. Asked on CNN whether the President Joe Biden’s plan to get 100 million Americans vaccinated in 100 days could restore a sense of normalcy, she responded with characteristic bluntness — a quality that could cause trouble in these polarized times.

“I told you I’d tell you the truth,” she said. “I don’t think we’re going to feel it then. I think we’re still going to have, after we vaccinate 100 million Americans, we’re going to have 200 million more that we’re going to need to vaccinate.”

Walensky is facing a historic challenge and leading an agency for which she’s never worked.

Already, she’s fielded blowback for the new CDC guidance on when and how schools should reopen, and she’s openly worried about new, more transmissible variants spreading nationwide.

Still, Boston colleagues said they have no doubt she’ll succeed in making the transition from leading an infectious diseases division of 300 staffers to a public health agency of about 13,000.

“I would lie down in traffic for her,” said Elizabeth Barks, the infectious diseases division’s administrative director at Mass General. “And I think our entire division would lie down in traffic for her.”

Leading and rebuilding the CDC in the midst of a pandemic will be difficult. But Barks and others who know Walensky well said she’s clear-eyed and ready to dig in to meet the challenge; she’ll try a new approach if first attempts fall short.

Walensky brought a plaque from her desk in Boston to CDC headquarters in Atlanta. It reads: “Hard things are hard.”

This story is part of a partnership that includes WBUR, NPR and KHN.

‘It’s a Minefield’: Biden Health Pick Must Tread Carefully on Abortion and Family Planning

As President Joe Biden works to overhaul U.S. health care policy, few challenges loom larger for his health secretary than restoring access to family planning while parrying legal challenges to abortion proliferating across the country.

Physicians, clinics and women’s health advocates are looking to Xavier Becerra, Biden’s nominee to run the Department of Health and Human Services, to help swiftly unwind Trump-era funding cuts and rules that decimated the nation’s network of reproductive health providers over the past four years.

But Becerra, who as California’s attorney general fought the Trump administration’s family planning restrictions, faces increasingly conservative federal courts that have backed efforts to restrict reproductive health services, including a Supreme Court dominated by Republican appointees.

The new administration must also contend with an energized anti-abortion movement looking to leverage political power in red state legislatures to finally achieve its decades-long quest to ban abortion outright.

Any Biden administration moves to preserve abortion and other family planning services could set up new legal battles between the federal government and states.

“It’s a minefield,” said Mary Ziegler, a law professor at Florida State University who has written extensively about the history of the nation’s abortion debate. 

“Expectations on both sides are extremely high,” she said. “And the Supreme Court may force the issue to the top of the agenda if it does something aggressive to restrict abortion.”

The outlines of the brewing showdown came further into focus Tuesday as Becerra faced opposition from a number of Republicans on the Senate health committee on the first of two days of confirmation hearings.

“For many of us, your record has been … very extreme,” Sen. Mike Braun (R-Ind.) told Becerra at the hearing, accusing him of being “against pro-life.” More than three dozen groups opposed to abortion rights have urged the Senate to reject Becerra, who has been a longtime advocate of abortion rights and federal support for contraceptives.

By contrast, Becerra has drawn strong support from abortion rights groups, which have applauded his efforts challenging Trump restrictions on family planning services. “He will be a great partner,” said Alexis McGill Johnson, president of the Planned Parenthood Federation of America.

Becerra, whose wife, Dr. Carolina Reyes, is an obstetrician, is scheduled to appear before the Senate Finance Committee on Wednesday, after which his nomination is expected to move to the floor or the Senate for consideration by the whole body.

Successive presidential administrations since the 1980s have restricted or expanded federal support for family planning, depending on which party controlled the White House.

But tensions between the two sides intensified under President Donald Trump, making the task before Biden and Becerra that much more delicate.

Trump, who relied heavily on political backing from religious conservatives, moved more aggressively than his GOP predecessors to curtail access to abortion and clamp down on federal funding for clinics that provide reproductive care.

Organizations such as Planned Parenthood that long received federal money through the half-century-old Title X program were forced out of it when the Trump administration effectively barred recipients of federal aid from providing abortions or counseling women about the procedure.

That, in turn, led to widespread cutbacks at clinics across the country and huge drops in the number of people able to get family planning services, according to health care providers.

“We’re seeing so many fewer clients,” said Brenda Thomas, chief executive of Arizona Family Health Partnership, which coordinates the state’s Title X program. Thomas said the number of patients in Arizona’s program dropped 24% in 2019 after the Trump administration issued the new rules and declined an additional 40% in 2020, as the covid-19 pandemic further hampered services.

In Missouri, a provider operating three family planning clinics left the program, leading to a 14% decrease in patients getting services through Title X, according to the Missouri Family Health Council.

And in California, the Title X restrictions led to a 40% reduction in patients in 2019, said Lisa Matsubara, general counsel at Planned Parenthood Affiliates of California.

Like many other family planning advocates, Matsubara said Biden needs to do more than just reverse the cuts. “We don’t want to just, like, go back to what it was before the Trump administration,” she said. “We’re really looking and hoping that the administration really takes the necessary steps to expand access.”

Biden has pledged to rewrite the family planning regulations so clinics providing reproductive health services can return to the program.

Within days of taking office, Biden issued an executive order to reverse other family planning restrictions imposed by the last administration, including rescinding the so-called global gag rule that prevented international aid groups that receive U.S. funding from counseling pregnant patients about abortion.

Rolling back some federal policies, like the restrictions on international aid, are relatively simple. Biden and Becerra likely also could quickly reverse Trump-era restrictions on mifepristone, a pill used to induce abortion early in a pregnancy.

