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Governor Doug Ducey officially designates November 19, 2020, Ruralth Health Day in Arizona.

Early in the pandemic it became clear certain groups suffered more from COVID-19, the disease caused by the novel coronavirus SARS-CoV-2. In particular, African Americans, Hispanics/Latinos and Native Americans not only were diagnosed with COVID-19 in disproportionate numbers, but also were more likely to suffer serious health consequences or die from the disease. Their populations account for more than half of all reported U.S. cases, which now have surpassed 8 million.

Sairam Parthasarathy, MD, chief of the UArizona Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, leads the Arizona effort to reduce disparities in underrepresented communities in COVID-19 research and clinical trials. Sairam Parthasarathy, MD, chief of the UArizona Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, leads the Arizona effort to reduce disparities in underrepresented communities in COVID-19 research and clinical trials. 

In response, the National Institutes of Health, as part of an 11-state effort to address such health disparities, has awarded $12 million for outreach and engagement efforts in ethnic and racial minority communities disproportionately affected by COVID-19. This 11-state alliance created by the NIH is called the Community Engagement Alliance Against COVID-19 Disparities, or CEAL. Teams in Alabama, Arizona, California, Florida, Georgia, Louisiana, Michigan, Mississippi, North Carolina, Tennessee and Texas have received initial funding to create CEAL programs immediately.

“It was clear to us early in the pandemic the University of Arizona needed to reach out and assist communities across the state to help understand and fight COVID-19,” said University of Arizona President Robert C. Robbins, MD. “With this support from the NIH, we will be able to work closely with Arizona’s other public universities and other partners to look at why specific populations in the United States are suffering at a much greater rate from COVID-19. It also builds on a recent commitment by the Tohono O’odham Nation to give $1 million toward efforts to accelerate the work of University of Arizona researchers to create new and more efficient, effective and affordable COVID-19 tests.”

In Arizona, the CEAL program is being led by Sairam Parthasarathy, MD, the program’s lead principal investigator and chief of the Division of Pulmonary, Allergy, Critical Care and Sleep Medicine in the UArizona College of Medicine – Tucson. Co-investigators for the UArizona Health Sciences effort include: Tracy Crane, PhD; Daniel Derksen, MD; Kacey Ernst, PhD, MPH; Fayez Ghishan, MD; Nirav Merchant and Francisco Moreno, MD.

“This collaborative effort, which seeks to help ease the burden on some of Arizona’s most vulnerable populations, also will increase their participation in the development of vaccines and clinical therapies to fight this dreadful disease,” said Michael D. Dake, MD, UArizona Health Sciences senior vice president. “The Arizona team’s collaborative outreach efforts can only make these potential remedies more effective in addressing the disparate health impact of COVID-19.”

Tracy Crane, PhD, RD, a UArizona assistant professor of nursing and public health and co-director, Behavioral Measurement and Interventions Shared Resource for the Cancer Prevention and Control Program, UArizona Cancer CenterTracy Crane, PhD, RD, a UArizona assistant professor of nursing and public health and co-director, Behavioral Measurement and Interventions Shared Resource for the Cancer Prevention and Control Program, UArizona Cancer Center

Splitting a $1 million, one-year subcontract award, the UArizona Health Sciences team – along with researchers from Arizona State University, Northern Arizona University and Mayo Clinic in Scottsdale – have formed the Arizona CEAL COVID Consortium, or AC3. As AC3 co-principal investigators, Sabrina Oesterle, PhD, leads the ASU effort, Samantha Sabo, DrPH, leads the NAU effort, Chyke Abadama Doubeni, MD, leads the Mayo Clinic effort and Floribella Redondo Martinez heads up the effort by the Arizona Community Health Workers Association. Their overarching goal is to conduct community-engaged research and outreach to increase COVID-19 awareness and education among communities disproportionately affected by COVID-19 and to reduce misinformation and mistrust.

