Senate Democrats will release legislation as soon as Thursday to meet President Joe Biden‘s promise to expand in-home care for the elderly and disabled while boosting caregivers’ wages and unionizing opportunities, according to a draft bill obtained by Bloomberg Law.

States would implement the proposal using a major influx of federal funding through Medicaid. The bill would condition the funds on states’ ability to shift people to home-based care from nursing homes, recruit and train more home health workers, provide caregiver pay increases, and establish oversight capacity. 

The bill’s goal is to deliver on Biden’s pledge—from the “human capital” portion of his infrastructure plan—to put $400 billion toward reducing the sizable waiting lists facing those who wish to receive support in their homes instead of in institutional settings, and also to improve the quality of life for a predominantly female, minority workforce. 

Congress would initially authorize $100 billion for state grants, but the ultimate price tag may wind up much higher, depending on how many states elect to participate.

Sources briefed on the legislation said the draft is in near-final form ahead of its official introduction, tentatively planned for Thursday. It offers the first-known details of a critical piece of a package Democratic lawmakers aim to pass this year using the budget reconciliation process, which would avoid the need for Republican votes in the Senate. 

The bill was drafted with the intention of meeting reconciliation rules, but it remains to be seen whether it’s actually in compliance, as determined by the Senate parliamentarian. Reconciliation can only be used for provisions with budget effects that are more than just incidental, among other requirements.

The bill’s architect and lead sponsor, Sen. Bob Casey (D-Pa.), briefed his caucus on the details Tuesday, along with Senate Majority Leader Chuck Schumer (D-N.Y.) and Senate Finance Chair Ron Wyden (D-Ore.), said three sources familiar with the process. 

Worker Raises, Recruitment

Under the legislation, states could receive grants to create plans for expanding their home-based services and boosting worker pay. If approved, the federal government would pay up to 90% of the costs for implementing those plans.

States would have flexibility in designing their programs to revamp their home- and community-based care systems, but would need to prove they have achieved outcomes related to home-care service availability, worker raises, and recruitment and retention of enough in-home aides to meet demand. States could also get funds to continue programs to expand home health started this year using funds from a Covid-19 relief law enacted in February (Public Law 117-2).

Officials Lay Out Rules for Expanding Medicaid’s Home-Based Care

States could apply for an additional 2% bump in federal Medicaid dollars if they establish an oversight entity to administer a program for “self-directed care,” which lets those receiving care customize their plan without involving an outside employer agency. 

Among the oversight entity’s mandates: registering qualified caregivers and connecting them to beneficiaries; recruiting and training workers; and ensuring that the program policies are cooperative with home-care worker labor unions—either when it comes to bargaining with existing unions or remaining neutral in the face of a union organizing drive. 

This final prong is geared toward meeting demands of the Service Employees International Union, which represents some 740,000 home-care workers and has been lobbying for inclusion of robust home care funding in an infrastructure package. 

Congressional Negotiations

The draft is the product of months of negotiations between congressional lawmakers and a broad range of constituents in the aging, disability, and labor communities. 

Republicans, some of whom are separately trying to reach a narrower bipartisan deal focused on roads, bridges, and other physical repairs, have resisted the arguments from Democrats and worker advocates that home care investments belong in an infrastructure bill. That’s an obstacle shaping Democrats’ preference for the go-it-alone strategy in a budget reconciliation measure.

“We’re working with reconciliation, and we have got a broad but somewhat unique coalition in the disability community. We have AARP, SEIU,” Casey said in a June 10 interview. “It’s a pretty broad coalition that hasn’t always been on the same page.”

Read AHA Letter

The American Hospital Association flipped on Tuesday (June 23) from praising HHS’ revised provider relief guidance to saying the phased spending deadlines are unfair and HHS should give all hospitals more time to spend their relief funds — either until the end of the public health emergency or until June 30, 2022, the final spending deadline currently set for only new recipients in HHS’ latest guidance.

HHS’ phased provider relief spending deadline strikes a balance between providers who finally received their relief after waiting months to get it and those who received and immediately spent their relief. While hospitals and other providers support the new guidance broadly, AHA points out advocates had asked for all providers to receive an extension.

