The Washington PostDemocracy Dies in Darkness

The Health 202: The Biden administration is waving money at a dozen states to expand Medicaid

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with Alexandra Ellerbeck

Persuading Texas to expand Medicaid would be one of the quickest ways to start tamping down a rising U.S. uninsured rate — a problem that has only worsened amid the coronavirus pandemic.

But it’s unclear whether a new pot of money promised by Democrats will be enough to sweeten the deal for Texas and 11 other states that have resisted expansion for more than a decade.

“I’m more hopeful than I have been in a while. … The truthful answer is I don’t know,” said Elena Marks, CEO of the Episcopal Health Foundation, a Houston-based group that advocates for health care for low-income people. 

The Biden administration is trying to entice the dozen holdout states to finally expand Medicaid.

There are already financial incentives in place. Under the Affordable Care Act, the federal government covers 90 percent of adults newly covered by expansion. Those optics have led many states, including those led by conservatives, to expand over the past few years.

But those incentives apparently weren’t strong enough for Texas and the others, whose Republican leaders have largely opposed the ACA and its various programs.

As a result, around 4 million Americans who would otherwise be eligible for expanded Medicaid live in the dozen holdout states. Nearly one-third of them are in Texas, whose uninsured rate hovered around 18 percent in 2019 and rose over the past year because of the pandemic. (At this moment, the state is in the middle of an extreme cold snap, sending electricity demand skyrocketing and leaving millions of residents without power.)

A coronavirus relief bill working its way through Congress and backed by President Biden includes a hefty incentive for states to expand Medicaid. If a state did so, the federal government would increase its Medicaid contribution to the state by 5 percent. The increased match rate would apply to everyone outside the expansion group and would last two years.

For Texas, that would mean nearly $6 billion extra dollars in Medicaid funds over two years.

That’s according to the left-leaning think tank Center on Budget and Policy Priorities. It’s an offer state activists think legislators shouldn’t be able to refuse — although they’re cautious about making any predictions.

“It’s certainly going to be part of the debate,” said Anne Dunkelberg, associate director of health at Every Texan.

Texas has more uninsured residents than any other state — partly because the massive state has spurned expansion. That means no Medicaid for most adults earning up to 133 percent of the federal poverty level (around $17,000 for a single person or $35,000 for a family of four).

Some Texas Republicans are now showing openness.

Last month, state Rep. Lyle Larson became the first Republican since 2013 to file a bill to expand Medicaid. In an op-ed in the Austin American-Statesman, he called it a “bad business decision” for Texas to opt out, arguing it was losing out on billions in federal dollars and the chance to get a million more residents insured.

“Say you were told that every dollar you contribute toward a cause would be matched with $9,” Larson wrote. “Sounds like a pretty good deal, doesn’t it? This is the deal that Texas is forgoing by refusing to expand Medicaid.”

The promised new Medicaid dollars, combined with the pandemic’s toll, are creating an environment in which lawmakers are more receptive to hearing arguments about expansion, both Marks and Dunkelberg said.

Even Gov. Greg Abbott, a Republican who has called Medicaid a bloated government program, has recently talked about needing to address the state’s rising uninsured rate, they noted.

“You have a surprising number of Republicans who have been talking about it,” Dunkelberg said.

But persuading Texas and the other holdout states to expand won’t be easy.

Most of the other non-expansion states are clustered in the nation’s southeast corner. They include Florida, Georgia, Mississippi, Alabama, Tennessee and both Carolinas. There’s also Wisconsin, Wyoming, Kansas and South Dakota.

Some GOP-led states were persuaded to expand Medicaid by obtaining permission from the federal government to set up additional requirements or safeguards, such as charging premiums or co-payments, setting up additional anti-fraud measures, getting funds in the form of a block grant or enacting work requirements. 

But the last and most controversial of those work requirements will no longer be allowed, according to a draft plan from the Biden administration obtained by my colleagues last week. The administration is planning to immediately rescind permission to states to compel poor residents to work in exchange for receiving Medicaid benefits, Dan Diamond and Amy Goldstein reported.

“The swift rescinding of the Trump administration’s effort to remake the safety-net program represents a particularly sharp pendulum swing on the ideological divide over the proper roles of government and individuals living under economic strain,” Dan and Amy wrote.

Ahh, oof and ouch

AHH: The rate of newly recorded coronavirus infections is plummeting.

The rolling daily average of new infections hit an all-time high of 248,000 on Jan. 12. On Sunday, it was at 91,000, its lowest level since November, The Post’s Reis Thebault reports. Yet the current level of cases is still more than double what the country saw over the summer.

Scientists at the University of Washington’s Institute for Health Metrics and Evaluation, which has published a number of prominent coronavirus models, attribute the declining cases to the quickening pace of vaccine administration and the natural seasonal ebb of respiratory viruses.

But some epidemiologists say vaccinations aren’t yet widespread enough to make a dent in the number of cases. Nearly 40 million people — roughly 12 percent of the U.S. population — have received a vaccine shot.

“I don’t think the vaccine is having much of an impact at all on case rates,” former Centers for Disease Control and Prevention director Tom Frieden said in an interview Sunday on CNN’s “Fareed Zakaria GPS.” Instead, Frieden attributed the declining cases to improved public health precautions. “It’s what we’re doing right: staying apart, wearing masks, not traveling, not mixing with others indoors.”

A less optimistic explanation for the declining number of cases has also emerged. Some experts worry the U.S. may be detecting fewer cases as public health resources shift toward vaccine administration and away from testing.