“Community engagement is the cornerstone for performing highly relevant and impactful health disparities research,” Dr. Parthasarathy said. “ASU, Mayo, NAU and University of Arizona investigators under AC3 will work closely with community advisers to identify urgent unmet needs and rapidly develop and tailor existing infrastructures, such as AZCOVIDTXT, and a diverse workforce of community health workers.”

The AZCOVIDTXT initiative, which allows volunteers to relay household health information anonymously via a two-way text messaging service, was created this past spring by a team of UArizona researchers to better track COVID-19 and gather and disseminate information about available resources for those affected.

“With the AC3 CEAL initiative,” Dr. Crane said, “we will be able to better understand the needs of our underrepresented – or, in this case, overrepresented – communities to meet their needs via tailoring of AZCOVIDTXT, as well as utilizing community health workers through a toll-free health number that will link directly to the community health workers so people who don’t have a smart cellphone can receive the same help and information.”

The initiative also will involve mobile health units, such as those deployed in the Phoenix and Tucson areas by the UArizona Mel and Enid Zuckerman College of Public Health in outreach to Spanish-speaking communities, as well as additional outreach to rural and Native American communities throughout the state.

This multiprong approach, Dr. Parthasarathy said, aims to establish effective, culturally appropriate strategies to enhance participation of communities disproportionally affected by COVID-19 in research designed to advance the prevention and treatment of COVID-19 and reduce the burden of disease on the hardest-hit communities. They will do that, in part, by leveraging existing relationships with more than 30 Arizona community-based organizations and partners. These steps aim to help community organizations address misinformation, build trust and broaden awareness to reduce the overall impact of COVID-19. A key focus will be to promote and facilitate inclusion and participation of these ethnic and racial groups in vaccine and therapeutic clinical trials to prevent and treat the disease.

They also will promote nationally developed information resources and a clinical trial patient registry. Dr. Parthasarathy pointed out that even though half of all COVID-19 cases are among minority/ethnic groups, only a small proportion of participants who signed up for clinical trials are from these underrepresented communities. You can follow the AC3 initiative via Twitter here.

“One of our tasks,” Dr. Parthasarathy said, “is to enable greater awareness for coronavirus information available at the coronaviruspreventionnetwork.org website, which is the NIH COVID-19 Prevention Network that is orchestrating these clinical research studies related to vaccines and other therapeutic remedies. The site not only disseminates educational material and resources in multiple languages, but also establishes a COVID-19 volunteer registry for potential research participants.”

About the University of Arizona Health Sciences
The University of Arizona Health Sciences is the statewide leader in biomedical research and health professions training. UArizona Health Sciences includes the Colleges of Medicine (Tucson and Phoenix), Nursing, Pharmacy, and the Mel and Enid Zuckerman College of Public Health, with main campus locations in Tucson and the Phoenix Biomedical Campus in downtown Phoenix. From these vantage points, Health Sciences reaches across the state of Arizona, the greater Southwest and around the world to provide next-generation education, research and outreach. A major economic engine, Health Sciences employs nearly 5,000 people, has approximately 4,000 students and 900 faculty members, and garners $200 million in research grants and contracts annually.

EASTERN ARIZONA COURIER | By Kim Smith editor@eacourier.com | Oct 23, 2020

Gila Valley residents could soon see expanded cardiology, wound care and inpatient dialysis services if things go as planned for Mt. Graham Regional Medical Center.

The hospital is taking the final steps necessary to be designated a critical access hospital, which would allow it to be reimbursed differently by Medicare and Medicaid.

A public meeting was held Thursday night to inform Gila Valley residents about the effort and as part of the application process.

Hospital CEO Roland Knox and Jill Bullock from the Arizona Center for Rural Health, which is helping the hospital during the process, spoke to roughly a dozen people at Graham County’s general services building.

Right now, the hospital is reimbursed a lump sum of money based on a diagnosis code and it doesn’t matter if the patient takes a few days longer to recover in the hospital than anticipated, Knox said.

