At a moment when anxiety over coronavirus is paramount, it is worth noting on the Affordable Care Act’s tenth anniversary that it will provide important coverage and access protections in this pivotal moment. The ACA still has its critics and challenges, but this would be the worst time to pull out a substantial health care safety net or consider a replacement.

The ACA has increased coverage through an expansion of Medicaid eligibility and new subsidies and standards for private insurance (Figure 1) that have led to about 19 million fewer people lacking coverage in 2018 compared to 2010. As the coronavirus outbreak puts pressure on the economy and there is likely a coming recession, the ACA will provide additional coverage options for those losing their jobs or experiencing large declines in income. This would be the first recession since the ACA was implemented, and the health law will provide a safety net that never existed before for those losing job-based health insurance. The ACA also includes new private insurance standards that were designed to ensure that health insurance provides meaningful access to care. At the same time, gaps in the U.S. health insurance system remain. While the number of uninsured has declined, 27.9 million people in the United States still lack health insurance.

Even as the ACA has reshaped the health insurance coverage landscape and a clear majority (55%) of the public now views the law favorably, the law’s future is still uncertain. Later this year the Supreme Court is scheduled to hear arguments in California v. Texas (known as Texas v. U.S. in the lower courts). This ongoing litigation, supported by the Trump administration, challenges the ACA’s individual mandate and raises questions about the entire law’s survival.

If all or most of the law ultimately is struck down, it will have complex and far-reaching consequences and potentially eliminate many of the ACA provisions that would otherwise help some individuals avoid becoming uninsured due to the economic upheaval caused by the coronavirus pandemic.

For now, the ACA is the law of the land and is poised to help many people remain insured. However, access and affordability challenges remain for those with private insurance, including high deductibles, and some will be unable to qualify for Medicaid because they live in a state that has not expanded the program. Nationally, more than two million poor uninsured adults fall into the “coverage gap” that results from state decisions not to expand Medicaid, meaning their income is above current Medicaid eligibility but below the lower limit for Marketplace premium tax credits.

Gaps in private coverage remain as well, and deductibles and high coinsurance and copays are a hurdle for many and could lead to substantial out-of-pocket costs from a serious illness resulting from coronavirus infection. Additionally, balance billing from out of network claims—including surprise medical bills—can leave patients facing thousands in unexpected costs and do not count towards the annual maximum on out-of-pocket costs included in the ACA. A new analysis finds that nearly one in five (18%) patients hospitalized at in-network hospitals for pneumonia (one complication that can arise from COVID-19) incurred at least one out-of-network charge. Also, short-term health insurance and health sharing ministries are exempt from the ACA’s insurance standards and may not offer the comprehensive coverage that patients will need if they have complications from coronavirus. If affordability or coverage challenges lead to people delaying or forgoing care, it could have consequences for all of us.

However, despite the gaps, the ACA has led to improved access to care for millions in the United States. For a refresher on specific aspects of the law that will influence access and insurance coverage as our nation faces this new pandemic, see below for a link to a KFF resource on each topic.

• Medicaid expansion
• Individual Market Reforms, including marketplace subsidies and an end to medical underwriting
• Essential health benefit standard
• Dependent coverage up to age 26
• No lifetime or annual dollar limits
• Coverage of preventive services

At a moment when anxiety over coronavirus is paramount, it is worth noting on the Affordable Care Act’s tenth anniversary that it will provide important coverage and access protections in this pivotal moment.  The ACA still has its critics and challenges, but this would be the worst time to pull out a substantial health care safety net or consider a replacement.

The ACA has increased coverage through an expansion of Medicaid eligibility and new subsidies and standards for private insurance (Figure 1) that have led to about 19 million fewer people lacking coverage in 2018 compared to 2010.  As the coronavirus outbreak puts pressure on the economy and there is likely a coming recession,¹  the ACA will provide additional coverage options for those losing their jobs or experiencing large declines in income.  This would be the first recession since the ACA was implemented, and the health law will provide a safety net that never existed before for those losing job-based health insurance.  The ACA also includes new private insurance standards that were designed to ensure that health insurance provides meaningful access to care.  At the same time, gaps in the U.S. health insurance system remain.  While the number of uninsured has declined, 27.9 million people in the United States still lack health insurance.

Even as the ACA has reshaped the health insurance coverage landscape and a clear majority (55%) of the public now views the law favorably, the law’s future is still uncertain.  Later this year the Supreme Court is scheduled to hear arguments in California v. Texas²  (known as Texas v. U.S. in the lower courts). This ongoing litigation, supported by the Trump administration, challenges the ACA’s individual mandate and raises questions about the entire law’s survival.

If all or most of the law ultimately is struck down, it will have complex and far-reaching consequences and potentially eliminate many of the ACA provisions that would otherwise help some individuals avoid becoming uninsured due to the economic upheaval caused by the coronavirus pandemic.

For now, the ACA is the law of the land and is poised to help many people remain insured. However, access and affordability challenges remain for those with private insurance, including high deductibles, and some will be unable to qualify for Medicaid because they live in a state that has not expanded the program. Nationally, more than two million poor uninsured adults fall into the “coverage gap” that results from state decisions not to expand Medicaid, meaning their income is above current Medicaid eligibility but below the lower limit for Marketplace premium tax credits.

Gaps in private coverage remain as well, and deductibles and high coinsurance and copays are a hurdle for many and could lead to substantial out-of-pocket costs from a serious illness resulting from coronavirus infection.  Additionally, balance billing from out of network claims—including surprise medical bills—can leave patients facing thousands in unexpected costs and do not count towards the annual maximum on out-of-pocket costs included in the ACA.  A new analysis finds that nearly one in five (18%) patients hospitalized at in-network hospitals for pneumonia (one complication that can arise from COVID-19) incurred at least one out-of-network charge.  Also, short-term health insurance and health sharing ministries are exempt from the ACA’s insurance standards and may not offer the comprehensive coverage that patients will need if they have complications from coronavirus.  If affordability or coverage challenges lead to people delaying or forgoing care, it could have consequences for all of us.

