Health Care Priorities For A COVID-19 Stimulus Bill: Recommendations To The Administration, Congress, And Other Federal, State And Local Leaders From Public Health, Medical, Policy And Legal Experts

With nationwide community-spread of the novel coronavirus COVID-19 and extreme volatility in the economic markets, Congressional action is necessary and appropriate to help keep the United States healthy and to avoid financial calamity. Doing so will require significant financial investment, legislative and executive action, and the full participation of all segments of American society — government, the private sector, and individual citizens.

As experts in public health, medicine, policy and law, and with prior expertise in developing federal health legislation and public health initiatives, we hereby present a framework designed to protect the health of all Americans in the face of this unprecedented epidemic. Because this framework is directed at Congress, we do not detail critical efforts that must be undertaken, and in some cases already are being undertaken at the state level. States have broad emergency powers to regulate insurance and health care access. If asked, the President should immediately invoke the Stafford Act to trigger an influx of federal funds and support state, tribal, and local government response efforts. An additional Presidential declaration via the National Emergencies Act would empower multiple federal agencies to waive or relax current legal restrictions.

Four basic principles guided the development of the framework offered here:

  *   Ensuring health security is the fundamental duty and responsibility of government at all levels — federal, state, and local.

  *   Protecting Americans’ health in this time of crisis should be a unifying effort; it should not be and cannot be divisive.

  *   Immediate and targeted action is required to address the current coronavirus epidemic. 

  *   Sustained investments in public health are needed to respond to this acute crisis and to prepare the nation for future epidemics.

We also note that while this framework is focused on a health care response, this crisis also requires action in many other policy areas.  We recognize that there can be substantial harm to vulnerable populations from recession and other economic, workplace, and family disruptions. The federal government should expand access to programs like WIC, TANF, and SNAP, as well as increase the social services block grant in order to help families financially affected. We also urge Congress to require paid sick leave for employees so that they can stay home from work in order to prevent transmission. This should include paid leave to care for sick relatives including dependents and the elderly. We will defer to other proposals to address broader economic effects within the context of a stimulus/bailout package.

Affordable, Accessible Testing & Treatment

Privately Insured Individuals And Families Should Be Protected From High Out-of-pocket Costs That Threaten Financial Well-being And Represent Barriers To Timely Testing And Treatment For The Novel Coronavirus.

• No cost-sharing for COVID-19 related preventive services. All private insurance coverage should be required to cover preventive and diagnostic services related to COVID-19 with no cost-sharing, immediately. The ACA’s preventive services coverage mandate should be expanded to include services that HHS determines are necessary for mitigating the spread of COVID-19, including screening and diagnostic testing, and any eventual vaccine. Insurers should be required to cover these services immediately.
• Coverage for treatment, recovery, and complications arising from COVID-19 or suspected infection. All individual and group market insurance coverage and employer group health plans should be required to cover all medically necessary care related to suspected COVID-19, including testing, treatment, and recovery, and treatment for complications arising from COVID-19 or suspected infection. Plans must cover services regardless of whether covered services are obtained from in-network providers, with payment at the plan’s median in-network rate for out-of-network care, and regardless of whether the patient receives a COVID-19 test or whether the test is negative, and providers may not balance bill for these services.
• Extending these requirements to otherwise unregulated plans.
  • Association health plans and short-term limited duration health plans. Require all AHPs and short term limited duration health plans (STLDI) to cover all testing, treatment and recovery services for COVID -19, including treatment for complications arising from COVID 19. Bar such plans from cancelling or refusing to renew coverage based on a policyholder’s COVID-19 status.
  • Student health plans. Require self-insured student health plans to cover all testing, treatment and recovery services for COVID -19, including treatment for complications arising from COVID 19. Require student health plans (whether insured or self-insured) to cover testing and treatment services for any diagnosis or condition relating to COVID-19 delivered away from campus, and prohibit providers from balance billing for services delivered to students covered under a student health plan.
• Special enrollment period for Marketplace health plans. Create a sixty-day special enrollment period for individuals seeking coverage through the health insurance Marketplace.