But rewriting rules on funding for family planning or reissuing other complex regulations could be considerably more fraught, experts say.

“Both sides have really learned how to maximize use of courts,” said Alina Salganicoff, who directs women’s health policy at KFF, a health policy nonprofit. (KHN is an editorially independent program of KFF.) 

“If anyone understands the legal challenges, it’s Becerra,” Salganicoff said. “But these are thorny issues. There are questions about how the Biden administration can move forward and how fast. And there’s no question they are going to be sued.”

After taking office, Biden said his administration would review the Title X restrictions, which are also under review by the Supreme Court.

As California attorney general, Becerra sued to stop the Trump administration rules. The case was rejected by lower federal courts, though a separate lawsuit in Maryland challenging the rules was successful, setting up the case for the Supreme Court.

Last month, the court issued its first abortion-related decision since Trump appointee Amy Coney Barrett replaced Ruth Bader Ginsburg, upholding a Trump-era rule that blocked mail delivery of mifepristone. 

Many legal experts see more substantial court fights on the horizon as conservative-leaning states pass increasingly restrictive abortion laws.

Just last week, South Carolina Gov. Henry McMaster, a Republican, signed a bill barring abortions as soon as a fetal heartbeat can be detected with ultrasound, or about five or six weeks after a pregnancy begins.

The South Carolina law was temporarily blocked by a federal judge after Planned Parenthood filed a lawsuit. 

The Supreme Court has never upheld a law as restrictive as South Carolina’s. But the high court is the most conservative it has been in decades, raising the prospect that justices may reconsider the landmark 1973 Roe v. Wade decision, which recognized the right to an abortion.

That could force Biden — and potentially Becerra — to step much more directly into efforts in Congress to safeguard abortion rights, said Ziegler, the Florida law professor.

“There will be huge pressure on the Biden administration to do big, bold things,” she said. 

After Billions of Dollars and Dozens of Wartime Declarations, Why Are Vaccines Still in Short Supply?

The U.S. government has invested billions of dollars in manufacturing, used a wartime act dozens of times to boost supplies and yet there’s still not enough covid vaccine on the way to meet demand — or even the government’s own goals for national immunization.

President Joe Biden, in remarks at the National Institutes of Health this month, said the nation is “now on track to have enough supply for 300 million Americans by the end of July.” But at the current rate of production, Pfizer and Moderna will miss their targets of providing at least 100 million doses each by the end of March, let alone 200 million more doses each has promised by July.

Moderna would need to more than double its vaccine production rate from January — when it made roughly 19 million doses — to meet its contractual obligations. Pfizer supplied 40 million vaccine doses by Feb. 17. It has roughly six weeks left to deliver the first 120 million doses it has promised.

Biden and officials from the two companies say they are rapidly expanding production capacity. But critics are lining up. They want to know whether the government did enough, fast enough, to guarantee that companies would meet the urgent challenges of the pandemic. As for the manufacturers bolstered by extraordinary sums of taxpayer money, why did they not share technology and know-how sooner, or move more quickly into strategic production partnerships?

Experts say it’s complicated, noting that the output of raw materials and assembly lines can’t be ratcheted up 10,000-fold at the push of a button — and that the effort thus far has been close to miraculous. They cite bottlenecks in at least three areas: the production of specialty lipids, fatty materials that are a primary component of the Moderna and Pfizer-BioNTech vaccines; the hundreds of millions of glass vials that hold the vaccine; and the sterile automated assembly lines where vaccine moves from bulk containers into vials before shipment.

U.S. officials have run headlong into the limits of the Defense Production Act, a Korean War-era law that allows the federal government to ramp up supplies of critical materials in times of national emergency. The vaccine manufacturing process relies on a complex supply chain, from sourcing raw materials and equipment to designing chemical processes, building production lines and hiring and training workers.

Also, experts note, no one knew which vaccines would prove effective.

“A year ago there was no commercial market for mRNA product. There was scientific research and pharma making small-volume clinical lots. Now we need billions of doses, in the space of a year. That’s overloading the supply infrastructure,” said Kevin Gilligan, a senior consultant with Biologics Consulting and a former official with the Biomedical Advanced Research and Development Authority, or BARDA, a federal agency created in 2006 to deal with pandemics and bioterrorism.

As of December, the Trump administration through its Operation Warp Speed initiative had obligated nearly $14 billion for vaccine development and manufacturing, including investments to expand U.S. capacity, according to a Government Accountability Office report in January. The administration invoked the Defense Production Act on at least 23 vaccine-related contracts, in part to prioritize the government’s contracts over others, according to a KHN review of the federal contracts database, contracts obtained by the nonprofit group Knowledge Ecology International, GAO and government news releases.

They include the December contract that the Department of Health and Human Services signed with Pfizer for another 100 million doses, on top of the initial 100 million it committed to last summer. That contract, worth $1.95 billion, included DPA provisions to give the company priority access to raw materials and spare parts for factories, according to a former administration official.

The DPA has also been used in vaccine contracts with Moderna, Johnson & Johnson and other drug companies for hundreds of millions of doses. On top of that, the law has been invoked for at least 10 contracts with companies making needles or syringes. It’s been used to require glass makers Corning and SiO2 Materials Science to prioritize vial production for vaccine production, and in contracts for aspects of manufacturing with companies like Emergent BioSolutions, Fujifilm Diosynth Biotechnologies and Grand River Aseptic Manufacturing.