However, despite the gaps, the ACA has led to improved access to care for millions in the United States.  For a refresher on specific aspects of the law that will influence access and insurance coverage as our nation faces this new pandemic, see below for a link to a KFF resource on each topic.

• Medicaid expansion
• Individual Market Reforms, including marketplace subsidies and an end to medical underwriting
• Essential health benefit standard
• Dependent coverage up to age 26
• No lifetime or annual dollar limits
• Coverage of preventive services

1. P.F. Gruenwald et al., “Economic Research: COVID-19 Macroeconomic Update: The Global Recession Is Here And Now,” S&P Global (March 17, 2020). ↩︎
2. No. 19-840, https://www.supremecourt.gov/search.aspx?filename=/docket/docketfiles/html/public/19-840.html. The case has been consolidated with Texas v. California, No. 19-1019, https://www.supremecourt.gov/search.aspx?filename=/docket/docketfiles/html/public/19-1019.html. ↩︎

Introduction

The emergence of the novel coronavirus and COVID-19, the illness it causes, has impacted the lives of nearly everyone. Without practically any advance notice or planning, schools have closed in many states, employees have been asked to work from home, those who cannot work from home face potential exposure to the coronavirus, reduced work hours, or job loss. For many women, particularly those with children at home, the coronavirus pandemic has given new urgency to many of the challenges that they have long been confronting. Women are more likely to be the primary caretakers and in charge of health care responsibilities in their families. This brief presents additional analysis of a recent KFF Coronavirus Poll, conducted between March 11 and 15, 2020 and finds larger shares of women are worrying about the negative consequences of the coronavirus and taking greater precautions than men.

More Women than Men Worry about Getting Sick and Losing Income

A larger share of women compared to men worry that they or someone in their family will get sick from the coronavirus (68% vs. 56%, respectively) and worry about losing income due to a workplace closure or reduced hours because of COVID-19 (50% vs. 42%, respectively) (Figure 1). A larger share of women compared to men also worry they would put themselves at risk of exposure to coronavirus because they can’t afford to stay home and miss work (39% and 31%, respectively). A larger share of women who were surveyed reported being part-time workers than men (13% v. 9%).  The new law, Families First Coronavirus Response Act, addresses cost sharing for COVID-19 testing, but treatment costs remain a concern. A larger share of women (40%) compared to men (31%) worry that they will not be able to afford testing or treatment for coronavirus if they need it.

Men and Women with Children More Worried about Consequences of Coronavirus

A larger share of women and men with children compared to women and men without children said they were worried about losing income because of COVID-19 and of being exposed to COVID-19 because they can’t stay home from work (Figure 2).  Since the survey was conducted, many daycares, schools, and workplaces have closed, and parents may have to stay home with their children and simultaneously work from home or find other arrangements for their children if they are still working.

Women more Likely than Men to Report Mental Health Effects from Worrying about Coronavirus

A larger share of women (16%) compared to men (11%) reported that they feel that worry or stress related to COVID-19 has had a major negative impact on their mental health. Nearly four in ten women (36%) and three in ten men (27%) feel that worry or stress related to coronavirus has had some impact on their mental health (Figure 3). Women, in general, are more likely to be diagnosed with anxiety and depression compared to men. For both men and women, social distancing could also add another level of social isolation, depression, and anxiety on top of worrying about the negative consequences of the coronavirus.

Women Have Been More Proactive in Response to the COVID-19 Outbreak

While large shares of women and men are aware of the public health recommendations by the CDC, WHO, and state and local government officials, such as frequent hand washing and staying home if you are feeling sick, a larger share of women report taking precautionary measures. Larger shares of women compared to men say they decided not to travel or changed travel plans (47% vs. 37%); reported canceling plans to attend large gatherings such as concerts or sporting events (43% vs. 36%); say they stocked up on items such as food, household supplies, or prescription medications (39% vs. 30%); and say they stayed home instead of going to work, school, or other regular activities (30% vs. 22%) (Figure 4).

Conclusion

The coronavirus pandemic has upended lives across the world. The findings of the survey reinforce much of what we have known about the impact that balancing multiple responsibilities – often without a safety net — has on women. The COVID-19 pandemic has put a spotlight on the gaps in workplace supports, such as paid sick and family leave, as well as the lack of affordable childcare and long-term care supports. In the absence of a long-term policy response, these issues will persist long after the urgency of the pandemic has passed.

The rapidly increasing number of national COVID-19 cases is raising alarm among experts and state and local officials about health systems’ capacity to treat patients effectively and revealing the uneven geographic distribution of the country’s health care resources.

A special report by KFF’s Kaiser Health News (KHN) shows that more than half the counties in the United States have no intensive care unit (ICU) beds, which poses a particular danger to patients age 60 or older who fall victim to the coronavirus. Hospital ICUs have sophisticated equipment, such as bedside machines to monitor a patient’s heart rate and ventilators to help them breathe ― trouble breathing is a common symptom among seriously ill COVID-19 patients. Even in communities that do have ICU beds, the numbers vary wildly ― with some having just one bed available for thousands of senior residents.

KHN’s coverage includes a 50-state map that shows which counties have no lCU beds as well as which lack a hospital altogether. Thirty seven million Americans reside in such counties. An online “lookup” tool lets readers check the ICU bed capacity near their homes or in surrounding counties.