Strengthen State Medicaid Capacity To Respond To COVID-19.

• Medicaid expansion. Reinstate the 100 percent federal medical assistance percentage (FMAP) rate for any state that elects to adopt the ACA Medicaid expansion to encourage any state that has not already done so to expand eligibility on a long-term basis.
• State option for COVID-related care. Building on the precedent set by the Breast and Cervical Cancer Prevention and Treatment Act, amend Medicaid to add a state option to extend Medicaid eligibility for the duration of the COVID-19 outbreak, to any state resident who is uninsured for all medically necessary services in connection with COVID-related testing, treatment, and recovery, including treatment for complications and other health conditions arising from COVID-19 or that could be worsened by COVID-19. Set federal financial participation rates for this eligibility option at 100 percent. This option would be in place until the end of the quarter in which the HHS-declared public health emergency ends.
• Federal matching dollars for Medicaid. For the duration of the COVID-19 outbreak, increase the federal medical assistance percentage (FMAP) nationwide by 10 percentage points over each participating state’s otherwise applicable FMAP rate for both traditional and ACA expansion Medicaid beneficiary populations, through the end of the quarter in which the HHS-declared public health emergency ends. Condition enhanced federal Medicaid funding on maintenance of state effort in terms of eligibility, benefits, cost sharing, and premiums.
• Enrollment and renewal. Enhance the federal financial participation rate for states that seek to expand enrollment and renewal capabilities, including outstationed enrollment at hospitals and clinics and the addition of eligibility determination and enrollment staff.
• Increase Medicaid funding to Puerto Rico, the Virgin Islands, other U.S. territories, and sovereign states covered by the Compact of Free Association (COFA)
• Public charge rule. Suspend the operation of the public charge rule for the duration of the crisis and ensure that no medical services utilized during the crisis apply to any reinstated rule.

Protect Medicare Beneficiaries From Out-Of-Pocket Costs.

• COVID-related care. Clarify Medicare coverage (whether through original Medicare or Medicare Advantage) of all diagnosis, treatment, and recovery care related to COVID-19, including care for complications arising from COVID-19, without cost-sharing. In the case of Medicare Advantage plans, require plans to provide coverage at no out-of-pocket cost to patients, and regardless of whether treatment is obtained from in-network providers, with payment at a plan’s median in-network rate in the case of out-of-network care.

Ensure Hospitals Are Meeting Their Community Obligations.

• Clarify that hospitals with specialized treatment capabilities must accept transfers (unless capacity has been reached) in the case of inpatients at hospitals that lack such capabilities and that request such a transfer for patients who require specialized care in order to be stabilized.
• Financial assistance to patients and bar against extraordinary collection practices. Clarify the obligation of all hospitals that seek tax-exempt status under § 501(c)(3) of the Internal Revenue Code (and are thus, subject to community benefit obligations) to offer financial assistance to all patients at the time services are furnished and not to pursue extraordinary collection efforts (including liens, garnishment of wages, or seizure of real or personal property) in connection with claims related to COVID-19 or conditions related to complications arising from COVID-19.

Vulnerable Populations

Implement Specific Protections For Especially Vulnerable Groups.