AHA, the Medical Group Management Association and lawmakers had earlier asked HHS to tie the spending deadline to the public health emergency, which the Biden administration has indicated could last the entirety of 2021. Nursing homes had asked HHS to extend the June 30 spending deadline to Dec. 30, 2022. Providers said the additional time was necessary as providers have on-going costs related to the pandemic.

HHS stopped short of a complete extension of the June 30 spending deadline in its guidance released June 11. The department instead created four provider relief payments periods, giving providers one year to spend all their relief.

This means the upcoming deadline of June 30 applies to distributions received from April 10, 2020 to June 30, 2020. The next deadline of Dec. 31 applies to monies received July 1, 2020 to Dec. 31, 2020, and next year’s June 30 spending deadline will be for the period Jan. 1 to June 30.

AHA initially cheered HHS’ new guidance like other advocates, but in its letter to HHS Tuesday (June 22) raises concerns that the phased spending deadline is unfair for rural hospitals and hospitals serving high numbers of Medicaid and uninsured patients.

“While we had previously requested an extension and appreciate HHS’ action, we believe that providing additional flexibility is necessary, fair and appropriate,” AHA says, arguing the new guidance disadvantages certain providers without giving a clear reason. “Specifically, some providers will need to spend their funds well before others simply because they received a [provider relief] payment earlier in the distribution process.”

The AHA letter points out what Inside Health Policy previously reported that HHS began distributing a large chunk of the $178 billion provider relief fund early on. The first general distribution was set at $46 billion, while $20 billion in targeted relief for hospitals in so-called hot spots, $13 billion for safety net hospitals and $11 billion for rural facilities were all announced and distributed before June 30, 2020.

The other general and targeted distributions, including the problematic second general distribution, went to providers no earlier than July 3, 2020, according to the Government Accountability Office. HHS is still distributing provider relief.

AHA also raises concerns that some providers won’t be able to use provider relief to address the added costs that will go along with the new Occupational Safety and Health Administration Emergency Temporary Standards, which require certain health care employers to implement a plan that addresses COVID-19 hazards in the workplace.

Some providers think the presence of a fourth payment period in the newly released HHS guidance means the next provider relief distribution will be announced in July.

The last distribution was announced in October, and there is an estimated $24 billion left in unallocated provider relief.

“I think the FAQs that were released this time, in my opinion, look a lot more complete,” Donna Martin, American Network of Community Options and Resources director of state partnerships & special projects, said. “It looks like they’ve got a year’s worth of kind of managing these portals, dealing with both the technical side and the understanding — making it understandable by people that received those funds.”

This is a significant step as previous guidance seemed to change daily and at one point, Congress had to step in to clarify how it wanted HHS to let providers calculate their lost revenue due to COVID-19.

While AHA says additional spending flexibility is needed, some providers are praising the new HHS guidance.

One of those is a Pennsylvania provider that will benefit from the guidance’s final spending deadline. SPIN Inc., which serves children and adults with intellectual and developmental disabilities, waited eight months — July 15, 2020, until March 8 — to receive its $1.47 million in provider relief. It will have until June 30, 2022, to spend all this relief.

In the meantime, SPIN furloughed or cut administrative staff while using state COVID-19 relief to give its low-paid, direct care staff hazard pay and overtime.

“SPIN is a provider in an historically underfunded system in which we have struggled to pay Direct Support Professionals the wages that they deserve,” Patti Parisi, SPIN, Inc. chief financial officer, said in an email. “Due to the COVID-19 pandemic, we are now experiencing an unprecedented level of employee vacancies.”

Parisi said SPIN needs additional COVID-19 relief so it can pay a family-sustaining wage to recruit and retain its direct care staff. It will also need better state reimbursement rates so it can sustain the higher, more competitive wages into the future and stabilize a fragile system.

Northern Nevada Emergency Physicians, which received $801,139 in total from initial provider relief distributions, according to HHS, welcomed the clarity offered by the new guidance. Karen Massey, the organization’s executive director, said every piece of guidance providers receive creates certainty and stability.

“Understanding the final disposition of [provider relief] and all these programs allows us to demonstrate the appropriate use of these funds for taxpayer transparency and remove any uncertainty about our ability to retain the funds,” Massey said in an email. “This allows medical practices to pivot to these new challenges with the financial certainty we need to serve our patients through hiring staff, investing in technology and maintain the new level of care required by COVID-19.”