This report is part of KFF’s continuing efforts on the coronavirus outbreak. The national story also ran in USA Today and, as always, KHN content is available to republish free of charge. News organizations can request localized data by contacting Chris Lee.

About The Henry J. Kaiser Family Foundation and Kaiser Health News:

Filling the need for trusted information on national health issues, KFF (the Henry J. Kaiser Family Foundation) is a nonprofit organization based in San Francisco, California.  KHN is an editorially independent program of KFF and is the nation’s leading and largest health and health policy newsroom, producing stories that run on kffhealthnews.org and are published by hundreds of news organizations across the country.

Introduction

The domestic response to coronavirus in the U.S. is rapidly expanding. At this point, every U.S. state and territory has declared an emergency, and President Trump has declared the pandemic to represent a national emergency. Yet there are concerns that response capabilities and resources at the local and state levels could become overwhelmed in the coming days and weeks as spread occurs and severe cases outpace the capacities of health facilities. In the past, the U.S. military has sometimes been called on to provide support during a national emergency, and calls for it to play a similar role during the coronavirus response are growing. In recent days, U.S. governors, presidential candidates, and others have asked for military assistance for domestic coronavirus response, and President Trump has stated he is working with states and the Department of Defense to have the military provide additional resources and assets.

This brief answers key questions about potential U.S. military engagement in the domestic response to the coronavirus. For the purposes of this brief, “military” refers to the armed forces, specifically the active duty personnel and assets of the uniformed military service branches in the Department of Defense (Army, Navy, Air Force, Marines) as well as their reserve forces, including the National Guard. The role and specific information about other U.S. uniformed services including the Coast Guard (part of the Department of Homeland Security) and the U.S. Public Health Commissioned Corps (part of the Department of Health and Human Services) are not reviewed here.

Key Questions

1. Can states call in the National Guard and other parts of the U.S. military?

Local and state governments are expected to be initially responsible for emergency response in their jurisdictions, according the National Response Framework that guides federal, state, and local responses to emergencies. However, when the response capacity at local and/or state government level is felt to be exceeded, governors have the option to request military support by calling on national guard units in their states to mobilize. In fact, governors in almost half of U.S. states (44%) have already activated many state guard units for coronavirus response: The National Guard reports that as of March 19, over 2,000 guard members are assisting in coronavirus response activities in 27 states.

For additional military support beyond the National Guard (with state-level units under the command of their respective governors unless “federalized” by the President), governors go through a separate process (below).

2. Who decides when the U.S. military, beyond the National Guard, becomes involved in domestic emergency response?

While governors can request the help of the U.S. military beyond the National Guard, the decision of whether to provide support lies with the President of the United States or the Secretary of Defense. At the federal level, the U.S. military can become engaged in domestic response in one of two ways:

• One is that the federal agency leading an emergency response can request military support by submitting a Request for Assistance to the Department of Defense (DoD). HHS had been the lead agency in the U.S. response until March 18, when it was announced that FEMA would take over as the lead. Upon receipt of the request from the civilian agency, the Secretary of Defense and other DoD leadership would review the request and evaluate it based on a number of criteria, including whether the requested support complies with existing law, whether the type of support presents a risk to DoD personnel, and what impact meeting the request might have on DoD’s ability to pursue its primary mission of national defense. Once a national emergency has been declared, governors can make the request directly to DoD, without going through the lead Federal agency.
• The other is that either the President or the Secretary of Defense can choose to directly authorize federal military support for the domestic response, including deploying active duty personnel and/or calling in National Guard personnel to federal service.

3. If the U.S. military becomes involved in the domestic response to the coronavirus, who controls and commands military assets during these efforts?

State governors maintain command over state-level National Guard assets and personnel when they are mobilized for state-level responses.

For the federal response, even when the U.S. military becomes involved, leadership of the response remains with civilian agencies and DoD assets are in a support mission. In the case of coronavirus, FEMA is the lead federal agency and with support from HHS as a key operational agency, would work with military commanders to direct resources as needed, along with state and local leaders. On the military side, the Secretary of Defense typically designates one or more responsible officers, specifically one or more of the commanders of the regional combatant commands, to oversee military efforts and ensure they are coordinated with civilian efforts. For this type of domestic civil support operation, ordinarily the officers will be the commander of U.S. Northern Command (NORTHCOM) for the continental United States, Alaska, Puerto Rico, and the U.S. Virgin Islands, and commander of U.S. Pacific Command (PACOM) for Hawaii, Guam, American Samoa, and the Northern Mariana Islands.

If National Guard units are “federalized” by the President during the response, there is a joint military-civilian command structure that is put in place.

4. What U.S. military capabilities and assets could support the domestic response to the coronavirus?

The U.S. military has capabilities in a range of areas that could be called upon in the domestic response to coronavirus. It has significant capabilities and assets to support communications, transportation, infrastructure, engineering, construction, and other technical and logistical areas.

Importantly, the military also has a reservoir of experienced scientists and medical professionals, stockpiles of medical supplies (such as masks and other personal protective equipment, and respirators), and military medical facilities that include deployable, mobile “field hospitals,” permanent health facilities, and two large hospital ships with an estimated 1,000 bed capacity each – the USNS Mercy and USNS Comfort.

5. Are these capabilities available and appropriate to the domestic civilian response to coronavirus?

Even though the military has significant capabilities as described above, not all resources are available for civilian use, and not all are likely to be appropriate for civilian coronavirus response needs.