• Vulnerable population-centered policy. Craft all programs with vulnerable populations in mind, including homeless and undocumented individuals. Communicate with tailored messaging to these and other populations around the urgency of seeking care and provide assurances they will be held harmless when they do seek care with respect to both cost and immigration status.
• Institutionalized populations. Additional attention is needed for institutionalized populations (e.g., group home residents, nursing home or long-term care facility residents and incarcerated individuals) who are at high risk of quick transmission of COVID-19.
• Undocumented patients. Prohibit immigration enforcement in health care facilities so immigration status does not prevent care-seeking for undocumented individuals.
• Low-income families. Increase funding for the Social Services Block Grant (SSBG) by $1 billion for the remainder of FY20 to provide funding for states to assist low-income families negatively impacted by COVID-19. Services provided by states would be specifically tied to the following SSBG statutory goals:
  • Prevent or reduce inappropriate institutional care by providing for community-based care, home-based care, or other forms of less intensive care; and
  • Secure referral or admission for institutional care when other forms of care are not appropriate.
• Community health centers and Medicaid Disproportionate Share Hospital (DSH) Payments.
  • Increase funding for community health centers by 25% through the end of FY20 to allow these providers to extend their COVID19 response, particularly to uninsured individuals.
  • Delay scheduled Medicaid DSH cuts beyond the May 22 expiration (when cuts are currently scheduled to be imposed) through the end of 2020.
• Access to care for incarcerated individuals. Expand Medicaid coverage for hospitalization of incarcerated individuals. Eliminate the 24-hour waiting period before Medicaid can provide payment for care provided in an inpatient setting outside of the correctional institution.
• Insurance barriers. For patients with chronic health conditions who require ongoing prescription medications, require insurers to waive refill limits and prior authorization requirements.
• Nutritional services. Access to food is a critical part of health for vulnerable populations under quarantine; consider funding existing visiting nurses or home health providers to provide nutritional services to quarantined vulnerable populations.

Frontline Health Care Workers

Institute Protections For Health Care Workers Of All Professions On The Frontlines In The Epidemic. 

• Ensuring frontline workers are properly equipped. Increase manufacturing of personal protective equipment (e.g. masks), ventilator equipment, IV saline, and other medically critical supplies to ensure our frontline providers can safely and appropriately care for patients with infection, with government decree if necessary. The Strategic National Stockpile and other similar resources should be mobilized.
• Financial protection for frontline health care workers. Establish a health care worker fund similar to the James Zadroga fund established for 9/11 first responders to protect frontline health care providers including but not limited to physicians, nurses, respiratory therapists, radiology technicians, emergency medical service providers and other first responders, advanced practice providers (e.g., physician assistants, nurse practitioners), certified nursing assistants, and nursing home staff, and their families from financial harm resulting from exposure or infection.
• Child and elder care for health care workers working extra or unscheduled shifts. Allow for child care and elder care expenses to be tax exempt and consider how to create tax-deferred funding pools to compensate for emergency childcare for healthcare workers and public health workers called to work outside of expected scheduling due to increased COVID-related demand.
• Facilitate sharing of best practices among healthcare providers. Use a multimedia approach to reach as many health care personnel as possible with a goal of sharing best practices (how to set up COVID-19 wards most efficiently, how to consider an alternate staffing model, facilitating testing during a surge demand, etc.).
• Continuity of funding. The Centers for Medicare and Medicaid services should not deny residency funding to hospitals if residents are sent home for safety or quarantine related to COVID-19.

Healthcare Delivery Capacity

Strengthen The Capacity Of Health Care Delivery Organizations To Respond To Escalating Demand.

• Funding and capacity of hospitals and clinics.
  • Provide emergency subsidies to support under-resourced hospitals and clinics, particularly in rural areas, to support re-purposing clinical units, quarantines, and the cost of additional labor to meet increased demand.
  • Increase funding flexibility for states so they can deploy funds from various sources (Medicaid, CDC transfer funds, emergency supplemental funding) to address shortages.
  • Mobilize Public Health Service to fill staff shortages in local and regional health structures and charge the Surgeon General to be able to quickly add personnel to the Public Health Service if necessary, particularly for vulnerable populations which might lack appropriate staffing, such as border and rural populations.
• Build on emergency expansions in Medicare telemedicine coverage by encouraging states to waive telemedicine requirements that a provider be licensed in the state where care is delivered. Collaborate with national telehealth delivery systems to enhance use of telehealth triage across the country, to efficiently identify patients with suspected COVID-19 infection and refer for testing.
• Regulatory flexibility.
  • Allow off site treatment under all federal programs.
  • Allow licensed health care facilities to establish temporary locations to provide care based on need to limit exposures or treat large volumes of patients without waiting for state or local regulatory approval of those locations.
  • Allow emergency departments to divert patients meeting certain criteria (e.g. mild symptoms not requiring urgent stabilization or hospitalization), only during declared public health emergencies, to alternative facilities without fear of EMTALA violations.
  • Approve lab applications to the Food and Drug Administration for emergency use authorization so commercial lab companies to offer testing to meet the need.
  • Exempt clinical laboratories from certain Clinical Laboratory Improvement Amendments (CLIA) regulations for local testing protocols to enable hospitals with capability to enhance testing by mobilizing local PCR lab resources to do so.
• Establish temporary COVID-specific clinics. Establish drive-through testing in community areas (e.g. parking lots) to increase capacity to evaluate patients with concerning symptoms and to offset the burden on hospitals. The deployment of pallets to set up tents for evaluation and treatment may accelerate this process.
• Mental health care. Provide support to boost mental health workforce capacity beyond the period of a declared public health emergency in order to allow for care related to the consequences of COVID-19.

