A new KFF resource compiles publicly available information on donor funding for the global novel coronavirus response. Donors have begun providing support to China and other low- and middle-income countries, but currently there is no centralized repository to track this information.Through March 9, donors have pledged over $8.3 billion in financial support for the COVID-19 response. This includes donor assistance provided directly to countries as well as their contributions to the World Health Organization. The vast majority of the funding was provided by donor governments (including the U.S.), the World Bank, and other multilateral organizations. It does not include funding from governments for their own domestic response efforts or commitments focused on economic stimulus or recovery efforts related to the outbreak.The tracker will be updated as more information becomes available.

On February 14, 2020, the U.S. Court of Appeals for the D.C. Circuit issued a unanimous decision setting aside the Health and Human Services (HHS) Secretary’s approval of a Section 1115 Medicaid waiver amendment that included work and reporting requirements and restriction of retroactive coverage in Arkansas. The court found that Secretary’s approval was unlawful because he failed to consider the impact on coverage. The case was decided by a 3-judge panel, and the opinion was written by Judge David Sentelle, appointed by President Reagan. The appeals court affirmed the district court’s earlier decision that reached the same conclusion. In addition to Arkansas, the district court has set aside similar waiver approvals in Kentucky and New Hampshire.

The appeals court’s decision likely ultimately affects not only the Arkansas Medicaid program and its enrollees but also is being watched by other states with pending litigation, other states with waiver approvals and those seeking approvals for work requirements, and other states considering adopting similar policies. While litigation is ongoing, in January 2020, the Trump Administration released guidance inviting states to apply for new Section 1115 demonstrations that would allow states to impose work requirements and other restrictions on eligibility and benefits in exchange for a cap on federal financing and has again proposed a legislative change to condition Medicaid on work and reporting requirements in all states in its budget for fiscal year 2021. This issue brief answers three key questions about the implications of the appeals court’s decision.

1. What is the rationale behind the appeal court’s decision setting aside Arkansas’ waiver amendment?

The appeals court decided that the HHS Secretary’s approval of Arkansas’s waiver amendment was outside the scope of his Section 1115 demonstration authority. The court set the waiver amendment approval aside because the Secretary failed to adequately analyze its impact on Medicaid’s primary objective: providing health insurance coverage to low income people, consistent with the ruling and rationale of the district court. While Congress has granted the Secretary “considerable discretion” to approve waivers, the Secretary must exercise that discretion within the guardrails established by Congress. Specifically, the Secretary’s waiver authority is limited to approving experimental projects that will advance Medicaid program objectives. The courts’ role is to review the Secretary’s decisions and determine whether those guardrails are being observed.

The court found that the Secretary’s waiver amendment approval in Arkansas is arbitrary and capricious because he failed to consider the impact on coverage. The appeals court underscored that the “text of the [Medicaid] statute includes one primary purpose, which is providing health care coverage without any restriction geared to healthy outcomes, financial independence or transition to commercial coverage.” The Administrative Procedures Act – which governs agency decision-making — requires a reasoned basis for the Secretary’s decision, grounded in evidence in the administrative record. The administrative record includes the evidence before the Secretary when deciding whether to approve the waiver, such as the state’s waiver application and public comments. Estimates and concerns about coverage loss were raised in the public comments on Arkansas’ waiver amendment, and the court determined that the Secretary dismissed these concerns “in a handful of conclusory sentences.” The court found that the failure to consider an important aspect of the problem is not “reasoned decision-making.”

The court found that the Secretary’s waiver amendment approval in Arkansas also is flawed because he prioritized other objectives that are not in the statute to the exclusion of the objective identified by Congress. Congress did not include improving health outcomes or promoting financial independence as among Medicaid’s objectives, and the Secretary cannot approve a demonstration to further objectives that Congress has not identified, according to the court. The appeals court “agree[s] with the district court that the alternative objectives of better health outcomes and beneficiary independence are not consistent with Medicaid.” While HHS argued that the waiver restrictions were appropriate because ACA expansion adults in its view are a different population compared to other Medicaid populations, the appeals court concluded that nothing in the statute indicates that Congress intended to treat expansion adults differently from any other Medicaid enrollees. The appeals court also rejected HHS’s argument that the waiver restrictions are appropriate because they promote financial independence, observing that the statute’s reference to independence refers to assisting people with achieving functional independence by provided rehabilitative and other health care services. In contrast to the TANF and SNAP statutes, Congress has not conditioned Medicaid coverage on fulfilling work requirements.