Eleanor Murray, a professor of epidemiology at Boston University School of Public Health:

OOF: The CDC is recommending schools fully reopen only when community transmission levels are extremely low.

It's a standard almost no community in the U.S. meets today. Advocates are criticizing the new guidelines, saying they set the bar too high for getting kids back in classrooms. 

Biden has been urging schools to reopen, and promised that guidelines from the Centers for Disease Control and Prevention would help them do so safely, The Post’s Laura Meckler reports. But the much-anticipated guidelines released Friday were more measured than some expected.

While pandemic school closures have been challenging for many children, special-needs students like McKenzie West are falling further behind. (Video: Jorge Ribas/The Washington Post)

The CDC’s plan recommends hybrid classes for elementary schools when community spread is high, to make it easier for children to distance in the classroom. It recommends that middle and high schools in high-transmission areas either go fully remote or adopt stringent mitigation strategies to implement a hybrid model.

The plan received praise from teachers unions, while sparking criticisms from some experts who noted the CDC has previously said the virus hasn't spread much within schools that did reopen.

The guidelines add “new and unnecessary demands that will ultimately keep millions of kids out of school,” public health experts Joseph Allen and Helen Jenkins wrote in The Post. They said they had once favored tying school reopening to metrics for community spread, but changed their position on this "in light of overwhelming scientific evidence that transmission within schools can be kept low regardless of community spread, so long as good mitigation measures are in place.”

Still, some elements of the plan could encourage reopening. It doesn't require vaccination of teachers for reopening and puts almost no emphasis on improving ventilation systems, which has been a point of contentious debate between some teachers unions and school systems.

OUCH: New York Gov. Andrew Cuomo admitted to a lack of transparency in his administration’s initial reporting of nursing home deaths.

Yesterday, for the first time, Cuomo (D) acknowledged the “void” of information furthered disinformation and induced anxiety amid a deadly pandemic – although he didn't apologize, Meryl Kornfield reports.

“Cuomo, who was a Democratic favorite early in the crisis, admitted his administration did not promptly answer questions from the public and media about the number of residents in New York’s nursing homes and long-term care facilities who died from covid-19 — now more than 13,000,” Meryl writes. 

Cuomo said that delayed response allowed for a void “filled with skepticism, cynicism, and conspiracy theories which furthered the confusion.” But he defended his administration’s actions in the face of an unprecedented strain.

“If you could do it all over again,” Cuomo said, “I understand the public had questions and concerns and the press had many questions about nursing homes.”

“Cuomo’s remarks come days after his top aide Melissa DeRosa admitted in a call with state lawmakers that the administration ‘froze’ handling an inquiry sent from the legislature about the data while it handled a request sent by the Department of Justice regarding the deaths,” Meryl writes. “In DeRosa’s conversation with lawmakers, first reported by the New York Post, she said the administration feared the data would be ‘used against us.’”

More coronavirus news

Hundreds of public health workers who have been deployed to combat the coronavirus are still waiting on vaccines.

“Two months after federal officials authorized the first coronavirus vaccine for use, there is still no plan to allot vaccine supply to fully inoculate the commissioned corps of the U.S. Public Health Service, a 6,000-person force that has been deployed to care for coronavirus patients, set up vaccination sites and perform other health tasks on behalf of the federal government,” The Post’s Dan Diamond reports.

The corps is a uniformed service of the government, and health department officials say they should be eligible for vaccinations under the Pentagon’s vaccination priority list, but some officers have been turned away when they try to get vaccines at military treatment sites. 

The Biden administration has repeatedly touted the corps as a central part of the president’s plan to ramp up vaccinations.

A Health and Human Services Department official, speaking on the condition of anonymity to discuss in-progress plans, told The Post the administration was working to vaccinate the commissioned corps and had secured additional doses to be administered at Walter Reed National Military Medical Center.

  • A new study suggests the virus variant B.1.1.7, first identified in the United Kingdom, is more deadly for those who contract it. U.K. scientists had already estimated that the variant is more transmissible, and they now think it is likely 30 to 70 percent more deadly and is also associated with an increase in hospitalizations, The Post’s Miriam Berger reports.
     
  • The World Health Organization listed AstraZeneca and Oxford University’s coronavirus vaccine for emergency use, Reuters reports. The global health organization’s move will widen global access to the shot, which is cheaper and easier to distribute compared with some of its rivals. The United States has still not approved the vaccine and is waiting for the results of U.S.-based clinical trials.
  • U.S.-based Moderna pledged it would uphold “equitable access principles” with its coronavirus vaccine when it accepted a $900,000 early investment from the Coalition for Epidemic Preparedness Innovations, a nonprofit committed to equally distributing vaccine doses globally, The Post’s Emily Rauhala reports. But more than a year later, the company has almost completely shut poor countries out of its vaccine allocations and has yet to make any commitments to Covax, the WHO-backed effort to ensure equitable vaccine distribution.
     
  • Millions of rapid coronavirus antigen tests distributed to states have gone unused, the Wall Street Journal’s Brianna Abbott and Sarah Krouse report. At least 32 million of 143 million BinaxNow rapid tests, made by Abbott Laboratories, were not used as of February, according to a review of state inventories.

Elsewhere in health care

A new enrollment window for health insurance markets has opened in most states.

The opening comes after Biden last month ordered markets that ended their enrollment period in December to reopen. The new enrollment period will last through May 15.

“This new window could be useful for people who recently lost their coverage or couldn’t find a plan last year. Experts have said the number of uninsured people has risen during the pandemic due to layoffs,” the Associated Press reports.

Sugar rush

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