Operation Warp Speed awarded Emergent BioSolutions $648 million last year to boost the manufacturing capacity it needed to enter agreements with Johnson & Johnson and AstraZeneca — worth at least $615 million and $261 million, respectively — to help make their vaccines. Grand River Aseptic Manufacturing won a $160 million award from BARDA and has contracted with Johnson & Johnson to fill vials and finish packaging of its single-shot covid vaccine, which is expected to get emergency authorization from the Food and Drug Administration as soon as this month but will only have a few million doses available initially.

The Biden administration has expanded its use of the wartime act to prioritize equipment like filling pumps and filtration systems for Pfizer. “We told you that when we heard of a bottleneck on needed equipment, supplies or technology related to vaccine supply, that we would step in and help,” Tim Manning, the White House official leading the administration’s covid supply efforts, said during a February press briefing.

Yet it can do only so much, according to medical supply chain experts. Prashant Yadav, a senior fellow at the Center for Global Development at Harvard University, said it could take months for the impact of that DPA action to be felt because of the time it takes to procure equipment and get it installed, with each step tightly regulated.

The U.S. is unlikely to get a meaningful bump in capacity “unless we think about co-production deals,” in which a drug company agrees to manufacture a competitor’s vaccine, said Tinglong Dai, an associate professor at Johns Hopkins University’s Carey Business School.

So far, such arrangements have proliferated in Europe — which has less capacity to produce drugs than the United States does. Deals with other major vaccine manufacturers have been less common on the U.S. side of the pond.

“Though we have not partnered with, say, another large pharma for production, we have built strategic partnerships with a number of organizations that have been instrumental to our scaling up and meeting supply and commercialization plans,” Moderna spokesperson Ray Jordan said in an email.

Moderna this month said that its manufacturing process would scale up rapidly in the coming weeks, that it would provide the U.S. between 30 million and 35 million doses in February and March and between 40 million and 50 million doses monthly from April to July. The company declined to elaborate on what made the boost possible.

Vaccine manufacturers long ago should have been sharing technology and expertise to boost production in the U.S. and Europe, and especially in developing countries, said James Love, director of Knowledge Ecology International, a nonprofit focused on patent rights.

“We’ve wasted about a year by not doing some of the obvious things,” he said. “The rhetoric is that it’s an emergency. But on the scale-up of manufacturing, you just don’t see it.”

It’s not that simple, others say. “There wasn’t any excess capacity available in the United States a year ago. Zero,” Paul Mango, a former HHS official heavily involved in Operation Warp Speed, said regarding vaccines. “It’s getting the equipment. It’s quality control. It’s getting the employees. People make it sound like this is easy. You can’t just push 400 workers and say, go at it.”

Each Pfizer-BioNTech or Moderna shot contains billions of lipid nanoparticles, each particle containing four lipids and a strand of the nucleic acid RNA, the five pieces assembled in a way that allows the RNA to enter our cells and create a particle that stimulates the immune system to defend against the covid virus.

The lipids, which are made only in a handful of factories, have been a major supply problem. “No one has ever thought of a scenario where we would use lipid nanoparticle formulation for [billions of] doses,” Yadav said. “We have not invented a process for doing lipid nanoparticles at scale.”

Two of the lipids in the vaccine, cholesterol and DSCP, have long been used in industry to shape and buffer chemical formulations. A third lipid prevents the particles from clumping together. A fourth enables the lipid shell of the vaccine to fuse with human cells and, once inside the cell, to crack open so the RNA can move to a structure called a ribosome and make proteins that stimulate immunity.

All of these raw materials are produced under regulated conditions — in Massachusetts, Missouri, Colorado and Alabama by companies under license with Moderna, Pfizer or Acuitas Therapeutics, which was co-founded by Pieter Cullis, a University of British Columbia professor who is considered the grandfather of lipid nanoparticle technology.

Before the pandemic, these companies produced meager amounts for use in small clinical trials, laboratory experiments or in one licensed drug, patisiran, which is used to treat a rare genetic disease in about a thousand people worldwide. Now they are producing thousands of kilograms of the stuff, said Stefan Randl, a vice president at Evonik, a lipid maker. Evonik recently announced it would scale up production at two German sites, possibly in the second half of the year, to be used in the Pfizer-BioNTech vaccine. The company last year bought a U.S. lipid manufacturer in Alabama.

“All of a sudden the quantities had to be ramped up a thousand-fold or more,” Randl said. “This is the biggest bottleneck.”

Several elements of the vaccine, including lipids and enzymes used in making the mRNA, until recently were produced using animal products such as sheep’s wool, said Andrew Geall, chief scientific officer at Precision NanoSystems, which designs equipment for mixing the mRNA and lipids. Animal products could cause contamination or disease, even in minute quantities, so manufacturers now use synthetic chemicals.

Luckily, the cosmetic industry — a major user of some of the same lipids used in the vaccines — has been switching from animal products in recent decades, noted Julia Born, an Evonik spokesperson.

Still, only a limited number of companies globally have expertise and facilities to make the lipids, said Thomas Madden, CEO and a co-founder of Acuitas, and they’ve all struggled to move from quantities produced in a laboratory to industrial-scale production. For instance, he said, hazardous solvents and chemicals used in laboratory procedures need to be avoided in industrial processes, where they could give rise to workplace safety issues.

“This is a hugely complex supply chain,” Madden said. “Once you address a bottleneck at one point, you identify the next bottleneck in the process. It’s a bit of a game of whack-a-mole.”

Although it’s not particularly difficult to make the lipids used in vaccines, it takes time to get FDA authorization of a facility that can make them in high quantities, said Cullis, the UBC professor. It would take two to three years to start such a factory from scratch, so instead, Moderna and Pfizer-BioNTech have been hooking up with existing manufacturers and getting them to convert to lipid production, he said.