Both Secretary of Defense Esper and military officials including the Joint Staff Surgeon (the highest ranking military medical official) have cautioned against overestimating the capabilities that the U.S. military can provide in coronavirus response. The Joint Staff Surgeon has stated DoD has “less than 3% of the number of hospital beds that the private sector has” and has only 36 hospitals in the U.S., most of which are not well suited for “caring for large numbers of contagious patients.” Military doctors are trained primarily to address the health needs of a young, healthy population of active duty personnel, not necessarily communicable illnesses that are a risk primarily to older populations and those with pre-existing chronic medical conditions (though military doctors may provide such care to service members, retirees, and their dependents).

The military has the capability to deploy/construct temporary field hospitals, as well as retrofit or otherwise prepare other facilities for use as makeshift hospitals. The Navy also has two large hospital ships, each with 1,000 bed capacity. Even so, military field hospitals and hospital ships have been designed and used primarily for humanitarian, trauma and battle injury care rather than infectious disease care, and usually provide short term care, with patients typically discharged quickly to other health facilities. Secretary Esper has stated that the hospital ships might provide care for trauma cases to help alleviate pressure on U.S. hospitals and free beds for infectious disease cases when deployed as part of the domestic coronavirus response.

Another consideration for deployment of military medical resources such as field hospitals and hospital ships is who will staff these units once they are deployed. With concerns about shortages of civilian health workers already, and the continued need for DoD medical professionals to focus on military needs, it is unclear where additional health worker capacity will come from to staff multiple field hospitals and hospital ships.

6. What military capabilities have been called on thus far?

In addition to the National Guard mobilizations noted above, as of March 18 Secretary of Defense Esper has directed the department to release some supplies in support of the domestic civilian response, including 5 million masks and other personal protective equipment, along with 2,000 deployable ventilators. Secretary Esper has also stated the Navy is in the process of readying the hospital ships, with plans to deploy the USNS Comfort to New York harbor and the USNS Mercy to a location on the west coast. Both are expected to deploy before the end of March.

In remarks during a recent press conference, President Trump commented that states have also requested the U.S. military help by standing up temporary field hospitals, though no specific information about when and where these hospitals will deploy is currently available.

New York Governor Cuomo specifically asked for the Army Corps of Engineers to be used to convert, retrofit, and upgrade existing civilian facilities to serve as makeshift hospitals, and Secretary Esper has said that he will “get the Corps of Engineers up there soonest to assess the problem and see how we can help out.” Before Secretary Esper’s commitment on March 18, a spokesperson for the Corps stated they are “prepared to assist” but have not yet been assigned a mission.

7. Can the U.S. military be used to enforce quarantines or take on other policing or law enforcement activities during the domestic coronavirus response?

There are restrictions on federal military actions and responsibilities in domestic response circumstances, which are outlined in various guidelines and laws, including the Defense Support of Civil Authorities doctrine and DoD Directive 3025.18 on Defense Support for Civil Authorities, as well as several sections of the U.S. Code, including Military Support to Civilian Law Enforcement Agencies and the Posse Comitatus Act. These prohibit the federal military from serving in any law enforcement or policing role. Restricted activities include: “search, seizure, arrest, apprehension, stop and frisk, surveillance, pursuit, interrogation, investigation, evidence collection, security functions, traffic or crowd control.” An exception to these restrictions can be expressly authorized by the President (through invocation of the Insurrection Act) or granted through an act of Congress. These restrictions do not apply to state-level National Guard efforts under governors’ orders.

Under extreme circumstances some states allow governors to declare “martial law” in their states, which would have the effect of replacing civilian authority with military authority, and also the possibility of suspension of certain civil liberties. California Governor Newsom stated, “If you want to establish a framework of martial law, which is ultimate authority and enforcement, we have the capacity to do that, but we are not feeling at this moment that is a necessity.” Similarly, the President in theory has the ability to establish martial law at the federal level; however, this power is highly contested, and there is no indication this is currently being considered for the coronavirus situation.

8. Could U.S. military medical resources deployed for civilian response affect the ability of the military to meet the needs of its own members and dependents?

DoD prioritizes the health of its personnel and dependents and in the past has sought to minimize the risk for military members posed by infectious diseases as much as possible. DoD is concerned about exposure to and the spread of COVID-19 among its personnel, reporting 37 confirmed cases as of March 17 (18 among military personnel, 13 among dependent family members, 3 in civilian employees, and 3 in contractors).

Military officials have expressed concerns about military medical resources being redirected from their current tasks. With force health protection a primary objective for U.S. military medical resources, decisions about their use for domestic civilian response will weigh the potential effects on the military’s efforts to address the health of its own members and dependents.

Likewise, many health care workers who serve in reserve units of the armed forces, including the National Guard, have civilian jobs in health care. Calling them up to reserve duty would remove them from their civilian role which might negatively affect civilian response, so careful consideration of the proper role for health care workers called up for service is necessary.

A new KFF brief answers key questions about potential U.S. military engagement in the domestic response to the novel coronavirus. With concerns that local response capabilities could become overwhelmed in the coming weeks,  there have been increasing calls to have the U.S. military play a greater role in support of civilian response.

The U.S. military has significant capabilities in a range of areas that could be called upon in the domestic response to coronavirus — including communications, transportation, infrastructure, engineering, construction, and other technical and logistical areas. The military also has a reservoir of experienced scientists and medical professionals, stockpiles of medical supplies (such as masks and other personal protective equipment, and respirators), and military medical facilities.

However, not all military resources are available for civilian use, and not all are likely to be appropriate for civilian coronavirus response needs.  U.S. law and military rules and regulations also place some restrictions on the kinds of activities that the military can engage in as part of a domestic response.  The brief examines these and other important aspects of greater military engagement in coronavirus response in the U.S.