Massey said in addition to helping providers pay for personal protective equipment, COVID-19-positive patients and testing supplies, provider relief offered financial stability when there was very little certainty in business operations.

“For most medical practices, there was this odd dichotomy of seeing substantially reduced volume, yet knowing that there was pent-up demand from the routine conditions we care for, and also new challenges of COVID-19,” Massey said.

Michael Strazzella, Buchanan, Ingersoll and Rooney federal government relations leader, said HHS might not have given providers everything they asked for, but the new timeline gives them the needed stability to rebuild and plan what their post-COVID-19 normal will look like.

“While the community was asking for the June 30 date to be moved, they [HHS] did address other pieces of it and there are other benchmarks to now be used,” Strazzella said. “In many ways, they have responded to the community’s concerns.” — Dorothy Mills-Gregg (dmillsgregg@iwpnews.com)

Senate Finance Committee Chair Ron Wyden has released a document outlining “legislative principles” for controlling drug prices.

The major provisions include: Medicare price negotiation and inflation rebates, giving commercial insurers the same drug prices that Medicare negotiates, blocking a Trump-era ban on rebates, and tailoring policies to protect small biotechnology companies.

The bill also will include cost-saving measures for Medicare beneficiaries, which both parties want. Legislation from 2019 in both the House and Senate called for restructuring the Part D benefit to cap beneficiaries’ annual out-of-pocket spending and reduce the government’s responsibility for catastrophic costs.

Senate Finance Committee: Principles for Drug Pricing Reform

Wyden Releases Principles For Lowering Drug Prices for Americans

Physician Workforce: Caps on Medicare-Funded Graduate Medical Education at Teaching Hospitals

Before physicians practice medicine independently, they receive on-the-job training as residents in teaching hospitals. These residents are vital providers of health care during their training, and many stay in the geographic area to practice after their training is completed.

Medicare pays these hospitals to offset some of the costs of training physician residents. For most hospitals, Medicare caps the number of residents it will fund per hospital based on how many residents it funded in 1996.

We found that 70% of hospitals trained more residents than Medicare funded—indicating they can train more physicians now than when these caps were set.

Read the report.

Reps. Van Drew, Smith, Pascrell, Payne and nearly 100 other House members sent a letter to HHS and the Treasury urging that their rulemaking for the No Surprises Act reflect congressional intent for a balanced process to settle payment disputes between health plans and providers.

See the letter here

Reps. Liz Cheney (R-Wyo.) and Debbie Dingell (D-Mich.) are introducing legislation today to make it easier for older adults to access telehealth services. The bill, shared first with PULSE, would codify new telehealth flexibilities for Medicare beneficiaries granted during the pandemic.

Providers would be allowed to deliver telehealth services to patients in their homes regardless of what part of the country they live in, and would permanently allow Medicare to pay for doctor’s visits via audio-only phone calls, rather than requiring a video component for every call.

Temple University Hospital lost a bid to challenge its reassignment to a lower-paid geographic area for purposes of calculating its Medicare payments because it didn’t pursue an administrative action first, the Third Circuit said.

The Medicare Act requires hospitals objecting to their operating cost reimbursements to present their claims to the Provider Reimbursement Review Board, the U.S. Court of Appeals for the Third Circuit said. 

The provision works in tandem with the Social Security Act’s jurisdiction-stripping section, which precludes courts from hearing claims for reimbursement “arising under” the Medicare Act unless they’ve been through the agency’s appeals process, the court said.

Together, the provisions create a channeling requirement that operates as a “near-absolute bar” to the court’s authority to hear cases arising under the Medicare Act that haven’t first been presented to the U.S. Health and Human Services Department, the court said.

Medicare repays hospitals for certain operating costs, including wages. The wage index varies based on the geographic area to which a hospital is assigned to reflect the prevailing wages in that area.

In February 2020, Temple secured reassignment to a geographic classification that upgraded its wage index to that for New York City, thereby increasing its reimbursements. 

Temple’s reclassification was supposed to be in effect from 2021 to 2023, but HHS redrew the borders and reassigned the hospital to a new, lower-paid geographic area. The hospital sued, arguing HHS improperly withdrew its New York City wage index classification.