If the hospital receives the critical access designation, the reimbursements will become cost-based, he said.

The additional funding would allow the hospital to expand services, including cardiology, Knox said.

More than 200 rural hospitals closed in the 1990s because the payment system wasn’t working, Bullock said. As a result, lawmakers passed the Medicare Rural Hospital Flexibility Program in 1997 to make changes to the payment system and improve the health and wellness of people living in rural communities.

There are 15 critical access hospitals in Arizona right now and both Mt. Graham Regional Medical Center and San Carlos Apache Healthcare Corporation are seeking the designation, Bullock said. Nationally, 22 percent of all hospitals have the designation.

In order to become a critical access hospital, the hospital must be located in a rural area 35 miles or more from another hospital and provide 24/7 emergency care, she said. The hospital must also have no more than 25 acute care and swing beds.

Knox explained that Mt. Graham will be losing 23 medical/surgical beds and one bed in obstetrics, but adding 10 observation beds if it receives the CAH designation.

However, the CEO stressed that over the last four years, the medical/surgery unit usually only had five or six patients a day anyway. The obstetrics unit averaged three patients a day.

If the hospital had designated observation beds over the last four years, it would’ve averaged five or six patients a day.

Overall, the hospital only has a 33 percent occupancy rate right now, Knox said. Once the hospital is designated a critical access hospital, the occupancy rate will be around 46 percent.

Besides the cost-based reimbursements from Medicare, another benefit to being a critical access hospital is getting access to educational resources, technical assistance and funding for special projects, Bullock said.

Over the next couple of months, the hospital and Arizona Center for Rural Health will finish up the application, sent it to the Arizona Department of Health Services and then on to the Centers for Medicare and Medicaid Services.

If all goes well, Knox said the hospital will get the designation by spring.

MedScape Family Medicine | by Leigh Page | August 12, 2020

Physicians — like all Americans — are trying to size up Joe Biden's healthcare agenda, which the Democratic presidential nominee has outlined in speeches and on his official website.

Many healthcare professionals, patients, and voters of all political stripes think our current healthcare system is broken and in need of change, but they don't agree on how it should change. In Part I of this article, we take a look at Biden's proposals for changing the US healthcare system. Then, we include comments and analysis from physicians on both sides of the fence regarding the pros and cons of these proposed healthcare measures.

Part 1: An Overview of Biden's Proposed Healthcare Plan

Biden's proposed healthcare plan has many features. The main thrust is to expand access to healthcare and increase federal subsidies for health coverage.

If elected, “I’ll put your family first,” he said in a speech in June. “That will begin the dramatic expansion of health coverage and bold steps to lower healthcare costs.” He said he favored a plan that “lowers healthcare costs, gets us universal coverage quickly, when Americans desperately need it now.”

Below are Biden's major proposals. They are followed by Part 2, which assesses the proposals on the basis of comments by doctors from across the political spectrum.

Biden Says We Should Restore the ACA

At a debate of the Democrat presidential candidates in June 2019, Biden argued that the best way to expand coverage is "to build on what we did during the Obama administration," rather than create a whole new healthcare system, as many other Democratic candidates for president were proposing.

“I’m proud of the Affordable Care Act,” he said a year later in his June 2020 speech. "”n addition to helping people with preexisting conditions, this is the law that delivered vital coverage for 20 million Americans who did not have health insurance.”

At the heart of the ACA are the health insurance marketplaces, where people can buy individual insurance that is often federally subsidized. Buyers select coverage at different levels ― Gold, Silver, and Bronze. Those willing to pay higher premiums for a Gold plan don't have high deductibles, as they would with the Silver and Bronze plans.

Currently, federal subsidies are based on premiums on the Silver level, where premiums are lower but deductibles are higher than with the Gold plan. Biden would shift the subsidies to the Gold plan, where they would be more generous, because subsidies are pegged to the premiums.