Public Health Infrastructure

Invest And Improve The Operations Of The Nation’s Key Public Health Institutions To Enhance  Their Capacity To Respond To The Current Epidemic And To Address The Next One (Which Is Inevitable).

• Deploy federal resources, including appropriate medical and public health personnel to states which request assistance.
• Provide funding directly to state and local governments to hire additional public health personnel, enhance laboratory capacity, and support data collection efforts.
• Reimburse state and local governments for their resources already expended in carrying out these activities.
• Increase funding immediately for CDC and FDA to bolster their containment, monitoring, and mitigation functions, including those related to testing for the coronavirus and COVID-19.
• Establish a dedicated CDC public health emergency fund that (1) is not subject to the annual appropriations process; (2) cannot be used for purposes other than to address public health emergencies, and (3) is automatically replenished when monies from the fund are drawn down. A portion of the fund would be designated for use by state and local health departments, as appropriate, and at CDC’s discretion.
• Renovate and otherwise improve outdated CDC buildings and laboratories.
• Undertake a major CDC data modernization initiative designed to allow the agency to collect, analyze, produce, and release relevant information quicker and more efficiently to state and local health departments as well as the public.
• Exempt CDC (and other appropriate HHS agencies) from Paperwork Reduction Act requirements regarding the collection of information during the conduct of research and appropriate public health interventions.
• Revisit Office of Personnel Management (OPM) waiver authority to allow greater direct hire flexibility to CDC (and HHS more broadly), especially in times of public health emergencies.
• Increase funding for the CDC Foundation, an independent, non-profit organization created by Congress to mobilize philanthropic and private sector resources to support CDC health protection work. Because it is an independent organization (and therefore, not subject to government bureaucratic procedures), the Foundation can act quickly in assisting CDC and state and local governments in addressing public health emergencies.
• Data sharing for tracking and monitoring.
  • Require all labs to report testing data to the CDC (can be accomplished via presidential emergency declaration).
  • Direct the Department of Health and Human Services (HHS) to establish a national monitoring mechanism of test kit availability with the ability to facilitate just in time testing capacity by having specimens sent to labs with supply.
  • Leverage the recent HHS Interoperability Rule to facilitate rapid sharing of patient-centered data. Consider tasking the US Digital Service and the HHS Office of the Chief Technology Officer to work in partnership with the private sector to create real time information sharing related to lab testing, supplies, access issues, and hotspots.
• Providing timely, factual information to the public. Establish both a national hotline and a dedicated Medicare hotline for the public whose purpose, in each instance, is to provide information, answer questions, offer guidance, and triage patients. Such hotlines could be linked to existing call lines such as 211 or 911 or tie into regional poison control hotlines.

Vaccine, Treatments, & Research

Support Research And Discovery Related To A COVID-19 Vaccine, Development Of Novel Pharmaceutical Treatments, And Research On Epidemiology, Risk Factors, Outcomes, And Response To Existing Therapies.