A federal district court entered judgment for HHS. The reclassification decision deserved deference, it said.

The Third Circuit vacated the judgment and sent the case back to the district court for dismissal Monday. The federal court lacked subject matter jurisdiction because Temple hadn’t first filed its objections with the PRRB, it said.

Judge Peter J. Phipps wrote the opinion. Judges Richard L. Nygaard and Jane R. Roth joined. 

Joseph D. Glazer, Princeton, N.J., represented Temple. The U.S. Department of Justice represented HHS.

The case is Temple Univ. Hosp., Inc. v. Secretary, U.S. Dep’t of Health & Human Servs., 2021 BL 230209, 3d Cir., No. 21-1293, 6/21/21.

President Joe Biden’s plan for trillions of dollars in proposed spending and tax increases is entering a procedural and political thicket in Congress that’s likely to take at least until September to clear.

If all goes according to plan for Biden and Senate Majority Leader Chuck Schumer, the Senate would pass a bipartisan infrastructure deal next month as well as a budget blueprint that sets up a vote later on a far larger bill with trillions in social spending paid for in large part by tax hikes on the wealthy and corporations. The budget bill could be passed with only Democratic votes in the Senate.

But progressive Democrats in the House and Senate say they may not back an infrastructure package that includes concessions to Republicans without a guarantee that their priorities — on climate, health care and social welfare — will be accommodated in follow-up budget legislation. At the same time, moderate Democrats like Senator Joe Manchin of West Virginia are so far refusing to commit to supporting a massive spending bill that would be passed on a party-line vote.

Here’s how the Democrats’ two-track strategy is likely to unfold:

Work Remains on Bipartisan Infrastructure Deal

A bipartisan group now numbering 21 senators — 11 Republicans, nine Democrats and one independent — still has to hash out the final details of their infrastructure proposal and negotiate with the White House. A sticking point is a proposal that was part of a preliminary outline to partly offset the cost by indexing the federal gasoline tax to inflation.

The White House on Friday reiterated its opposition to raising the gas tax, and some of the Democrats in the group said that piece remains in flux. The outline released last week leaves it up to Biden to offer an alternative, but Republicans have rejected raising income taxes on the wealthy or corporations. The White House last week suggested increased tax enforcement on the wealthy as an alternative, according to a White House official.

No Guarantees Even if Agreement is Reached

Even if a deal is hammered out, written and put on the Senate floor shortly after lawmakers return from their July 4th break, passage isn’t a slam dunk. A number of Democrats are opposed to how it would be paid for and complain that it lacks sufficient steps to address climate change. That could mean the bipartisan group and the White House will have to hunt for more Republicans in order to get the 60 votes needed to overcome a filibuster.

If the Senate passes the package, the House would then become critically important as a backstop for liberals. Representative Alexandria Ocasio-Cortez of New York said recently the House could hold up final passage of a bipartisan infrastructure package until a larger Democratic plan passes the Senate, and vote on both at approximately the same time. A similar tactic was used by Speaker Nancy Pelosi to pass the Senate version of the Affordable Care Act and an accompanying reconciliation package on the same day in March 2010.

A Budget Plan to Set Up Spending Bill

In order to get the remainder of Biden’s $4 trillion in jobs and family proposals across the finish line, Democrats in the House and Senate will first have to pass a budget resolution that would tee up follow-on legislation with the rest of Biden’s agenda. That would allow them to fast-track the bill through the Senate with a simple majority vote — a procedural tactic known as reconciliation — bypassing any Republican effort to block it with a filibuster.

House Budget Committee Chairman John Yarmuth plans to work on a budget blueprint the week of July 12. Senate Budget Committee Chairman Bernie Sanders has not yet set a date for his committee to begin work. He told reporters last week that he wants a $6 trillion package, though several moderates have balked at that figure.

Democrats will have to agree on a limit over how much the so-called reconciliation package can add to the deficit. They will also have to agree on topline spending levels for regular appropriations and are expected to provide for an increase in the debt limit later this year as well.

The Final Push for a Comprehensive Bill

It could take Democrats months to draft what is now likely to be one massive package jammed with as much of Biden’s economic agenda as they can get all 50 senators who caucus with Democrats and a House majority to approve.