Another bottleneck is “fill/finish” — getting the finished vaccine into vials or syringes so the shots can be shipped to customers. Vaccine filling lines require extremely high levels of efficiency and sterility, and few companies in the world have this capacity, said Mike Watson, former president of Valera, a Moderna subsidiary. Moderna has hired Catalent, a contract manufacturer that recently experienced delays that slowed the release of some doses, to fill and finish U.S. doses at its facility in Bloomington, Indiana. At least two other companies will do the same for Moderna’s vaccine supply abroad.

In January, the French multinational Sanofi — whose own covid vaccine has been delayed by poor performance in producing immunity — agreed to offer its fill/finish line in Germany for the Pfizer-BioNTech vaccine. That line isn’t expected to be running until July.

In the U.S., the number of vaccine doses shipped to states has ticked up in recent weeks, partly because Pfizer said its five-dose vials actually provide six shots. Moderna is seeking FDA permission to add up to five doses to its 10-dose vials.

Pfizer has said it is manufacturing raw materials in St. Louis, the active ingredients for the vaccine in Andover, Massachusetts, and filling vials in Kalamazoo, Michigan.

CEO Albert Bourla, with Biden at his side in Kalamazoo on Friday, said the company added lipid production capabilities at plants in Michigan and Connecticut, as well as fill/finish lines in Kansas. He said it has significantly cut the average time it takes to make doses — from 110 days to 60 days.

“Today, during this meeting, the president challenged us to identify additional ways in which his administration could help us potentially accelerate even further the delivery of the full 300 million doses earlier than July,” Bourla said. “The challenge is accepted, and we will try to do our best.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN’s ‘What the Health?’: Open Enrollment, One More Time

Can’t see the audio player? Click here to listen on SoundCloud.

An estimated 9 million Americans eligible for free or reduced premium health insurance under the Affordable Care Act have a second chance to sign up for 2021 coverage, since the Biden administration reopened enrollment on healthcare.gov and states that run their own marketplaces followed suit.

Meanwhile, Biden officials took the first steps to revoke the permission that states got from the Trump administration to require many adults on Medicaid to work or perform community service in exchange for their health coverage. The Supreme Court is scheduled to hear a case on the work requirements at the end of March.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Kimberly Leonard of Business Insider and Rachel Cohrs of Stat.

Among the takeaways from this week’s podcast:

  • The Biden administration said it will promote the special enrollment period, a stark change from the Trump administration, which dramatically limited funding for outreach. But navigator groups, whose workers help individuals find and sign up for coverage, say they haven’t yet heard whether the federal government will be offering to pay them to help people during this three-month sign-up period.
  • The House appears poised to pass a bill next week that would fund the covid relief measures President Joe Biden is seeking, as well as major changes to the ACA. Senate staffers are working with the House to align legislation from both chambers as much as possible. With little or no Republican support and only razor-thin majorities in both the House and Senate, Democrats will need to find common ground among their caucus to push the bill through.
  • Congress has a firm deadline on the covid relief bill since many current programs, such as the expanded unemployment funding, expire March 14.
  • CVS announced this week that its insurance subsidiary, Aetna, will be participating in the ACA marketplaces in the fall, another sign that those exchanges are growing in acceptance.
  • The Biden administration’s effort to walk back Medicaid work requirements appears to be an effort to head off the arguments at the Supreme Court. Democrats fear that even if they stop the program through administrative action now, a high-court ruling saying the effort was legal could open the door for future Republican administrations to restore work requirements.
  • The federal government is pushing hard to get more covid vaccine shots in arms around the country and last week reported that 1.7 million doses had been distributed. But it is a race against the emerging threat of covid virus variants, which are even more contagious than the original coronavirus.
  • Among hurdles in the vaccination effort is hesitancy among certain groups to get the shot. There have been reports that 30% of military personnel refused to accept the vaccine and some high-profile athletes in the NBA don’t want to be in public service announcements promoting it. Groups opposed to vaccines in general are posting misinformation online that may also be a source of concern.
  • The latest controversy over New York Gov. Andrew Cuomo’s policies on counting deaths among nursing home residents with covid-19 has consumed Albany and led to inquiries by legal authorities. It also raises questions about whether politics — Cuomo, a Democrat, and President Donald Trump regularly sparred about covid policies — influenced public health decisions.

Also this week, Rovner interviews medical student Inam Sakinah, president of the new group Future Doctors in Politics.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: Stat’s “Hospitals’ Covid-19 Heroics Have Them Poised for Power in the New Washington,” by Rachel Cohrs

Rachel Cohrs: KHN’s “As Drug Prices Keep Rising, State Lawmakers Propose Tough New Bills to Curb Them,” by Harris Meyer; and Stat’s “States Still Can’t Import Drugs From Canada. Now, Many Are Seeking to Import Canadian Prices,” by Lev Facher

Alice Miranda Ollstein: Politico’s “How Covid-19 Could Make Americans Healthier,” by Joanne Kenen

Kimberly Leonard: The New Republic’s “The Darker Story Just Outside the Lens of Framing Britney Spears,” by Sara Luterman

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Prominent Scientists Call on CDC to Better Protect Workers From Covid

A prominent group of academics is pressing the Biden administration to move faster and take stronger action to protect high-risk workers from airborne exposure to the coronavirus, urging enforceable standards to help safeguard risky workplaces including health care, food processing and prisons.