• Development of vaccines, treatments, and methods to better protect health care workers. Provide incentives for both the public and private sector to develop, test, and produce new vaccines and treatment modalities, as well as novel or more efficient methods to sanitize health care facilities and equipment and to otherwise protect health care workers from COVID19 transmission.
•  Rapid, equitable access to new vaccines/therapies. Ensure mechanisms are in place to expedite access to vaccination and/or treatments as soon as they are available. This includes expedited processes for FDA review and approval, and potentially the authority to purchase intellectual property for a vaccine or treatment if price gouging occurs.
• New single-mission entity to develop a universal influenza vaccine. Provide support for the establishment of a new, independent, single-mission entity focused on accelerating the development of a universal influenza vaccine, to achieve global protection.
• Dedicated fund at National Institutes of Health (NIH). Provide a dedicated NIH fund to support both basic and applied research on COVID-19. Funded research should include elucidation of basic epidemiology (e.g. incubation period, R0, etc), description of risk factors for infection and for mortality, description of the normal course of and co-occurring disorders (e.g., myocarditis, acute respiratory distress syndrome) with COVID19 infection, development and validation of novel biomarkers of infection and of severe infection, development and validation of improved diagnostic tests, trials of treatments, trials of containment/mitigation strategies, and dissemination and implementation studies. This work should additionally include trials of electronic health record or other data monitoring and experimentation, to speed learning and provide better estimates of risk, outcomes, and strategies to best mitigate the risk.
• Health services research. Direct and fund health services, implementation, and comparative effectiveness research through directed mandates to PCORI, AHRQ, and CDC.
• Health communication. Direct and fund research on effective health communications strategies for all aspects of COVID19 response including communication with the public, with vulnerable populations, and with health care providers.

The letter will be sent to federal officials on March 12, 2020, but it will remain open for sign-ons at this link. The online version of the letter will be updated as new endorsements come in. Please email [email protected] with questions.

Signed

(All individuals speaking on their own and not on behalf of their institutions; affiliations are for identification purposes only.)

Howard P. Forman, Professor of Public Health, Radiology, and Management, Yale University. (Founding member and lead of the group.)

Elizabeth Fowler, Executive Vice President for Programs, The Commonwealth Fund; former special assistant to the president on health care and economic policy at the National Economic Council

Megan L. Ranney, Associate Professor of Emergency Medicine and Health Services, Policy, & Practice, Brown University

Ruth J. Katz, Vice President and the Executive Director of the Health, Medicine and Society (HMS) Program at the Aspen Institute; former Chief Public Health Counsel (Democratic Staff) with the Committee on Energy and Commerce in the U.S. House of Representatives

Sara Rosenbaum, Harold and Jane Hirsh Professor of Health Law and Policy and founding chair of the Department of Health Policy, Milken Institute School of Public Health, at the George Washington University; health policy advisor to six Presidential Administrations and nineteen Congresses

Kavita Patel, Vice President, Hopkins Medicine, The Johns Hopkins University, Nonresident Fellow, The Brookings Institution; former director of policy for the Office of Intergovernmental Affairs and Public Engagement in the White House

Timothy Stoltzfus Jost, Emeritus Professor, Washington and Lee University

Abbe R. Gluck, Professor of Law and Faculty Director, Solomon Center for Health Law and Policy, Yale Law School; Professor of Medicine (General Medicine) Yale Medical School

Christen Linke Young, Fellow, USC-Brookings Schaeffer Initiative for Health Policy, The Brookings Institution; former Principal Deputy Director of the Center for Consumer Information and Insurance Oversight at CMS

Brendan Carr, Chair of the Department of Emergency Medicine at the Icahn School of Medicine at Mt. Sinai; former Senior Advisor and Director of the Emergency Care Coordination Center within the Office of the Assistant Secretary for Preparedness and Response

Erica Turret, student, Yale Law School

Suhas Gondi, student, Harvard Medical School

Adam Beckman, student, Harvard Medical School 

Additional experts who express support: 