In addition, Biden would remove the current limit on subsidies, under which only people with incomes less than 400% of the federal poverty level qualify for them. “Many families making more than 400% of the federal poverty level (about $50,000 for a single person and $100,000 for a family of four), and thus not qualifying for financial assistance, still struggle to afford health insurance,” the Biden for President website states.

Under the Biden plan, there would still be a limit on insurance payments as a percentage of income, but that percentage would drop, meaning that more people would qualify. Currently, the level is 9.86% or more of a person's income; Biden would lower that level to 8.5%.

“We’re going to lower premiums for people buying coverage on their own by guaranteeing that no American ever has to spend more than 8.5% of their income on health insurance, and that number would be lower for lower-income people,” Biden said in the June speech.

Add a Public Option, but Not Medicare for All

In the primary, Biden parted company from rivals who backed Medicare for All, a single-payer health system that would make the government pay for everyone's healthcare. “I understand the appeal of Medicare for All,” he said in a video released by his campaign. “But folks supporting it should be clear that it means getting rid of Obamacare, and I'm not for that.”

However, Biden embraced a “public option” that would allow people to buy into or be subsidized into "a Medicare-like" plan. It is unclear how similar the public option would be to regular Medicare coverage, but the Biden campaign has made it clear that it would not take funds from the Medicare trust fund, which is expected to start losing funds by 2026.

The more than 150 million Americans who have employer-sponsored insurance could keep it, but they could still buy into the public option if they wanted to. In addition, the public option would automatically enroll ― at no cost to them ― some 4.8 million low-income Americans who were excluded from the ACA's Medicaid expansion when many states chose to opt out of the Medicaid expansion.

In addition, the 37 states that participate in expanded Medicaid could switch coverage to the new public option, provided that they continue to pay their current share of the costs. (In June, Oklahoma became the 37th state to allow the expansion, following the results of a ballot measure.)

“We need a public option now more than ever, especially when more than 20 million people are unemployed,” Biden said in the June speech. “That public option will allow every American, regardless of their employment status, the choice to get a Medicare-like plan.”

Lower the Medicare Age

In spring 2020, Biden proposed lowering the age to qualify for Medicare from 65 to 60. This provision is not included among the official policies listed on the Biden for President website, but it has been cited by many, including the Biden-Sanders Unity Task Force.

This provision would bring almost 23 million people into Medicare, including 13.4 million from employer-sponsored coverage, according to one analysis. It's not clear whether these people would buy into Medicare or simply be covered. Their care would not be paid for by the Medicare Trust Fund but would use tax dollars instead.

Provide Relief in the Covid-19 Pandemic

Biden would cover the cost of COVID-19 testing and the cost of health coverage for people laid off during the pandemic.

“Testing unequivocally saves lives, and widespread testing is the key to opening our economy again,” Biden said in his June speech. “To fix the economy, we have to get control over the virus.”

Prescription Drug Reform

Biden would repeal a Bush-era exception that bars the Medicare program from negotiating prescription drug prices for the Part D prescription drug benefit. “There’s no justification for this except the power of prescription drug lobbying,” the Biden for President website states.

In addition Biden's prescription drug reform plan would do the following:

• Limit launch prices for drugs. The administration would establish an independent review board that would assess the value of new drugs and would have the power to set limits on their prices. Such drugs are “being abusively priced by manufacturers,” the Biden for President site says.

• Limit price increases to inflation. As a condition of participation in government programs, drug prices could not rise more than the general inflation rate. Biden would impose a tax penalty on drugmakers whose prices surpassed inflation.

• Allow consumers to buy prescription drugs from other countries. Biden would allow consumers to import prescription drugs from other countries, provided the US Department of Health and Human Services certifies that those drugs are safe.

• Stop tax breaks for pharma ads: Biden would drop drugmakers’ tax breaks for advertising, which amounted to $6 billion in 2016.