But the fast-track process for bypassing filibusters is subject to arcane rules on what can be included informally ruled over by the parliamentarian. Items have to relate to the budget to qualify.

And the bill also is wide open to amendments. Senate Republicans will be able to offer changes designed to either try and split Democrats or pile up difficult votes that they plan to exploit in next year’s midterm elections. That process took a 25-hour marathon of votes when the Senate passed Biden’s $1.9 trillion coronavirus relief bill in March.

Democrats Have a Slim Margin of Error

Any Democratic absence or defection in the 50-50 Senate could delay or even kill the bill. In the House, Democrats can’t afford to lose more than four votes.

Every progressive interest group and faction will be pushing to attach their favored legislation on topics as varied as curbing climate change, slicing prescription drug prices, expanding Medicare and adding a path to citizenship for unauthorized immigrants. Lobbyists for affected industries and the wealthy will be seeking carve-outs or to kill the package entirely.

And Democrats are not yet united behind Biden’s tax increases. Some want to revive the full state and local tax deduction — a pricey item that would primarily benefit the wealthy that the White House has not yet proposed — while others oppose Biden’s proposal to tax unrealized capital gains at death in excess of $1 million.

Read More: Biden Rebuff on Gas Tax Casts Doubt on Infrastructure Deal

A move to accommodate one faction’s concerns would shrink the money available for spending somewhere else.

The longer the process drags on, the closer the 2022 midterm elections, potentially making lawmakers more reluctant to take tough votes. Democrats like Schumer are wary of a repeat of the Affordable Care Act battle in 2009 and 2010, which took months longer than they hoped in part because of failed bipartisan talks, while issues like climate and immigration languished. That was followed by a massive Republican wave in the 2010 midterm elections

–With assistance from Erik Wasson and Laura Litvan.

To contact the reporter on this story:
Steven T. Dennis in Washington at sdennis17@bloomberg.net

Hospital admissions declined precipitously in the early months of the pandemic, as providers cut down on elective procedures and many patients stayed away for fear of the virus, but by summer 2020 they were at 90 percent of levels in previous years. By the end of last year, overall health spending was up 3.4 percent compared to 2019.

An analysis from Kaufman Hall found that hospital operating margins rose by more than 100 percent between April 2020, at the start of the pandemic, and April 2021. The report noted, however, that hospitals have seen a big increase in expenses, and margins remain thin.

Ge Bai, an expert on health-care finance at Johns Hopkins, questioned whether the extension on funding this late in the game was a good use of taxpayer money.

“Right now, the hospitals have already resumed their normal operations, and most of the hospitals are capable of overcoming short-term financial difficulty,” Bai said.

Some hospitals have reaped large profits. 

Between a faster-than-expected recovery in patient volumes and an influx in funding, some big hospital systems found themselves flush with cash during the pandemic.

HCA Healthcare, one of the nation’s largest hospital chains, finished 2020 with increased profits compared to the previous year. The health-care giant ended up returning $6 billion in relief from the government.

Other wealthy hospitals such as Baylor Scott & White Health, the largest nonprofit hospital system in Texas; Mayo Clinic; Pittsburgh’s UPMC; and NYU Langone Health all recorded hundreds of millions in surpluses, according to a Kaiser Health News report.https://30472cc52713179365a86f069617ac1b.safeframe.googlesyndication.com/safeframe/1-0-38/html/container.html

A Kaufman Hall report found that with the federal funding, the hospital operating margins were 2.7 percent. Without funding, they would have been 0.3 percent.

Yet hospitals still petitioned the federal government for an extension to apply for relief money.

Hospitals and other providers were told that they needed to use their coronavirus relief money by June 30, but under pressure from industry and lawmakers, the Biden administration announced earlier this month changes that will allow more time to most providers who received money after June 30, 2020.

Some providers say the extension was necessary given burdensome reporting requirements and delays from HHS in getting funds out the door.The administration is facing pressures from lawmakers to get money out quickly but also provide more oversight. The agency has yet to distribute about $24 billion from the original allocation.

HHS Secretary Xavier Becerra told Congress last month that the administration would work on ensuring “the money goes to those who need it most.”

The hospital industry welcomed the extension.