Harlan Krumholz, Harold H. Hines, Jr. Professor of Medicine (Cardiology) and Professor in the Institute for Social and Policy Studies, of Investigative Medicine and of Public Health (Health Policy); Director, Center for Outcomes Research and Evaluation, Yale-New Haven Hospital

Nirav R. Shah, Former NY State Commissioner of Health; Senior Scholar, Stanford University Clinical Excellence Research Center

Bob Kocher, Former Special Assistant to the President for Healthcare and Economic Policy; Partner Venrock and Senior Fellow at the Leonard D. Schaeffer Center for Healthcare Policy at USC

Seth Trueger, Assistant Professor of Emergency Medicine, Northwestern University; Digital Media Editor, JAMA Network Open 

Dave A. Chokshi, Chief Population Health Officer, NYC Health + Hospitals

Albert Icksang Ko, Professor of Epidemiology and Medicine and Chair, Department of Epidemiology of Microbial Diseases, Yale School of Public Health

Donald M. Berwick, Former Administrator of the Centers for Medicare and Medicaid Services; President Emeritus and Senior Fellow, Institute for Healthcare Improvement 

Leana S. Wen, Former Health Commissioner for City of Baltimore; Visiting Professor, Health Policy and Management, George Washington University School of Public Health

Ezekiel J. Emanuel, Former Special Advisor for Health Policy to Director of White House Office of Management and Budget; Vice Provost for Global Initiatives; Chair, Department of Medical Ethics and Health Policy at the University of Pennsylvania

Benjamin K. Chu, Former President of NYC Health + Hospitals; Former Acting Commissioner of Health for the New York City Department of Health; Senior Advisor, Manatt Health

Bruce Lesley, Former Senior Health Policy Advisor on the Senate Finance and Health, Education, Labor, and Pensions Committees; President, First Focus

Alice Chen, Co-Founder and Former Executive Director, Doctors for America  

Aaron Kesselheim, Professor of Medicine and Director, Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics of Harvard Medical School and Brigham and Women's Hospital

Neel Shah, Founder, Costs of Care; Director, Delivery Decisions Initiative at Ariadne Labs; Assistant Professor of Obstetrics and Gynecology, Harvard Medical School

Abdul El-Sayed, Former Executive Director of the Detroit Health Department and Health Officer for the City of Detroit

Gretchen Berland, MacArthur Fellow; Associate Professor of Medicine, Yale School of Medicine 

Helen Burstin, Executive Vice President and Chief Executive Officer, Council of Medical Specialty Societies

Jeremiah Schuur, Chair and Physician-in-Chief, Department of Emergency Medicine,The Warren Alpert Medical School of Brown University; Founding Chief, Division of Health Policy Translation, Department of Emergency Medicine, Brigham and Women’s Hospital

Linda DeGutis, Former Director of National Center for Injury Prevention and Control at the Centers for Disease Control; Executive Director, Defense Health Horizons; Adjunct Professor, Rollins School of Public Health, Emory University

Cary P. Gross, Professor of Medicine (General Medicine) and of Epidemiology (Chronic Diseases); Founder and Director, Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine

Edison Machado, Senior Vice President, American Health Quality Association 

Laurie Zephyrin, Vice President, Delivery System Reform, The Commonwealth Fund; Former Acting Deputy Under Secretary for Health for Community Care and National Director of the Reproductive Health Program at the Department of Veterans Affairs

Eric Topol, Founder and Director, Scripps Research Translational Institute

Asaf Bitton, Executive Director, Ariadne Labs; Former Senior Advisor to Centers for Medicare and Medicaid Innovation

Saad Omer, Director, Yale Institute for Global Health; Associate Dean (Global Health Research), Yale School of Medicine; Professor of Medicine (Infectious Diseases), Yale School of Medicine; Susan Dwight Bliss Professor of Epidemiology of Microbial Diseases, Yale School of Public Health

Complete and growing list of supporters is being updated here.