The researchers say that even though the Centers for Disease Control and Prevention has acknowledged the virus can spread through tiny airborne particles, it needs to take “strong immediate” action to update its guidance to reduce the risk.

“This is the opportunity now,” said David Michaels, a professor at George Washington University and former director of the Occupational Safety and Health Administration.

Changes to help drive down the spread of the virus could include broader use of N95 masks in workplaces as well as better ventilation, according to a letter sent Monday to the CDC.

High-profile signers include Rick Bright, who was dismissed from the Trump administration after pushing for more careful attention to science; Michael Osterholm, an adviser to the Biden transition team; and Virginia Tech aerosol scientist Linsey Marr.

Current CDC guidelines reflect the initial supply chain crisis the country faced, which to a large degree has eased, the letter says. They also fail to acknowledge months of research that showed the heightened risks faced by essential workers in several industries.

The letter criticizes current guidelines that say that those outside health care should not get N95 masks, and that even within health care those masks should be reserved for workers doing “aerosol-generating” procedures like intubations.

Yet, since those guidelines were written, research has shown that deadly outbreaks have occurred in meatpacking plants and prisons, with aerosol spread believed to be at play. And within health care, researchers discovered that “front door” staff members like paramedics and those in emergency rooms faced the highest infection risks.

“It really bothers me that health care workers and essential workers who need this extra level of protection have gone this long with a crisis standard of care and without appropriate … respiratory protection,” Bright said in an interview.

Even more recent research that painstakingly examined a September covid-19 outbreak in a Boston hospital with “mature” infection-control practices showed that health technicians caught the virus from a patient while wearing surgical masks and face shields — common personal protective equipment for health workers caring for covid patients. The finding spurred the authors to suggest broader use of N95s throughout hospitals.

KHN and The Guardian have been writing about hundreds of more than 3,400 health care workers who died of covid for the Lost on the Frontline project. Families of many workers have expressed concern about PPE in at least 100 cases, and many others were not aware of what a loved one was wearing. Worker complaints to government officials about protective gear, one story in the series found, preceded a worker’s death in dozens of cases.

Jane Thomason, lead industrial hygienist for National Nurses United, who was not involved with the letter, applauded its contents and said it reflected many of the concerns of nurses the past year.

To add to the list of concerns, Thomason said the CDC guidelines fail to reflect research showing that pre-symptomatic and asymptomatic spread of the virus is common.

Current guidance to hospitals that they screen only patients with covid-like symptoms means that many with the virus slip through and are placed under the care of workers with suboptimal PPE. Thomason said solutions would include universal patient testing and providing the N95 as the minimum respiratory protection in a hospital.

“The crisis standards the CDC created essentially serve as a menu for employers to race to the bottom,” she said. “I think it’s appalling that these are still the same issues a year in.”

The CDC did not respond Tuesday evening. CDC Director Dr. Rochelle Walensky has already announced a thorough review of the agency’s guidelines, based on “the best available evidence,” the letter notes.

Those guidelines will set a standard that workplace safety regulators can enforce, said Lisa Brosseau, a University of Minnesota aerosol scientist who signed the letter. She said CDC acknowledgment of the need to protect workers from inhaling the virus will give OSHA more clout to keep workers safe.

Dr. Donald Milton, a professor of environmental health at the University of Maryland School of Medicine who signed the letter, said now is the time to see how low we can drive virus levels — so we don’t have to shut the nation down again if there’s another pandemic.

“There needs to be a commitment to figuring it out and doing what needs to be done so we never have to do this again,” he said.

Why Biden Has a Chance to Cut Deals With Red State Holdouts on Medicaid

President Joe Biden has an unexpected opening to cut deals with red states to expand Medicaid, raising the prospect that the new administration could extend health protections to millions of uninsured Americans and reach a goal that has eluded Democrats for a decade.

The opportunity emerges as the covid-19 pandemic saps state budgets and strains safety nets. That may help break the Medicaid deadlock in some of the 12 states that have rejected federal funding made available by the Affordable Care Act, health officials, patient advocates and political observers say.

Any breakthrough will require a delicate political balancing act. New Medicaid compromises could leave some states with safety-net programs that, while covering more people, don’t insure as many as Democrats would like. Any expansion deals would also need to allow Republican state officials to tell their constituents they didn’t simply accept the 2010 health law, often called Obamacare.

“Getting all the remaining states to embrace the Medicaid expansion is not going to happen overnight,” said Matt Salo, executive director of the nonpartisan National Association of Medicaid Directors. “But there are significant opportunities for the Biden administration to meet many of them halfway.”

Key to these potential compromises will likely be federal signoff on conservative versions of Medicaid expansion, such as limits on who qualifies for the program or more federal funding, which congressional Democrats have proposed in the latest covid relief bill.

But any deals would bring the country closer to fulfilling the promise of the 2010 law, a pillar of Biden’s agenda, and begin to reverse Trump administration efforts to weaken public programs, which swelled the ranks of the uninsured.

“A new administration with a focus on coverage can make a difference in how these states proceed,” said Cindy Mann, who oversaw Medicaid in the Obama administration and now consults extensively with states at the law firm Manatt, Phelps & Phillips.

Medicaid, the half-century-old health insurance program for the poor and people with disabilities, and the related Children’s Health Insurance Program cover more than 70 million Americans, including nearly half the nation’s children.

Enrollment surged following enactment of the health law, which provides hundreds of billions of dollars to states to expand eligibility to low-income, working-age adults.

However, enlarging the government safety net has long been anathema to most Republicans, many of whom fear that federal programs will inevitably impose higher costs on states.