Rick Pollack, the president of the American Hospital Association, welcomed extra time, calling the relief money a “lifeline” and pointing out that the nation’s hospitals are continuing to respond to thousands of new cases a day.

“Hospitals and health systems continue to incur expenses related to these COVID-19 cases and hospitalizations, such as ensuring an adequate workforce, acquiring equipment and supplies such as personal protective equipment, pharmaceuticals and safety equipment, administering vaccines and maintaining testing and additional screening for patients and visitors,” Pollack said.

But some say the relief funds weren’t distributed evenly.

HHS is facing scrutiny over the $178 billion relief effort, which often favored larger and wealthier providers.

A February report from a congressional advisory commission found that fewer than 1 in 5 providers who accept payment from Medicaid and the Children’s Health Insurance Program, the safety-net insurance for children, but not Medicare have received relief funds. The report found that many pediatric and behavioral health providers were left out of relief funding.

Many hospitals that are smaller, poorer or more rural also face bleak financial prospects after the pandemic. Some of these struggling hospitals have been scooped up by larger, more successful hospitals over the past year. The trend worries experts and lawmakers who say that coronavirus relief to large hospitals was never meant to fuel increased hospital consolidation.

Critics point to HHS’s formula for distributing funds, especially early in the pandemic, as one reason for the uneven recovery. 

The first $46 billion of relief from the Cares Act targeted funding based on patient revenue. This advantaged hospitals with a greater share of privately insured patients and hurt providers that serve large numbers of uninsured or Medicaid patients. 

Experts say that HHS used this formula because it was a way to get initial funds out quickly.

“There was a lot of pressure to get money out the door, and this was the fastest way for the federal government to do that,” said Tricia Neuman, the director of the Kaiser Family Foundation’s Medicare program.

But it came with drawbacks. A Kaiser Family Foundation study found that the hospitals with the greatest share of private insurance revenue received more than double the federal relief funding compared to those where private insurance made up little of overall revenue. 

While later allocations did more to target funding toward safety-net and rural hospitals, Bai points out that well-resourced hospitals and larger systems were often still at an advantage with policy teams, lawyers and other resources to apply for grants.

“Eventually we have a winner-take-all situation, meaning that if you are larger, you get more. If you’re smaller you get less,” Bai said.

The HHS’ 2020 advisory opinion calling on pharmaceutical companies participating in the government’s 340B program to deliver drugs purchased by health centers to their contract pharmacies has been withdrawn in the “interest of avoiding confusion and unnecessary litigation,” the agency said in a June 18 court filing.

The withdrawal, however, “does not impact the ongoing efforts” to hold individual drugmakers accountable for limiting discounts, the HHS said in the filing.

The department’s rescinding of the advisory opinion follows lawsuits from drugmakers like AstraZeneca Pharma LP, Eli Lilly and Co., and Sanofi Aventis U.S. LLC that challenged the opinion, and it marks a blow to low-income health providers who allege they’re being cut off from discounts.

The HHS in Mary determined those drugmakers and others violated federal law by restricting discounts to covered entities via arrangements with contract pharmacies, and that they must immediately offer price cuts.

The HHS in Friday’s filing said this “enforcement process” functions “independently from the Opinion’s withdrawal.”

The advisory opinion on June 16 suffered another setback in AstraZeneca’s lawsuit. The U.S. District Court for the District of Delaware ruled that the HHS opinion was flawed and not the only way to view the law governing the 340B program.

However, the court declined to cut the advisory opinion down outright, allowing the HHS and the drugmaker to weigh in before the next move.

The HHS said it disagrees with the decision in the AstraZeneca case but is nevertheless withdrawing the opinion.

The case is Sanofi-Aventis U.S., LLC v. United States Dep’t of Health & Human Servs., D.N.J., No. 21-cv-00634, Notice 6/18/21.

To contact the reporter on this story: Ian Lopez in Washington at ilopez@bloomberglaw.com

The public option insurance plan has fallen off the national radar, despite being a major point of contention between moderates and progressives just a year ago during President Biden‘s campaign.

But rather than holding Biden’s feet to the fire on the issue, progressives are concentrating on other health care priorities, like ensuring drug pricing reform and expanded Medicare are included in a massive infrastructure package.