2. What happens next in Arkansas?

The appeals court’s decision means that work and reporting requirements cannot be re-instated in Arkansas at this time. Arkansas’s waiver implementation began in summer 2018, with over 18,000 people losing coverage by the end of that year. The district court’s decision stopped implementation, before the first coverage losses scheduled for 2019 took effect on April 1^st. In addition to the work and reporting requirements, Arkansas also cannot re-instate the restriction of retroactive coverage, which also was included in the vacated waiver amendment.

Looking ahead, HHS and/or Arkansas can ask the entire DC Circuit Court of Appeals to reconsider the case in a rehearing “en banc.” They also can ask the U.S. Supreme Court to grant cert and review the case. This means that the recent appeals court decision might not be the last word on the scope of the Secretary’s waiver authority, although both of these further appeals are at each’s court’s discretion.

3. What does the decision mean for HHS and other states that want to condition Medicaid coverage on work and reporting requirements?

While the appeals court’s decision in Arkansas does not directly invalidate Medicaid work requirement approvals in other states, it does signal that lawsuits challenging similar approvals are likely to be successful. While a similar appeal in Kentucky has been dismissed as moot after the new governor terminated the waiver, the New Hampshire case is currently pending in the appeals court, and there are cases challenging waiver approvals in Indiana and Michigan in the district court. In addition to the waivers currently being challenged in court, HHS has approved similar work requirement waivers in five other states, while 10 other states’ requests are pending as of February 14, 2020. The New Hampshire appeal was put on hold while the Arkansas appeal was pending. The appeals court has ordered the parties in the New Hampshire case to file motions by March 16, 2020, setting out how they think the case should proceed given the Arkansas decision.

Applying the appeals court’s decision in Arkansas, the district court set aside the work requirement waiver approval in Michigan; the Indiana case is still pending in the district court. The district court has to follow the legal standards set out in the appeals court’s decision. Prior to the appeals court’s decision in Arkansas, HHS conceded that the Indiana and Michigan work requirements would be unlawful “absent further judicial review” if the appeals court affirmed the district court’s decision setting aside the Arkansas approval. However, HHS argues that other waiver provisions challenged in Indiana and Michigan such as premiums and healthy behavior requirements were lawfully approved and should survive even if the work requirements are vacated; the court has not yet ruled on these other provisions. The plaintiffs argue that the Secretary’s entire approval is flawed, and none of the challenged provisions can survive.

Implementation of work requirements has been suspended in New Hampshire, Indiana, and Arizona, given the pending litigation, leaving Utah as the only state currently implementing a work requirement. Other states pursuing similar requirements also may reconsider, given the recent appeals court decision about Arkansas. However, there is nothing to stop states from adopting programs to support Medicaid enrollees’ ability to work without the threat of coverage loss. Montana has a voluntary work supports program, Maine rejected a work requirement waiver in favor of a similar program, and Kansas has pending Medicaid expansion legislation that includes a voluntary work referral.

The appeals court’s statements about Medicaid’s primary purpose as articulated by Congress and the bounds of the Secretary’s discretion under Section 1115 are likely to inform potential future lawsuits challenging other demonstration approvals. The recent CMS guidance inviting states to apply for new demonstrations with capped federal funding would allow states to impose work requirements and other restrictions on eligibility and benefits similar to those set aside in Arkansas, Kentucky, and New Hampshire to date, making continuing developments in the current lawsuits important to watch.

Source

The Role Of Health Care In The 2020 Election

Democratic voters across the primary states that have already cast their ballots for the 2020 Democratic presidential nomination consistently name health care as the top issue or among the top issues in this year’s election.

A new interactive map highlights what Democratic primary voters are saying about health care as they vote.