In this article in the Journal of Health Politics, Policy and Law, Larry Levitt examines the Affordable Care Act 10 years after it’s enactment. The article notes that the law has taken numerous blows, both from the courts and from opponents seeking to undermine it. Yet, due to its policy design and the political forces the ACA has unleashed, the law has shown remarkable resilience. While there remain ongoing efforts to undo the ACA, the smart money has to be on its continued existence.

More than 170 million people in the US are covered by many different group and individually purchased private health plans. People cannot take for granted that every plan covers the same benefits, applies the same cost sharing and utilization review standards, or offers access to the same network of participating hospitals, doctors, labs, and other providers. Research demonstrates that out-of-pocket costs can, and frequently do, effectively limit access to needed care for insured patients. Public health experts warn that efforts to control spread of the coronavirus that causes COVID-19 will be less effective if people fail to seek appropriate diagnosis or care due to the cost.

Congress recently passed a new law, the Families First Coronavirus Response Act, that will, among other things, require most private health plans to cover testing for the coronavirus with no cost sharing during the emergency period. Some states have adopted similar requirements for insurers they regulate, and many private insurance companies will voluntarily expand coverage for testing.

To date, fewer changes have been adopted or considered with respect to treatment for complications from the disease.

This brief reviews current coverage standards for private health plans and how these may change in response to the COVID-19 pandemic.

What health services might patients need for COVID-19?

COVID-19 is an infectious respiratory disease caused by a new coronavirus. No vaccine or cure or specific treatment for COVID-19 has yet been developed.

Testing – Diagnosis of COVID-19 is confirmed by a test that is currently available via public health departments and, increasingly, via private laboratories. Testing also typically involves a visit to a physician office, clinic, or emergency room to collect the patient’s specimen.

Treatment – Once diagnosed, treatment for complications from COVID-19 would vary based on the patient and severity of the case. According to the World Health Organization, 80% of people who become infected will recover without needing special treatment. However more than 105 million adults in the U.S. have a higher risk of developing serious illness if they are infected with coronavirus, due to their older age (60 and older) or health condition, that could require more extensive care, such as hospitalization, respiratory therapy and other services.

What does private health insurance cover? 

Most Americans under the age of 65 (about 6 in 10) are covered under one of many different job-based group health plans. Another 7 percent of the nonelderly are covered under one of thousands of different private insurance policies offered in the non-group market.

To understand what private health insurance covers, one must consider

• what benefits and services are covered under a plan;
• what level of cost sharing, if any, applies to covered benefits;
• how, if at all, the plan covers care from out-of-network providers, which could result in “balance billing.”

In general, private plans can vary in each of these respects.

The Affordable Care Act (ACA) sets a few minimum coverage standards that apply to most private health plans. For example, the ACA requires most private plans to cover designated preventive services with no cost sharing. Even these ACA coverage standards do not apply to all private coverage, however, including short-term policies, health care sharing ministries, and certain Farm Bureau health plans that are not subject to any federal minimum coverage standards.

States also regulate and set coverage standards for private health plans, although a federal law, ERISA, preempts state regulation of many employer-provided health plans.

Within this regulatory framework, private health plans vary, at least to some extent, in terms of their covered benefits, cost sharing, and benefit limits.

Benefits

The ACA requires policies in the individual and small group health insurance markets to cover 10 categories of essential health benefits (EHB), including hospitalization, ambulatory care, lab tests, and prescription drugs. However, the details of covered benefits within each category can and do vary from plan to plan – for example, whether the ambulatory care EHB category covers telemedicine visits. In addition, large group health plans and self-insured group health plans of any size are not required to cover EHB, though most provide major medical coverage.

Coronavirus testing – The new law passed by Congress requires all group health plans and individual health insurance coverage to cover testing and associated visits related to the diagnosis of the COVID-19 during the emergency period.

This new law will not apply to some types of private coverage sold to individuals. For example, regulations issued by the Trump Administration in 2018 promote the sale of short-term policies that are not required to cover EHB.

• The Administration estimated an additional 1.3 million people would be enrolled in short-term policies in 2020 as a result of this regulation.

In addition, health care sharing ministries are a private health coverage arrangement not subject to federal standards.

• About 1 million people have health coverage through sharing ministries.

Also, two states have authorized their Farm Bureaus to sell private coverage that, explicitly, is not defined or regulated as health insurance.

• As of 2017, 73,000 people were enrolled in Farm Bureau plans in Tennessee. The State of Iowa also has a law specifying that private coverage offered by the Farm Bureau is not insurance.

Under the new federal law, however, people enrolled in these types of non-compliant private coverage will be considered uninsured.  The law also gives states the option to provide free Medicaid coverage for coronavirus testing for their uninsured residents.  In addition, the new law appropriates $1 billion to the National Disaster Medical System to reimburse providers for the costs associated with diagnosis and testing of uninsured individuals.

Treatment for complications of COVID-19 – While most private health plans likely cover most items and services needed to treat complications due to COVID-19, there is no clear federal requirement to do so.

The EHB standard under the ACA defines categories of services to be covered, but it is left to states to designate “benchmark” policies that define specific covered services. As a result, coverage for at least some services needed to treat COVID-19 – such as home-delivered care, telemedicine visits, or respiratory therapy visits – could vary under health insurance plans that are subject to EHB.

Large employer health plans are not required to cover EHB. Most large employers offer major medical coverage under their group health plans, but some do not.

• About 4 percent of large firms offer so-called “mini-med” plans to some or all workers as a less expensive option. For example, one mini-med plan currently marketed covers preventive services, 4 doctor visits per year, and no hospitalization or emergency care. Such plans would provide limited, if any coverage, for services to treat complications of COVID-19.

Short-term plans, health sharing ministries, and certain Farm Bureau plans are not subject to any federal coverage standards.  The Families First Coronavirus Response Act does not address coverage of COVID-19 treatment costs for people who are uninsured.

