- Historic COVID Relief Bill Passes
- New CMS Guidance Allows Visitors in Nursing Homes
- Medicare and the Dilemma of “Choice”
- Register Now – 2021 National Voices of Medicare Summit & Sen. Jay Rockefeller Lecture
Following passage in the Senate on March 6, 2021, the House of Representatives passed the $1.9 trillion American Rescue Plan Act of 2021 on March 10, and President Biden signed the bill into law on March 11. The Center for Medicare Advocacy applauds the passage of this landmark bill that will provide wide-ranging relief to people struggling with the ongoing global pandemic.
According to the New York Times, the bill is “one of the most far-reaching federal relief efforts ever to pass Congress” and “is estimated to cut poverty by a third this year and […] would potentially cut child poverty in half”. The Rescue Act, which is the sixth major COVID relief bill passed in the last year in which the pandemic has gripped the nation, includes a range of economic stimulus provisions and an expansion of federal safety net programs (some of which is temporary), including: child tax benefits; extension of unemployment benefits; stimulus checks; additional funding for COVID testing and contract tracing and vaccine distribution; aid to state and local governments; housing assistance; funding to support the opening of schools; support for child care providers; relief for multi-employer pension plans; and a number of health care related provisions, discussed below. (For summaries of the bill, see, e.g., this Senate Title-by-Title summary; the Center on Budget and Policy Priorities (CBPP) issue brief “American Rescue Plan Act Will Help Millions and Bolster the Economy”; also see this Washington Post summary and NPR summary.)
Health care specific provisions of the Rescue Act include:
- Expansion of marketplace coverage – according to CBPP, “the Act eliminates or vastly reduces premiums for many people with low or moderate incomes who enroll in plans through the Affordable Care Act (ACA) marketplaces and provides new help to people with somewhat higher incomes who face high premiums.” The Kaiser Family Foundation has updated its 2021 Health Insurance Marketplace Calculator to reflect these changes, which will be in effect for two years. In addition, there are protections for marketplace enrollees with fluctuating income over the last year from having to repay significant portions of their federal premium tax credits.
- Expansion of COBRA coverage – per the Senate summary, the “bill subsidizes 100 percent of COBRA premiums for six months for individuals who lost employment or had reduced hours.”
- Medicaid – provisions include:
- Increased financial incentives for the states that have not implemented the ACA’s Medicaid expansion to do so
- Increased federal portion of Medicaid funding for Home and Community Based Services (HCBS)
- According to the Senate summary referenced above, “The bill also includes numerous investments to reduce health disparities, including an option for states to provide one-year of postpartum Medicaid coverage, […] and resources for COVID-19 response in nursing homes.”
The American Rescue Plan will provide much needed relief to a nation seeking to emerge from the pandemic, but the work is not done. The Center for Medicare Advocacy now urges Congress and the Administration to address additional health care and Medicare issues. This includes: confronting long-standing problems faced by those who reside in nursing homes, including addressing staffing, infection control, and management problems; filling the gaps in Medicare coverage, including adding oral health coverage; and ensuring that all Medicare-eligible individuals can access their earned Medicare benefits during the COVID-19 pandemic and beyond, including reinstating enrollment flexibilities and addressing hospital observation status. See the Center’s legislative priorities outlined in our Medicare Platform, our Transition Memo to the Department of Health and Human Services, and our joint letter with the Medicare Rights Center outlining our organizations’ priorities for immediate administration actions.
On March 10, 2021, the Centers for Medicare & Medicaid Services (CMS) confirmed that all nursing home residents can have visitors indoors: “Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission.” A resident who is fully vaccinated “can choose to have close contact (including touch) with their visitor while wearing a well-fitting face mask and performing hand-hygiene before and after.” CMS and the Centers for Disease Control and Prevention recommend that facilities, residents, and families adhere to core infection control principles.
In three situations, CMS allows indoor visits to be limited (except for compassionate care visits, discussed below):
- Unvaccinated residents, the nursing home’s COVID-19 county positivity rate is more than 10%, and less than 70% of the residents in the facility are fully vaccinated.
- Residents with confirmed COVID-19, whether vaccinated or unvaccinated, until they have met the criteria to discontinue transmission-based precautions.
- Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine.
“Compassionate care visits,” expanded in the September 2020 guidance to include, in addition to end-of-life situations, other circumstances where residents are struggling, grieving, or needing cueing and encouragement, “should be allowed at all times, regardless of a resident’s vaccination status, the country’s COVID-19 positivity rate, or an outbreak.”
If there is a COVID-19 outbreak (defined as a single new case among residents or staff), “the facility should immediately begin outbreak testing and suspend all visitation (except that required under federal disability law), until at least one round of facility-wide testing is completed.” Indoor visitation can resume as follows:
If no additional COVID-19 cases are identified in other units of the facility, visitation can resume in units where there is no COVID.
If the first round of testing reveals one or more additional cases of COVID-19 in two or more units, the facility “should suspend visitation for all residents (vaccinated and unvaccinated), until the facility meets the criteria to discontinue outbreak testing.”
Although CMS encourages visitors to become vaccinated “when they have the opportunity,” facility should not require visitors to be tested or vaccinated “(or show proof of such) as a condition of visitation.”
CMS continues to recommend outdoor visitation, even when residents and visitors are fully vaccinated.