Based on KFF’s analysis of the state-level AP VoteCast data collected in most states as they hold their primary elections, health care ranked as either the top issue or tied as the top issue in each contest analyzed, with between 31% to 39% of voters ranking it as the most important issue in each state. However, a larger share of Democratic voters in each primary contest say it is very important to choose a candidate who can beat President Trump than to choose a candidate who has the best policy ideas.

Across states, majorities of Democratic voters favor a single-payer health plan, similar to the one proposed by Sen. Bernie Sanders, and a proposal similar to the one put forward by former Vice President Biden, in which all Americans would have the option of buying a government health insurance plan. In each state, the public option plan garnered more support from Democratic voters than the single-payer plan.

The map includes links to state-specific charts highlighting other health care findings from the AP VoteCast data, including key demographic breakouts. Currently, state data is available from Iowa, New Hampshire, South Carolina, as well as eight of the 14 states that voted Tuesday: Alabama, California, Colorado, Massachusetts, Minnesota, North Carolina, Texas, and Virginia. KFF will add analysis for additional states after they vote.

The interactive map is part of KFF’s ongoing efforts to provide useful information related to the health policy issues relevant for the 2020 primary and general election campaigns, including policy analysis, polling, and journalism.

This slideshow examines the role of health care as an issue in the 2020 North Carolina Democratic primary and is based on KFF analysis of AP VoteCast, a survey of North Carolina primary voters conducted for the Associated Press by NORC at the University of Chicago.

The survey was conducted for seven days, concluding as polls closed, and is based on 2,706 interviews conducted in English and Spanish with registered voters drawn from a random sample of the state voter file and from self-identified registered voters selected from non-probability online panels. The margin of sampling error for results based on the full sample is plus or minus 4 percentage points. Find more details about AP VoteCast’s methodology here.

Updated: March 4, 2020 at 2:30pm EST

This slideshow examines the role of health care as an issue in the 2020 California Democratic primary and is based on KFF analysis of AP VoteCast, a survey of California primary voters conducted for the Associated Press by NORC at the University of Chicago.

The survey was conducted for seven days, concluding as polls closed, and is based on 4,023 interviews conducted in English and Spanish with registered voters drawn from a random sample of the state voter file and from self-identified registered voters selected from non-probability online panels. The margin of sampling error for results based on the full sample is plus or minus 3 percentage points. Find more details about AP VoteCast’s methodology here.

Updated: March 4, 2020 at 2:30pm EST

A new KFF brief explains June Medical Services LLC v. Russo, a challenge to a Louisiana abortion regulation that will be heard at the Supreme Court on March 4, 2020. The brief discusses the issues raised by this case and reviews the potential implications of various rulings.

The June Medical Services LLC v. Russo case is a challenge to a Louisiana law, the Louisiana Unsafe Abortion Protection Act (“Act 620”), which requires physicians who perform abortions in the state to have “active admitting privileges” at a hospital within 30 miles of the facility where the doctor provides abortions. Doctors who perform an abortion without having admitting privileges may be imprisoned or fined and the clinics that employ them can have their licenses revoked and may also be fined or face civil liability.

The law in dispute is nearly identical to the Texas admitting privileges law struck down in Whole Woman’s Health v. Hellerstedt in June 2016, the last time the Court ruled on abortion. In that case, the Court ruled that the Texas admitting privileges law was unconstitutional as the burden the law placed on women’s access to abortion outweighed the benefit.

The Supreme Court will likely issue its decision in this case at the end of its term, in late June 2020. With the election only months away, and party conventions in July, this case once again puts abortion right in the middle of the political debate. While the Court’s decision is unlikely to overturn Roe v. Wade, the decision could affect the type and scope of abortion restrictions that states can enact and the availability of abortion services in Louisiana and other states with similar laws.

This slideshow examines the role of health care as an issue in the 2020 South Carolina Democratic primary and is based on KFF analysis of AP VoteCast, a survey of South Carolina primary voters conducted for the Associated Press by NORC at the University of Chicago.

The survey was conducted for seven days, concluding as polls closed, and is based on interviews conducted in English and Spanish with a random sample of 1,499 registered voters drawn from the state voter file. The margin of sampling error for results based on the full sample is plus or minus 4 percentage points. Find more details about AP VoteCast’s methodology here.