Stop Surprise Billing

Biden proposes to stop surprise billing, which occurs when patients receive care from a doctor or hospital that is not in their insurer's network. In these situations, patients can be surprised with very high bills because no payment limit has been negotiated by the insurer.

Twenty-eight states have enacted consumer protections to address surprise medical billing, but Congress has not passed such a measure. One proposed solution is to require payers to pay for out-of-network services on the basis of a benchmark, such as the average Medicare rate for that service in a specific geographic area.

Closely Monitor Healthcare Mergers

Biden would take a more active stance in enforcing antitrust laws against mergers in the healthcare industry.

“The concentration of market power in the hands of a few corporations is occurring throughout our health care system, and this lack of competition is driving up prices for consumers,” the Biden for President website states.

Overhaul Long-term Care

Biden’s latest plan calls for a $775 billion overhaul of the nation's caregiving infrastructure. Biden says he would help create new jobs, improve working conditions, and invest in new models of long-term care outside of traditional nursing homes.

Restore Funding for Planned Parenthood

Biden would reissue guidance barring states from refusing Medicaid funding for Planned Parenthood and other providers that refer for abortions or that provide related information, according to the Biden for President website. This action would reverse a Trump administration rule.

Boost Community Health Centers

Biden promises to double federal funding for community health centers, such as federally qualified health centers, that provide care to underserved populations.

Support Mental Health Parity

Biden says he supports mental health parity and would enforce the federal mental health parity law and expand funding for mental health services.

Part 2: Physicians’ Opinions on Biden's Healthcare Plans: Pro and Con

Biden’s plans to expand coverage are at the heart of his healthcare platform, and many see these as the most controversial part of his legislative agenda.

Biden's Medicare expansion is not Medicare for All, but it can be seen as “Medicare for all who want it.” Potentially, millions of people could enter Medicare or something like Medicare. If the Medicare eligibility age is dropped to 60, people could switch from their employer-sponsored plans, many of which have high deductibles. In addition, poor people who have no coverage because their states opted out of the Medicaid expansion would be included.

The possibility of such a mass movement to government-run healthcare alarms many people. “Biden's proposals look moderate, but it is basically Medicare for All in sheep’s clothing,” said Cesar De Leon, DO, a family physician in Naples, Florida, and past president of the county’s medical society.

Reimbursements for Doctors Could Fall

A shift of millions of people into Medicare would likely mean lower reimbursements for doctors. For example, the 13.4 million people aged 60 to 65 who would switch from employer-sponsored coverage to Medicare would be leaving some of the best-paying insurance plans, and their physicians would then be reimbursed at Medicare rates.

“Biden’s plan would lower payments to already cash-strapped doctors and hospitals, who have already seen a significant decrease in reimbursement over the past decade,” De Leon said. “He is trying to win the support of low-income voters by giving them lower healthcare prices, which doctors and hospitals would have to absorb.”

“Yes, the US healthcare system is dysfunctional,” De Leon added, “but the basic system needs to be fixed before it is expanded to new groups of people.”

The American Association of Neurological Surgeons/Congress of Neurological Surgeons warns against Biden’s proposed government-run system. “We support expanding health insurance coverage, but the expansion should build on the existing employer-based system,” said Katie O. Orrico, director of the group's Washington office. “We have consistently opposed a public option or Medicare for All.” 

“Shifting more Americans into government-sponsored healthcare will inevitably result in lower payments for physicians’ services,” Orrico added. “Reimbursement rates from Medicare, Medicaid, and many ACA exchange plans already do not adequately cover the costs of running a medical practice.”

Prospect of Higher Taxes

Paying for ambitious reforms means raising taxes. Biden’s plan would not make the Medicare trust fund pay for the expansions and would to some extent rely on payments from new beneficiaries. However, many new beneficiaries, such as people older than 60 and the poor, would be covered by tax dollars.