Cost sharing

Private health plans typically apply cost sharing – deductibles, copays, or coinsurance – to covered benefits other than preventive services.

Coronavirus testing – The Families First Coronavirus Response Act requires all group health plans and individual health insurance coverage to waive all cost sharing for testing and associated visits related to the diagnosis of the COVID-19 during the emergency period.

Coronavirus vaccine – Certain preventive services under ACA-regulated private plans must be covered with no cost sharing. The U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices, and other agencies are tasked with periodically reviewing and recommending preventive services to be covered under this requirement, and this would likely include a coronavirus vaccine, if developed. The ACA preventive services coverage requirement takes effect for each new service 1 year after it is recommended.

Treatment for complications of COVID-19 – There is no federal requirement for private plans to waive cost sharing for COVID-19-related treatment. While many private health insurers recently announced they will voluntarily waive cost sharing for testing, industry leaders have clarified that this waiver does not generally apply to treatment. The ACA limits the amount of cost sharing that can apply for in-network covered benefits under most private plans to $8,150 in 2020 for single coverage, $16,300 for family policies. Within these limits, privately insured COVID-19 patients could face significant out-of-pocket costs for covered care.

• Increasingly, cost sharing is becoming unaffordable for many private health plan enrollees. Half of adults covered under job-based plans report foregoing or delaying needed care in the past year due to cost. Among adults who do skip or delay needed care due to cost, 13% report their health condition worsened as a result.
• Among covered workers in job-based plans with a deductible for self-only coverage in 2019, the average deductible was $1,655. Employer-sponsored health plan deductibles have increased six times faster than average wages over the past decade.
• Under non-group plans, deductibles are even higher – on average more than $4,500 for self-only coverage in silver plans this year – although half of marketplace enrollees qualify for subsidies to significantly reduce deductibles and other cost sharing. 

Provider networks

Nearly all private health plans use networks of participating hospitals, doctors, laboratories, and other providers, which could have implications for those in need of coronavirus testing or care, depending on where they present for services. Claims for out-of-network services, other than emergency services, can be denied by HMOs and other plans with closed networks. Under PPO plans that provide some coverage for out-of-network care, patients can be face higher cost sharing (e.g. patients might be required to pay 20% coinsurance for in-network claims and 50% coinsurance for out-of-network claims.)

In addition, out-of-network care exposes patients to “balance billing,” or the difference between the provider’s undiscounted charge and the amount the health plan considers reasonable. Private plan enrollees generally try to seek care from in-network providers, though sometimes they receive out-of-network care inadvertently, resulting in surprise medical bills.

• Analysis of emergency visits by patients covered by large employer plans found 18% included at least one out-of-network charge.
• Among non-emergency stays at in-network hospitals and facilities, 16% involved at least one out-of-network claim (e.g., by an anesthesiologist).

Coronavirus testing – Surprise medical bills could result if patients seek testing in an emergency room; even at an in-network emergency facility, physicians and other providers who work there may not be in-network. Surprise medical bills could also result in other ambulatory care settings, for example, if a patient’s in-network primary care doctor sends her test to an out-of-network commercial lab.

Treatment for complications of COVID-19 – Patients could also receive surprise out-of-network bills for treatment services, particularly when patients are hospitalized. New analysis finds that patients hospitalized at in-network hospitals for pneumonia (one complication that can arise from COVID-19 infection) are 20% more likely than average to incur at least one out-of-network charge.

Other limits on covered benefits

In addition to network restrictions on covered benefits, most private plans employ other medical management and utilization review techniques, such a requiring referrals or prior authorization for certain services before they will be covered, which could also have implications for those with COVID-19. Congress is poised to enact a law requiring waiver of prior authorization for coronavirus testing.

For most private plans, the ACA prohibits most annual or lifetime dollar limits on covered benefits, and prohibits plans from denying coverage for pre-existing conditions. These standards do not apply to short-term plans, health sharing ministries or to certain Farm Bureau plans.

Changes in Private Plan Standards for COVID-19

The policy landscape is changing rapidly as the outbreak spreads. Notable recent developments include:

The new law passed by Congress requires ACA-regulated health plans to cover coronavirus testing and to waive cost sharing and prior authorization. In addition to the test, itself, this requirement applies to visits in physician offices, urgent care centers, and emergency rooms associated with testing. This standard does not apply to short-term plans, sharing ministries, or certain Farm Bureau plans. The law does not address standards for private health plan coverage or cost sharing for COVID-19 treatment. Nor does it address balance billing.

Voluntary coverage changes by the insurance industry – Before Congress acted, many private health insurers had announced voluntary efforts to extend and expand coverage for coronavirus testing under their fully-insured policies, although in general, private insurers have not addressed balance billing (surprise bills). A few private insurers, including one serving federal employees, committed to waiving cost sharing for COVID-19-related treatment, as well. Insurers making coverage changes not otherwise required by law note that self-insured group health plans, which they administer, have the option to adopt or reject these changes. Sixty percent of covered workers in employer-sponsored plans are in self-insured coverage arrangements.

Changes in requirements for state-regulated plans – A number of state insurance commissioners have issued directives to health insurers they regulate regarding COVID-19. For example, in Washington state, all state-regulated health insurance plans and short-term medical plans must suspend prior authorization for treatment or testing of COVID-19, waive cost sharing for testing, and allow enrollees to receive testing and treatment from an out-of-network medical provider if the plan’s network does not provide reasonable access. The order also requires plans to allow enrollees a one-time refill of prescription medications before the waiting period on refills expires. In New York, guidance requires state regulated plans to cover COVID-19 testing and waive cost sharing for the lab test and the associated patient visit to in-network physician offices, urgent care centers, or emergency departments. New York-regulated insurers also must cover out-of-network testing if in-network providers are unable to provide COVID-19 testing, waive prior authorization for COVID-19 testing, and cover telehealth services. New York’s surprise medical bill protections also apply for patients who receive out-of-network bills in certain circumstances, including when in-network physicians send specimens to an out-of-network laboratory or pathologist for testing.