Updated: March 1, 2020 at 1:00pm EST

Early in the 2020 presidential election cycle, one consistent message from Democratic voters so far is that health care is an important issue in deciding their vote.

In this February 2020 post for The JAMA Health Forum, Mollyann Brodie and Ashley Kirzinger examine the role health care has played in the primary election to date, what the polling data says about the issue, including Medicare-for-all and a public option, and what to expect from the issue during the rest of the 2020 election campaign.

Other contributions to The JAMA Forum are also available.

Democrats and Republicans in Congress have been working on legislation to protect patients from surprise medical bills. As of February 2020, no legislation has been passed. The term “surprise medical bills” is usually used to describe charges incurred when an insured individual inadvertently receives care from an out-of-network provider, however there are various other scenarios in which patients might encounter medical bills that they weren’t expecting.

The February KFF Health Tracking Poll gauged public worries about and experience with unexpected and surprise medical bills.

Two in three adults worry about unexpected medical bills

About two-thirds of Americans say they are either “very worried” (35%) or “somewhat worried” (30%) about being able to afford unexpected medical bills. This is larger than the share that say they are worried about affording a variety of expenses, including other types of health care costs as well as other household expenses. About half of insured adults say they worry about being able to afford their health insurance deductible (49%) and four in ten (40%) worry about being able to afford their premiums. More than four in ten adults overall worry about affording prescription drug costs (45%). Similar shares say they worry about affording their rent or mortgage (42%) and gasoline or other transportation costs (40%) and more than a third of adults say they worry about being able to afford utilities (38%) and food (34%).

Among insured adults, those ages 18-64 (65%) are more likely than those 65 and over (54%), most of whom have Medicare coverage, to say they are at least “somewhat worried” about unexpected medical bills. Among adults ages 18-64 without insurance, an even larger share (81%) say they are at least somewhat worried.

One-third of insured adults, 18-64, report RECEIVing An UNEXPECTED MEDICAL BILL IN THE PAST two YEARs

One-third of insured adults ages 18-64 say there has been a time in the past two years when they received an unexpected medical bill after they or a family member received care from a doctor, hospital, or lab that they thought was covered and their health plan either didn’t cover the bill at all or covered less than they expected. Overall, 16% of insured adults ages 18-64 say they have received a “surprise” bill related to care received from an out-of-network provider.

Unexpected medical bills can be of varying amounts. About half (49%) of those who report receiving an unexpected medical bill (16% of all insured adults ages 18-64) say the amount they were expected to pay was less than $500. One-third of those who received an unexpected bill (11% of all insured adults ages 18-64) say the amount was $1000 or more.

Even relatively small unexpected medical bills can present a financial hardship for some individuals. When asked how they would pay an unexpected $500 medical bill, 54% of insured adults, ages 18-64 say they would pay the bill in full at the time of service or put it on a credit card and pay it off at the next statement, while more than four in ten (45%) would not be able to immediately afford the $500 unexpected medical bill.

While more than seven in ten insured adults ages 18-64 with household incomes of $90,000 or more (76%) say they would pay their bill in full at the time of service or put it on a credit card and pay it off at the next statement, seven in ten of those with household incomes under $40,000 (72%) would not immediately be able to afford a $500 unexpected medical bill.

Public Wants Congress to take action on surprise Billing

As Congress continues to work on legislation to address surprise medical bills, this month’s KFF Health Tracking Poll finds broad public support for federal government actions to protect patients. At least two-thirds of the public say the federal government should take action to protect patients from covering the cost of care when they are taken to an emergency room by an out-of-network ambulance (72%), when they are taken to an out-of-network emergency room during a medical emergency (69%), or when they are at an in-network hospital but treated by an out-of-network doctor or specialist (67%).

Across partisans, more than eight in ten Democrats and more than two-thirds of independents think the federal government should take action to protect patients from having to pay costs not covered by their insurance when they are taken to an emergency room by an out-of-network ambulance, taken to an out-of-network emergency room during a medical emergency, or when they are at an in-network hospital but treated by an out-of-network doctor. Among Republicans, about half think the federal government should take action to protect patients from surprise bills in these situations.