Altogether, Biden's plan is expected to cost the federal government $800 billion over the next 10 years. To pay for it, Biden proposes reversing President Trump's tax cuts, which disproportionately helped high earners, and eliminating capital gains tax loopholes for the wealthy.

“Rather than tax the average American, the Democrats will try to redistribute wealth,” De Leon said.

“The elephant in the room is that taxes would have to be raised to pay for all these programs,” said Gary Price, MD, president of the Physicians Foundation. Because no one likes higher taxes, he says, architects of the Biden plan would try to find ways to save money, such as tamping down reimbursements for physicians, to try to avoid a public backlash against the reforms.

“Physicians’ great fear is that efforts to keep taxes from getting too high will result in cutting physician reimbursement,” he said.

Impact of COVID-19

Perhaps an even larger barrier to Biden’s health reforms comes from the COVID-19 crisis, which didn’t exist last year, when health reform was the central issue in the presidential primary that pitted Biden against Vermont Senator Bernie Sanders, the chief proponent of Medicare for All.

“The top two issues on voters’ minds right now are the pandemic and the economy,” said Daniel Derksen, MD, a family physician who is professor of public health policy at the University of Arizona in Tucson. “Any other concerns are pushed down the list.”

The COVID-19 crisis is forcing the federal government to spend trillions of dollars to help businesses and individuals who have lost income because of the crisis. Will there be enough money left over to fund an ambitious set of health reforms?

“It’s not a good time to start reforms,” warned Kevin Campbell, MD, a cardiologist in Raleigh, North Carolina. “Given the current pressures that COVID-19 has placed on physicians, healthcare systems, and hospitals, I don’t believe that we can achieve meaningful change in the near term.”

However, supporters of Biden’s reforms think that now, during the COVID-19 crisis, is precisely the right time to enact healthcare reform. When millions of Americans lost their jobs because of the pandemic, they also lost their insurance coverage.

“COVID-19 has made Biden’s healthcare agenda all the more relevant and necessary,” said Don Berwick, MD, who led the Center for Medicare & Medicaid Services (CMS) under President Obama. “The COVID-19 recession has made people more aware of how vulnerable their coverage is.”

Orrico at the neurosurgeons group acknowledges this point. “The COVID-19 pandemic has exposed some cracks in the US healthcare system,” she said. “Whether this will lead to new reforms is hard to say, but policymakers will likely take a closer look at issues related to unemployment, health insurance coverage, and healthcare costs due to the COVID-19 emergency.”

Many Physicians Want Major Reform

Although many doctors are skeptical of reform, others are impatient for reform to come and support Biden's agenda ― especially its goal to expand coverage.

“Joe Biden's goal is to get everyone covered,” said Alice Chen, MD, an internist who is a leader of Doctors for Biden, an independent group that is not part of the Biden campaign. “What brings Democrats together is that they are united in the belief that healthcare is a right.”

In January, the American College of Physicians (ACP) endorsed both Medicare for All and the public option. The US healthcare system “is ill and needs a bold new prescription,” the ACP stated.

The medical profession, once mostly Republican, now has more Democrats. In 2016, 35% of physicians identified themselves as Democrats, 27% as Republicans, and 36% as independents.

Many of the doctors behind reform appear to be younger physicians who are employed by large organizations. They are passionate about reforming the healthcare system, and as employees of large organizations, they would not be directly affected if reimbursements fell to Medicare levels ― although their institutions might subsequently have to adjust their salaries downward.

Chen, for example, is a young physician who says she has taken leave from her work as adjunct assistant clinical professor of medicine at the University of California, Los Angeles, to raise her young children.

She is the former executive director of Doctors for America, a movement of thousands of physicians and medical students “to bring their patients' experiences to policymakers.”

“Doctors feel that they are unseen and unheard, that they often feel frankly used by large health systems and by insurance companies,” Chen said. “Biden wants to hear from them.”