And although the GOP’s decadelong campaign to “repeal and replace” it has largely collapsed, hostility to the health law remains high among Republican voters.

That makes it perilous for politicians to embrace any part of it, said Republican pollster Bill McInturff, a partner at Public Opinion Strategies. “A lot of Republican state legislators are sitting in core red districts, looking over their shoulders at a primary challenge,” he said.

Many conservatives have called instead for federal Medicaid block grants that cap how much federal money goes to states in exchange for giving states more leeway to decide whom they cover and what benefits their programs offer.

Many Democrats and patient advocates fear block grants will restrict access to care. But just before leaving office, the Trump administration gave Tennessee permission to experiment with such an approach.

“It’s a frustrating place to be,” said Tom Banning, the longtime head of the Texas Academy of Family Physicians, which has labored to persuade the state’s Republican leaders to drop their opposition to expanding Medicaid. “Despite covid and despite all the attention on health and disparities, we see almost no movement on this issue.”

Some 1.5 million low-income Texans are shut out of Medicaid because the state has resisted expansion, according to estimates by KFF. (KHN is an editorially independent program of KFF.)

An additional 800,000 people are locked out in Florida, which has also blocked expansion.

Two million more are caught in the 10 remaining holdouts: Alabama, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Wisconsin and Wyoming.

Advocates of Medicaid expansion, which is broadly popular with voters, believe they may be able to break through in a handful of these states that allow ballot initiatives, including Mississippi and South Dakota.

Since 2018, voters in Idaho, Nebraska, Utah, Oklahoma and Missouri have backed initiatives to expand Medicaid eligibility, effectively circumventing Republican political leaders.

“The work that we’ve done around the country shows that no matter where people live — red state or blue state — there is overwhelming support for expanding access to health care,” said Kelly Hall, policy director of the Fairness Project, a nonprofit advocacy group that has helped organize the Medicaid measures.

But most of the holdout states, including Texas, don’t allow citizens to put initiatives on the ballot without legislative approval.

And although Florida has an initiative process, mounting a ballot campaign there is challenging, as political advertising is expensive. Unlike in many states, Florida’s leading hospital association hasn’t backed expansion.

Another route for expansion: compromises that could win over skeptical Republican state leaders and still get the green light from the Biden administration.

The Obama administration approved conservative Medicaid expansion in Arkansas, which funneled enrollees into the commercial insurance market, and in Indiana, which forced enrollees to pay more for their medical care.

Money is a major focus of current talks in several states, according to health officials, advocates and others involved in efforts across the country.

The health law at first fully funded Medicaid expansion with federal money, but after the first three years, states had to begin paying part of the tab. Now, states must come up with 10% of the cost of expansion.

Even that small share is a challenge for states, many of which are reeling from the economic downturn caused by the pandemic, said David Becker, a health economist at the University of Alabama-Birmingham who has assisted efforts to expand Medicaid in that state.

“The question is: Where do we get the money?” Becker said, noting that some Republicans may be open to expanding Medicaid if the federal government pays the full cost of the expansion, at least for a year or two.

Other efforts to find ways to offset state costs are underway in Kansas and North Carolina, which have Democratic governors whose expansion plans have been blocked by Republican state legislators. Kansas Gov. Laura Kelly this month proposed using money from the sale and taxation of medical marijuana.

Some Democrats in Congress are pushing to revise the health law to provide full federal funding to states that expand Medicaid now. Separately, in the stimulus bill unveiled last week, House Democrats proposed an additional boost in total Medicaid aid to states that expand.

Other Republicans have signaled interest in partly expanding Medicaid, opening the program to people making up to 100% of the federal poverty level, or about $12,900, rather than 138%, or $17,800, as the law stipulated.

The Obama administration rejected this approach, but the idea has gained traction in several states, including Georgia.

It’s unclear what kind of compromises the new administration may consider, as Biden has yet to even nominate someone to oversee the Medicaid program.

Some Democrats say it’s time to give up the search for middle ground with Republicans on Medicaid.

A better strategy, they say, is a new government insurance plan, or public option, for people in non-expansion states, a strategy Biden endorsed on the campaign trail.

“Democrats can no longer countenance millions of Americans living in poverty without insurance,” said Chris Jennings, a Democratic health care strategist who worked in the White House under Presidents Bill Clinton and Barack Obama and served on Biden’s transition team.

“This is why the Biden public option or other new ways to secure affordable, meaningful care should become the order of the day for people living in states like Florida and Texas.”

Los mercados de seguros de salud reabrieron. Esto es lo que necesitas saber

Para quienes han estado sin seguro médico durante la pandemia, el alivio ya está a la vista.

En enero, el presidente Joe Biden firmó una orden ejecutiva para abrir el mercado federal de seguros de salud durante tres meses, desde el lunes 15, para que las personas sin seguro puedan comprar un plan y o cambiar de cobertura si ya tienen uno.

Defensores de los consumidores aplaudieron la iniciativa. Desde 2016, el número de estadounidenses sin seguro médico ha ido en aumento, llegando a 30 millones en 2019. La crisis económica causada por el coronavirus ha empeorado lo que ya era una mala situación, privando a millones de personas de sus planes médicos.

La medida contrasta con el enfoque de la administración Trump. Mientras covid-19 se afianzaba la primavera pasada y la economía implosionaba, expertos en salud le rogaban a la administración Trump que abriera el mercado federal para que las personas pudieran comprar un seguro durante la peor emergencia de salud pública en un siglo.

La administración se negó, señalando que quienes se encontraban, repentinamente, sin cobertura porque perdieron sus empleos, podían inscribirse en el mercado bajo las reglas ordinarias. También citaron la preocupación de que los enfermos que se habían resistido a comprar un seguro antes lo hicieran ahora y aumentaran las primas.