“Crafting a public option is much more difficult than lowering the Medicare eligibility age and expanding benefits,” said Rep. Pramila Jayapal (D-Wash.), chairwoman of the Congressional Progressive.

“That’s where we are going to focus our attention at this moment. That doesn’t mean we’ve given up on the rest of the pieces. But I do think at this moment what we can immediately do is lower the Medicare eligibility age, add benefits and address prescription drug pricing,” Jayapal said.

Biden’s time in office has been consumed primarily with responding to the coronavirus pandemic, and the window to enact other parts of his ambitious agenda, like infrastructure, is now rapidly closing.

Outside advocates and Democrats say they haven’t given up on pursuing a government-run health care plan, but there’s an acknowledgement that a lot of legislative legwork is needed on that front.

Last month, Sen. Patty Murray (D-Wash.) and Rep. Frank Pallone Jr. (D-N.J.), who are in charge of health committees in their respective chambers, announced their intention to craft a public option bill.

Their process is just getting started, and there are numerous competing ideas on what a public option should look like at the national level. Pallone and Murray asked for feedback from key stakeholder groups, as well as the general public, on some of the most basic but thorny questions.

Frederick Isasi, executive director of the liberal advocacy group Families USA, said that while a public option remains important, he wants to focus on items that might be able to pass quickly.

“The No. 1 question for us is what can we get done to move the ball forward? Our window for doing that congressionally is not very long. It’s a matter of a few more months to tee things up before we hit next year’s cycle,” Isasi said.

“The most important question is what is achievable, what is real, and significant? This is not the drawing board phase for the things that will be happening this year,” he added.

Rep. Jan Schakowsky (D-Ill.) said Democrats are largely focused on passing H.R. 3, the sweeping drug pricing bill backed by Democratic leadership.

“I think it’s definitely more a conversation about drug pricing right now than about a public option. The personnel decides, and the Speaker decides. If this is an immediate issue, it will be,” she told The Hill.

Former President Obama abandoned the public option when drafting the Affordable Care Act (ACA) in order to secure the needed votes from moderate Democrats, to the outrage of progressives.

Biden campaigned on creating a public option, touting it as a way to reduce costs without completely ending private insurance, in contrast to “Medicare for All.” The Medicare-like government insurance plan backed by Biden would be sold on ObamaCare’s marketplaces.

Biden said his proposal would cost $800 billion, as opposed to the estimated $32 trillion to enact Medicare for All.

But while the president’s $6 trillion budget unveiled last month expressed support for creating a public option, it was not included in the funding request.

“I think you have to, you have to choose your battles, and I don’t quibble with the fact that the administration made the decision to prioritize COVID relief and infrastructure. I think that’s probably the right way to go,” Sen. Chris Murphy (D-Conn.) told The Hill.

Murphy said without a push from the White House, it may be difficult to build momentum behind a public option, especially since most of the health care industry opposes any kind of government-run insurance plan.

Health care companies argue a public option would not reimburse providers enough, and would pull customers away from traditional insurance plans by offering cheaper premiums.

Still, Murphy said he thinks it would be easier to sell Americans on the benefits of a public option than it was to promote ObamaCare.https://f67e4b9973a8a8eadf7b38afca45852e.safeframe.googlesyndication.com/safeframe/1-0-38/html/container.html

“The ACA was hard to understand. It was complicated. Worthwhile, but complicated. A public option — everybody should have the ability to buy a Medicare plan if they want. It’s really easy to message,” Murphy said.

Some progressives have never fully embraced a public option the way they did Medicare for All, because a public option would not abolish private insurance. Those lawmakers see expansions of health coverage as a stepping stone to Medicare for All.

House and Senate Democrats are currently eyeing a $6 trillion reconciliation proposal that would advance Biden’s infrastructure agenda and include lowering Medicare’s eligibility age to 60, broadening the program’s benefits to include vision, dental and hearing, and reducing the cost of prescription drugs.

“Most of the progressives believe that ultimately we should have a strengthened Medicare for All, and the steps that will get us there are the most important. And that’s why you see us prioritize the expansion of Medicare and the strengthening of Medicare,” said Rep. Ro Khanna (D-Calif.).

“Though we would vote for a public option,” Khanna added.