 CMS, “Nursing Home Visitation – COVID-19 (REVISED),” QSO-20-39-NH (revised Mar. 10, 2021), https://www.cms.gov/files/document/qso-20-39-nh-revised.pdf
On March 1, 2021, the New York Times published a column by Paul Krugman titled “Too Much Choice is Hurting America”. Mr. Krugman discusses how “Economics 101 and conservative ideology say that more choice is always a good thing.” He concludes, though, that the “spread of this ideology” means we live in “a country in which many of us are actually offered too many choices, in ways that can do a lot of harm.” With respect to health coverage, he notes that “many people end up with heavy financial burdens because they chose the wrong health insurance plan — yet even experts have a very hard time figuring out which plan is best.” He states that “many aspects of life that used to be just part of the background now require potentially fateful decisions [… for example] When you turn 65, you don’t just get put on Medicare, you also decide which of many Medicare Advantage plans to sign up for.”
In 2021 Medicare beneficiaries have an average of 33 private Medicare Advantage (MA) plans and 30 Part D stand-alone drug plans from which to choose. As discussed in a previous Center for Medicare Advocacy CMA Alert (November 2020), most people actually won’t choose a plan in a given year.
Mr. Krugman doesn’t even capture the full extent of choices most people with Medicare must make. Among other things, people must decide whether to remain in traditional Medicare (and, if so, can or should they purchase a Medigap plan) or enroll in an MA plan, should they choose a stand-alone Part D coverage or an MA plan with Part D coverage, and do they have some other coverage and if so, how will it coordinate with Medicare? As we discuss in another CMA Alert (March 2020), even the choices of coverage options in Medicare are unequal; for example, while people can get in and out of a Medicare Advantage plan on an annual basis, most people have limited opportunities to purchase a Medigap plan – a fact many people discover too late.
Once an individual with Medicare has made their original enrollment decision, even if the choice they originally made no longer meets their needs, the majority never change. It’s often too complicated, and many Medicare beneficiaries can’t make a choice. Their prior employer may have put them in a Medicare Advantage plan; they may not be able to return to traditional Medicare because they cannot purchase a Medigap policy to cover traditional Medicare’s high cost-sharing; they may not have the ability or connectivity to use the sophisticated tools needed to review and make choices.
Further, the information on which people rely to make decisions can be inaccurate, or worse, misleading. For example, there have been recent problems with the Medicare Plan Finder, the primary tool that people use to compare plan options, and in the last several years the Medicare program has departed from an objective approach towards coverage options – including in the Medicare & You Handbook – and has instead steered people towards enrollment in MA plans. Meanwhile, private Medicare Advantage costs the Medicare program more per enrollee than the traditional program, while usually offering its members fewer choices of health care providers. All this highly-touted choice is both harmful and elusive.
Krugman ends his column with a warning: “So the next time some politician tries to sell a new policy — typically deregulation — by claiming that it will increase choice, be skeptical. Having more options isn’t automatically good, and in America we probably have more choices than we should.” We agree. Choice in Medicare can be both burdensome and unequal. One way to address this is to rebalance some of these inequities by leveling the playing field between Medicare Advantage and the traditional Medicare program in the interest of all beneficiaries.
Medicare & Health Care:
Where We’ve Been, Where We Are, Where We Need to Be
Thursday April 1, 2021, 1:00 PM EDT- 4:00 PM EDT
We are honored to present 2021 Sen. Jay Rockefeller Lecturer
Dr. Donald Berwick
Dr. Berwick is one of the country’s leading advocates for high-quality health care, and one of the top thinkers in health care today. Dr. Berwick is currently President Emeritus and Senior Fellow at the Institute for Healthcare Improvement and previously Administrator of the Centers for Medicare & Medicaid Services.
Featuring speakers, panelists and moderators including Mary Ashkar (Senior Attorney, Center for Medicare Advocacy), Ben Belton (Director of Global Partner Engagement, AARP), Dr. Emily Cleveland Manchanda (Asst. Professor of Emergency Medicine, Boston University School of Medicine and Director for Equity Initiatives, Dept. of Emergency Medicine, Boston Medical Center), Robert Espinoza (Vice President of Policy, PHI), Dr. Judith Feder (Georgetown University Professor and Center for Medicare Advocacy Board President), Amy Hall (Staff Director, Subcommittee on Health, Committee on Ways and Means, U.S. House of Representatives), Chris Jennings (President, Jennings Policy Strategies), Kata Kertesz (Policy Attorney, Center for Medicare Advocacy), Wey-Wey Kwok (Senior Attorney, Center for Medicare Advocacy), David Lipschutz (Associate Director, Center for Medicare Advocacy), Patricia Neuman (Vice President for Medicare, Kaiser Family Foundation), Senator Jay Rockefeller, and Judith Stein (Executive Director, Center for Medicare Advocacy).
Challenges and Opportunities Facing Medicare and Health Care in the New Administration and Congress — This panel will explore issues such as Medicare solvency and coverage, the growing privatization of the program, and how these factors impact vulnerable Medicare beneficiaries. How do we advance fair access to quality health care through Medicare and other health coverage programs?
Acknowledging Health Disparities and Advancing Health Equity —This panel will consider how the pandemic has highlighted, and exacerbated, pre-existing disparities in access to quality health care. Panelists will discuss ways to address health care equity issues for all people who need health care, as well as for their caregivers and families.