El gobierno de Biden se ha comprometido a gastar $50 millones en actividades de divulgación y educación para dar a conocer el nuevo periodo de inscripción.

Esto es fundamental, según expertos. Aunque el número de personas que se inscriben en los planes de la Ley de Cuidado de Salud a Bajo Precio (ACA) se ha mantenido a buen nivel, el número de nuevos consumidores que se inscriben en el mercado federal ha disminuido cada año desde 2016, según la Kaiser Family Foundation, coincidiendo con los recortes de financiación para mercadeo y divulgación.

“Hay muchas personas sin seguro que, incluso antes de covid, eran elegibles para los altos subsidios del mercado o para Medicaid y no lo sabían”, dijo Sabrina Corlette, profesora de investigación en el Centro de Reformas de Seguros de Salud de la Universidad de Georgetown.

Una campaña de marketing puede llegar a una enorme cantidad de personas y, con suerte, atraerlas, independientemente de que, a causa de covid, hayan perdido su seguro o no, añadió Corlette.

A continuación, las respuestas a las preguntas sobre la nueva opción para inscribirse.

¿Cuándo pueden inscribirse los consumidores y en qué estados?

La ventana de inscripción estará abierta durante tres meses, del 15 de febrero al 15 de mayo. Los residentes sin seguro de cualquiera de los 36 estados que utilizan la plataforma federal cuidadodesalud.gov pueden buscar planes durante ese tiempo e inscribirse.

Los estados que operan sus propios mercados, y el Distrito de Columbia, están estableciendo períodos de inscripción especiales similares al nuevo federal, aunque pueden tener plazos o reglas de elegibilidad algo diferentes.

En Massachusetts, por ejemplo, la ventana de inscripción permanece abierta hasta el 23 de mayo, mientras que en Connecticut se cierra el 15 de marzo. Por su parte, Colorado ha reabierto la inscripción en su mercado para los residentes que carecen de seguro, pero cualquiera que ya esté inscrito en uno de los planes del mercado estatal no podrá cambiar de plan hasta el período regular de inscripción abierta en otoño.

¿Pueden inscribirse durante el nuevo período de inscripción las personas que perdieron su empleo y su seguro médico hace muchos meses?

Sí, la ventana de inscripción está abierta a cualquier persona que no tenga seguro y que normalmente sería elegible para comprar cobertura (las personas que están cumpliendo penas de prisión o cárcel y los que están en el país sin papeles no pueden inscribirse).

Las personas con ingresos de hasta el 400% del nivel federal de pobreza (unos $51,500 para una persona o $106,000 para una familia de cuatro miembros) pueden calificar para créditos fiscales para pagar las primas que pueden reducir sustancialmente sus costos, incluso hasta $0.

Normalmente, se puede comprar un plan del mercado sólo durante el período anual de inscripción abierta en otoño o si se vive un acontecimiento vital, como un nacimiento o una mudanza, o la pérdida del seguro por despido, en lo que se denomina período especial de inscripción.

Pero, por lo general, las personas deben inscribirse en el mercado dentro de los 60 días siguientes al acontecimiento.

Con el nuevo período de inscripción, el tiempo que una persona ha estado sin seguro no es relevante, ni tampoco tiene que proporcionar documentación de que ha perdido la cobertura basada en el trabajo.

“El mensaje es muy sencillo: vengan y apliquen”, explicó Sarah Lueck, analista política del Center on Budget and Policy Priorities.

¿Qué pasa con las personas que ya están inscritas en un plan del mercado? ¿Pueden cambiar su cobertura durante este nuevo período?

Sí, siempre que tu cobertura sea a través del mercado federal. Si, por ejemplo, alguien está inscrito en un plan de oro, pero quiere cambiar a un plan de bronce más barato con un deducible más alto, puede hacerlo. Sin embargo, como se ha mencionado anteriormente, algunos mercados estatales no ofrecen esta opción.

Muchas personas han perdido ingresos importantes durante la pandemia. ¿Cómo pueden decidir si un plan del mercado con subsidios es mejor para ellos que Medicaid?

No tienen que decidirlo. Durante el proceso de solicitud, el mercado les pide información sobre sus ingresos. Si los ingresos anuales están por debajo del umbral de Medicaid (para muchos adultos en la mayoría de los estados, el 138% del nivel federal de pobreza, o alrededor de $18,000 para un individuo), se les dirigirá a ese programa para obtener cobertura.

Si las personas son elegibles para Medicaid, no pueden obtener cobertura subvencionada.

Las personas pueden inscribirse en Medicaid en cualquier momento del año; no es necesario esperar a un período de inscripción anual o especial.

Las personas ya inscritas en un plan del mercado cuyos ingresos cambien deben volver al mercado y actualizar su información de ingresos lo antes posible. Tal vez puedan optar a mayores subsidios para las primas o, si los ingresos han disminuido considerablemente, a Medicaid.

Del mismo modo, si los ingresos han aumentado y no se ajustan a las estimaciones del mercado, se podría tener que hacer frente a los pagos excesivos de subsidios cuando hagan la declaración de impuestos.

¿Qué pasa con las personas que se inscribieron en la ley federal COBRA para continuar con la cobertura de su empleador después de perder su trabajo? ¿Pueden renunciar a ella e inscribirse en un plan del mercado?

Expertos en salud afirman que pueden dar ese paso quienes viven en los estados del mercado federal. En virtud de la ley COBRA, se puede exigir a las personas que paguen el importe total de la prima más una tasa administrativa del 2%. La cobertura del mercado es casi con toda seguridad más barata.