Federal law preempts state regulation of employer-sponsored health plans.

Introduction

The novel coronavirus, also known as “SARS-CoV-2” causing the illness “COVID-19”, has sparked international concern and emergency response. While both men and women are affected by COVID-19, this brief outlines considerations for how the pandemic may specifically impact pregnant women. With over 6 million pregnancies per year in the U.S., pregnant and breastfeeding women constitute a significant portion of the population that could be impacted by COVID-19. This brief summarizes what is known thus far about pregnancy and COVID-19.

What do we know thus far about the impact of COVID-19 in pregnancy?

Does risk for COVID-19 differ between men and women?

The COVID-19 outbreak is an evolving pandemic. Little is known on how, or if, the disease differentially impacts women compared to men. To date, initial studies on the outbreak in China have found men may account for slightly more of the overall cases, and that men may have a slightly higher mortality rate from COVID-19. This could be due to biological factors (i.e. differences in immune response), medical factors (i.e. comorbidities) and lifestyle factors (i.e. smoking). However, most trackers of the pandemic, including the CDC and WHO, have not published their data by gender. Therefore, more research on this topic is warranted before conclusions are made.

Does risk for COVID-19 differ between pregnant and non-pregnant women?

According to the CDC, there is insufficient data at this time to know whether pregnant women are at increased risk for adverse health outcomes if infected by the novel coronavirus as compared to non-pregnant people. A WHO-China Joint Mission investigation of 147 pregnant women in China with suspected or confirmed COVID-19 found that 8% had severe disease and 1% were in critical condition (14% severe, 6% critical for the overall population). In a small study of pregnant women in Wuhan, China, the clinical characteristics and severity of COVID-19 also appeared similar between pregnant and non-pregnant women. That said, the American College of Obstetricians and Gynecologists (ACOG) issued a statement that “pregnant women may be at higher risk of severe illness, morbidity, or mortality compared with the general population,” likely due to physiologic changes that happen during pregnancy, and because pregnancy constitutes a state of relative immunosuppression as compared to non-pregnancy.

Can the novel coronavirus be transmitted during pregnancy or breastfeeding?

Data are also lacking about whether pregnant women infected by the novel coronavirus can pass it to their fetuses across the placenta during pregnancy, called “vertical transmission.” However, several small studies of pregnant women infected with the novel coronavirus found no evidence of vertical transmission, as none of their infants tested positive at birth, and the virus was not detected in samples of the amniotic fluid, umbilical cord blood or placental tissue (Zhu et al. 2020; Chen et al. 2020; Chen et al. 2020; Zhang et al. 2020; Li et al. 2020). That said, a few cases of newborns infected by the novel coronavirus have been reported, and it remains unclear if they were infected before, during or after delivery (Qiao, 2020; Murphy, 2020). There is no evidence to date to suggest the novel coronavirus can pass to infants through breastmilk, however the CDC has issued precautionary guidance for women with suspected or confirmed COVID-19 who are also breastfeeding.

Adverse health outcomes have been found in infants born to mothers affected by COVID-19, including respiratory distress, premature labor, and even death. However, it is unclear whether these adverse outcomes are related or not to the COVID-19 infection in their mothers. Meanwhile, guidance published by the Royal College of Obstetricians and Gynecologists (RCOG) suggests there is no data yet linking COVID-19 with an increased risk of pregnancy loss. As for maternal outcomes, some initial evidence indicates outcomes are similar between women with and without COVID-19, however other studies show symptom severity in pregnancy varies from asymptomatic to life-threatening. As the outbreak continues, more data on maternal and neonatal outcomes will likely come forward.

Access to Care

Will pregnant women be reluctant to access prenatal care due to fear of COVID-19 exposure in medical settings?

Much of the general public is worried about COVID-19. A recent KFF poll conducted from March 11-15 found 62% of adults reported being very or somewhat worried that they or someone in their family will get sick from the coronavirus. 51% of adults reported being very or somewhat worried about putting themselves at risk of exposure to the virus because they can’t afford to stay home and miss work.

For pregnant women, concern over COVID-19 may be even more heightened.Social distancing, which is now recommended as a response to the containing the spread of coronavirus transmission, presents distinct challenges for pregnant women. This advice may be hard to follow in pregnancy; most women have monthly to weekly interactions with the health system during pregnancy for prenatal checkups.

Can telemedicine be used to provide more services to pregnant women?

One possible way to provide access to prenatal care during this outbreak is to expand use of telemedicine during pregnancy; this would enable some pregnant women to stay home and participate in prenatal visits over videoconference or the phone, without coming into clinic where they risk COVID-19 exposure (Figure 1). A KFF brief explains more about potential uses of telemedicine in pregnancy.

Currently, however, utilization of telemedicine for pregnancy-related services is minimal. Lack of insurance coverage for telemedicine poses a large barrier to its implementation. Nearly half of all births in the U.S. are financed by Medicaid, but only a handful of state Medicaid programs specifically address obstetrical care in their telemedicine reimbursement laws. No states specifically require private insurance plans to cover pregnancy services in their telemedicine reimbursement laws. However, in approximately half of states, if telemedicine services are shown to be medically necessary and meet the same standards of care as in-person services, private insurance plans must cover telemedicine services if they would normally cover the service in-person.