WSC Brief – PRF Spending and Reporting Extension – 6.15.21

The U.S. health-care law known as Obamacare spent its first decade dodging a series of existential risks. By a single vote in the Senate, the law survived a repeal attempt in 2017 pushed by then-President Donald Trump. The Supreme Court shut down the latest challenge in a 7-2 decision that denied Republican states’ challenge to the law’s constitutionality. Joe Biden’s presidency could give Obamacare (more formally, the Affordable Care Act) a chance to grow beyond its initial scope. Biden pushed for the law as vice president under President Barack Obama.

1. How much of Obamacare survived under Trump?

Most of it, including tax subsidies to help people afford coverage and, in 39 states (including the District of Columbia), expanded eligibility for Medicaid, the U.S. health insurance program for low-income Americans. Key Obamacare consumer protections that also remain in place allow children to stay on a parent’s policy until age 26, require insurance companies to treat people with preexisting conditions equally and prohibit the imposition of annual or lifetime coverage limits.

2. How many Americans are covered because of Obamacare?

Roughly 20 million. About half joined Medicaid as a result of the expanded eligibility. The rest found coverage by comparison-shopping among private insurers at government-run online marketplaces, where subsidies help people afford coverage. (The expanded version of Medicaid enrolls most adults earning up to 138% of the poverty line.) Even with Obamacare in place, 28.9 million Americans lacked coverage in 2019, two million more than in 2016, according to the Kaiser Family Foundation. The U.S. is an outlier among developed countries by not having universal health coverage.

3. Which parts have been eliminated?

Obamacare originally required all states to participate in the expanded Medicaid program; the Supreme Court, in a 2012 split ruling that upheld most of the law, struck down the requirement. The law as written also required all Americans to buy health insurance — the so-called individual mandate — at risk of a tax penalty. The Trump administration whittled away at Obamacare with executive actions, including one that cut funding for so-called navigator programs that help sign people up. A tax overhaul passed by Republicans and signed by Trump in 2017 eliminated the penalty for noncompliance, rendering the mandate moot. That paved the way for the broader constitutional challenge to the law that the Supreme Court rejected in June.

4. What did Biden promise to do about Obamacare?

He campaigned on a pledge to expand the program by offering a government-provided alternative to private insurance that’s known as a public option, a proposal he’s called “Bidencare.” It would be available to all Americans, including those who get their insurance through work. Low-income Americans would be automatically enrolled and, if eligible, their premiums would be free. Though he hasn’t released further details since taking office, his plan set him apart from the progressive wing of the Democratic party, which has pushed the idea of achieving universal coverage by scrapping private insurance and replacing it with “Medicare for All.”

5. What’s he done?

He reopened the federal Healthcare.gov market from Feb. 15 to Aug. 15, allowing more people who are uninsured during the pandemic to sign up for health coverage. Biden’s fellow Democrats in Congress passed a $1.9 trillion Covid-19 relief package that increased Obamacare subsidies for two years and offered more money to the 12 states that haven’t expanded Medicaid if they start covering the law’s newly eligible adult population. Democrats may look to make some of those changes permanent.

6. Is Obamacare viable for the long term in its current state?

Some economists worry about a “death spiral” of rising costs in the absence of a mechanism, like the individual mandate, that forces healthy Americans to get covered, since healthier people buying coverage keeps costs down for sick people. That’s one issue. Another is the limited coverage options available to Americans in rural and remote parts of the country. And in the mostly Republican-led states where elected leaders have declined to expand Medicaid eligibility, many residents fall in a coverage gap, earning just enough income that they don’t qualify for subsidies.

7. Do Americans want Obamacare to stay or go?

U.S. public opinion of the law was mostly negative from its passage in March 2010 until Trump became president and sought to repeal it, according to tracking surveys by the Kaiser Family Foundation. The threat of elimination — which failed when the late Senator John McCain of Arizona gave a memorable thumbs down in an early morning vote in 2017 — put a spotlight on popular provisions of the law, notably its prohibition on insurers charging sick people more for coverage and its list of “essential health benefits,” like hospitalization and maternity care, that must be covered. Kaiser’s tracking survey found in May that 53% of Americans viewed the law favorably, while 35% viewed it unfavorably.