Normalmente, si las personas tienen cobertura de COBRA y la abandonan a mitad de año, no pueden inscribirse en un plan del mercado hasta el período anual de inscripción abierta de otoño. Pero este nuevo período otorgará esa opción.

Related Topics

Insurance Noticias En Español The Health Law Uninsured

The ACA Marketplace Is Open Again for Insurance Sign-Ups. Here’s What You Need to Know.

For people who’ve been without health insurance during the pandemic, relief is in sight.

In January, President Joe Biden signed an executive order to open up the federal health insurance marketplace for three months as of Monday so uninsured people can buy a plan and those who want to change their marketplace coverage can do so.

Consumer advocates applauded the directive. Since 2016, the number of Americans without health insurance has been on the rise, reaching 30 million in 2019. The economic upheaval caused by the novel coronavirus has made a bad situation worse, throwing millions off their insurance plans.

The move is in stark contrast to the Trump administration’s approach. As covid-19 took hold last spring and the economy imploded, health experts pleaded with the Trump administration to open up the federal marketplace so people could buy insurance to protect themselves during the worst public health emergency in a century. The administration declined, noting that people who suddenly found themselves without coverage because they lost their jobs were able to sign up on the marketplace under ordinary rules. They also cited concerns that sick people who had resisted buying insurance before would buy coverage and drive up premiums.

The Biden administration is promising to spend $50 million on outreach and education to get the word out about the new special enrollment period. That’s critical, experts said. Although the number of people signing up for Affordable Care Act plans has generally remained robust, the number of new consumers enrolling in the federal marketplace has dropped every year since 2016, according to KFF, corresponding to funding cuts in marketing and outreach. (KHN is an editorially independent program of KFF.)

“There are a lot of uninsured people who even before covid were eligible for either hefty marketplace subsidies or for Medicaid and not aware of it,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. A marketing blitz can reach a broad swath of people and hopefully draw them in, regardless of whether they’re uninsured because of covid or not, she said.

Here are answers to questions about the new enrollment option.

Q: When can consumers sign up, and in which states?

The sign-up window will be open for three months, from Monday through May 15. Uninsured residents of any of the 36 states that use the federal healthcare.gov platform can look for plans during that time and enroll.

Most of the states and the District of Columbia that operate their own marketplaces are establishing special enrollment periods similar to the new federal one, though they may have somewhat different time frames or eligibility rules. In Massachusetts, for example, the sign-up window remains open until May 23, while in Connecticut, it closes March 15. Meanwhile, Colorado has reopened enrollment in its marketplace for residents who lack insurance, but anyone already enrolled in one of the state’s marketplace plans won’t be allowed to switch to a different plan until the regular open enrollment period in the fall.

At this point, only Idaho has not announced plans to open their marketplaces, said Corlette. It may still do so, however.

Q: Can people who lost their jobs and health insurance many months ago sign up during the new enrollment period?

Yes. The enrollment window is open to anyone who is uninsured and would normally be eligible to buy coverage on the exchange (people who are serving prison or jail terms and those who are in the country without legal permission aren’t allowed to enroll).

People with incomes up to 400% of the federal poverty level (about $51,500 for one person or $106,000 for a family of four) are eligible for premium tax credits that may substantially reduce their costs.

Typically, people can buy a marketplace plan only during the annual open enrollment period in the fall or if a major life event gives them another opportunity to sign up, called a special enrollment period. Losing job-based health coverage is one event that creates a special sign-up opportunity; so is getting married or having a baby. But usually people must sign up with the marketplace within 60 days of the event.

With the new special enrollment period, how long someone has been uninsured isn’t relevant, nor do people have to provide documentation that they’ve lost job-based coverage.

“The message is quite simple: Come and apply,” said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.

Q: What about people who are already enrolled in a marketplace plan? Can they switch their coverage during this new enrollment period?

Yes, as long as their coverage is through the federal marketplace. If, for example, someone is enrolled in a gold plan now but wants to switch to a cheaper bronze plan with a higher deductible, that’s allowed. As mentioned above, however, some state-operated marketplaces may not make that option available.

Q: Many people have lost significant income during the pandemic. How do they decide whether a marketplace plan with premium subsidies is a better buy for them than Medicaid?

They don’t have to decide. During the application process, the marketplace asks people for income information. If their annual income is below the Medicaid threshold (for many adults in most states, 138% of the federal poverty level, or about $18,000 for an individual), they will be directed to that program for coverage. If people are eligible for Medicaid, they can’t get subsidized coverage on the exchange.

People can sign up for Medicaid anytime; there’s no need to wait for an annual or special enrollment period.

Those already enrolled in a marketplace plan whose income changes should go back into the marketplace and update their income information as soon as possible. They may be eligible for larger premium subsidies for their marketplace plan or, if their income has dropped significantly, for Medicaid. (Likewise, if their income has increased and they don’t adjust their marketplace income estimates, they could be on the hook for overpayments of their subsidies when they file their taxes.)

Q: What about people who signed up under the federal COBRA law to continue their employer coverage after losing their job? Can they drop it and sign up for a marketplace plan?

Yes people in federal marketplace states can take that step, health experts say. Under COBRA, people can be required to pay the full amount of the premium plus a 2% administrative fee. Marketplace coverage is almost certainly cheaper.

Normally, if people have COBRA coverage and they drop it midyear, they can’t sign up for a marketplace plan until the annual fall open enrollment period. But this special enrollment period will give people that option.