Several major health insurance companies have mentioned coverage of telehealth in their response to COVID-19. For example, Aetna is offering telemedicine visits for any reason without copays, while Humana is waiving telemedicine costs for urgent care visits for 90 days. Others are “encouraging” use of telehealth, without word on cost sharing. In a White House Coronavirus Task Force briefing, Vice President Pence referenced the recently enacted Coronavirus Preparedness and Response Supplemental Appropriations Act, which broadens coverage and reimbursement for telemedicine services for Medicare. He also mentioned Medicaid may similarly make these services available. That said, the details of telehealth coverage remain murky, and there are likely to be significant gaps in access to telemedicine during this pandemic. Even beyond coverage considerations, there are logistical challenges that come with implementing a telemedicine program at a health center and start-up costs are high. For example, telemedicine platforms must be compliant with the Health Insurance Portability and Accountability Act (HIPAA), and integrate into an existing electronic health record, and clinicians must ensure their malpractice insurance covers telemedicine.

Even if telemedicine implementation became more widespread, almost all births in the U.S. occur in hospitals. Shortages of personal protective equipment (PPE) like masks, gloves, and gowns, and other hospital resources have been predicted by the World Health Organization as a result of the COVID-19 pandemic which could make frontline health workers increasingly vulnerable to COVID-19. In turn, patients may fear exposure to the virus while in the hospital for labor and delivery. Some women may also need to rearrange their birth plans, if family can no longer travel to be with them in the hospital, if family members are in quarantine, or if spouses have to stay home with children due to school closures.

Drug Development and Payment Policy

Will COVID-19 treatment and vaccine development for pregnant women lag behind rest of the population?

Implementation of an effective vaccine for the novel coronavirus is likely months to years in the future, however it is important to understand how the drug development process impacts pregnant women and how that could affect the use of any future COVID-19 treatment or vaccine. For almost all drugs in development, pregnant women (and often women who are breastfeeding) are specifically excluded from drug development trials. This is done to avoid exposing a fetus or breastfed infant to potentially harmful drugs. However, this means that when most drugs obtain FDA approval, they have not been tested in pregnant and lactating women. Only in post-approval studies, if ever, is the drug tested for these populations. This presents a lag time between when a drug is approved for use in the non-pregnant population and when safety and efficacy data is available for pregnant persons.

This same delay will likely hold true in the development of COVID-19 treatments and vaccines. To use another infectious disease as an example, the ministry of health in the Democratic Republic of Congo administered the Ebola vaccine to non-pregnant people months in advance of pregnant women; meanwhile, 319 pregnant women and 603 lactating women with infected contacts were excluded from vaccination from November 2018 to May 2019, even after the vaccine was approved for use in pregnant/lactating women in February 2019. During the 2009 H1N1 “swine flu” epidemic, pregnant women were especially vulnerable to severe complications. Vaccination of pregnant women was made a priority by the CDC and WHO, but even still, many pregnant people experienced delays in vaccination.

While there are often very compelling reasons to exclude pregnant women from research studies, it is significant to note potentially lifesaving COVID-19 treatment and vaccines may never be tested or approved for pregnant or lactating women, unless dedicated efforts to do so are made. It will be important that research and development on new treatments and vaccines for COVID-19 address the inclusion and needs of pregnant and lactating women in upcoming clinical trials. Of note, a current clinical trial of a possible COVID-19 treatment does not allow pregnant or breastfeeding women to participate at this time.

How will cost impact pregnant women’s access to COVID-19 treatments and vaccine once available?

When treatment and vaccines are eventually developed for COVID-19, cost sharing could hinder access to care. Cost plays a large factor into care seeking behavior. While women and men both feel the impact of health costs, data from KFF’s 2017 Women’s Health Survey show that cost can be particularly burdensome for women, who on average earn lower wages, have fewer financial assets, accumulate less wealth, and have higher rates of poverty than men. For example, 19% of women reported they put off or postponed preventative services in the last year due to cost, while 26% of women delayed or went without care due to cost.

The ACA requires most private health insurance plans and states with Medicaid expansion to cover recommended preventive services without cost sharing, including vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). Once ACIP recommends a new vaccine, however, it typically takes another year for coverage to commence (or in the next plan year). Therefore, even once a COVID-19 vaccine is developed and recommended by ACIP, there will likely be a significant lag time between when the vaccine is required to be covered without cost sharing. A few health insurers have said so far that they will offer a coronavirus vaccine without cost sharing once developed. CMS says a vaccine will be covered by Medicare Part D. For the individual and small group markets, and states with Medicaid expansion, the vaccine would likely be covered if and when it becomes a recommended preventive service by ACIP.

Research shows us that many pregnant women forgo recommended vaccines if not provided free of cost. A study of pregnant Medicaid patients in Florida found that vaccination rates for Tdap and influenza were low in the prenatal period when Medicaid did not cover these vaccines. However, rates rose in the postpartum period, when the vaccine was covered free of charge. These data suggest that costs pose a barrier to vaccination for at least a portion of pregnant patients.

Conclusions

There are a number of specific reasons why pregnant women may be uniquely affected by the COVID-19 pandemic, but information is limited currently. There is no definitive answer at this time about if the virus is transmitted during pregnancy or in breastmilk and more research is warranted about potential adverse health outcomes to mothers and infants. Inclusion of pregnant women and lactating women in treatment and vaccine development for COVID-19 will be important, as access to novel therapies for these groups has historically lagged far behind the non-pregnant population. Use of telemedicine for prenatal care visits could help pregnant women reduce their risk of virus exposure, however most pregnant women will still need to be admitted to hospitals for labor and delivery, potentially at time when hospitals are stressed beyond their capacity and resources. Keeping in mind the pregnant population during the COVID-19 pandemic may help mitigate potential preventable health disparities.