Many idealistic young physicians look to health system leaders like Berwick. “I believe this nation needs to get universal coverage as fast as we can, and Biden’s policies present a path to get there,” the former CMS director said. "”his would be done chiefly through Biden’s public option and his plans to expand coverage in states that have not adopted the ACA Medicaid expansion.”

But what about the potential effect of lowering reimbursement rates for doctors? “The exact rates will have to be worked out,” Berwick said, “but it’s not just about who pays physicians, it’s about how physicians get paid.” He thinks the current fee-for-service system needs to be replaced by a value-based payment system such as capitation, shared savings, and bundled payments.

The Biden-Sanders Task Force

Berwick was a member of the Biden-Sanders Unity Task Force, which brings together supporters of Biden and Sanders to create a shared platform for the Biden campaign.

Is the Nation Ready for Another Health Reform Battle?

Clearly, many Democrats are ready to reform the system, but is the nation ready? “Are American voters ready for another major, Democratic-led health reform initiative?” asked Patricia Salber, MD, an internist and healthcare consultant who runs a blog called The Doctor Weighs In.

“I’ve been around long enough to remember the fight over President Clinton’s health plan and then President Obama’s plan,” she said. Each time, she says, there seemed to be a great deal of momentum, and then there was a backlash. “If Biden is elected, I hope we don't have to go through the same thing all over again,” Salber said.

Derksen believes Biden’s proposed healthcare reforms could come close to rivaling President Obamas Affordable Care Act in ambition, cost, and controversy.

He shares Biden’s goal of extending coverage to all ― including paying the cost of covering low-income people. But the result is that “Biden's agenda is going to be a ‘heavy lift,’ as they say in Washington,” he said. “He has some very ambitious plans to expand access to care.”

Derksen speaks from experience. He helped draft part of the ACA as a health policy fellow in Capitol Hill in 2009. Then in 2011, he was in charge of setting up the ACA's insurance marketplace for the state of New Mexico.

Now Biden wants to begin a second wave of health reform. But Derksen thinks this second wave of reform could encounter opposition as formidable as those Obama faced.

“Assuming that Biden is elected, it would be tough to get this agenda passed ― even if he had solid Democratic majorities in both the House and Senate,” said Derksen,

According to polls by the Kaiser Family Foundation (KFF), 53% of Americans like the ACA, while 37% dislike it ― a split that has been relatively stable for the past 2 years, since the failed GOP effort to repeal the law.

In that KFF poll, the public option fared better ― 68% of Americans support the public option, including 42% of Republicans. These numbers help explain why the Biden campaign moved beyond its support of the ACA to embrace the public option as well.

Even when Democrats gain control of all the levers of power, as they did in 2009, they still have a very difficult time passing an ambitious healthcare reform bill. Derksen remembers how tough it was to get that massive bill through Congress.

The House bill’s public option might have prevailed in a reconciliation process between the two bills, but that process was cut short when Sen. Ted Kennedy died and Senate Democrats lost their filibuster-proof majority. The bill squeaked through as the Senate version, without the public option.

The ACA Has Survived

The ACA is much more complex piece of legislation than the public option.

“The ACA has survived for a decade, despite all efforts to dismantle it,” Salber said. “Biden wants to restore a law that the Republicans have been chipping away at. The Republicans eliminated the penalty for not having coverage. Think about it, a penalty of zero is not much of a deterrent.”

It was the loss of the ACA penalty in tax year 2019 that, paradoxically, formed the legal basis for the latest challenge of the ACA before the Supreme Court, in a suit brought by the Trump administration and 18 Republican state attorneys general.

The Supreme Court will make its ruling after the election, but Salber thinks the suit itself will boost both Biden and the ACA in the campaign. “I think most people are tired of all the attempts to repeal the ACA,” she said.

“The public now thinks of the US healthcare system as pathetically broken,” she added. “It used to be that Americans would say we have the best healthcare system in the world. I don’t hear that much anymore.”

Physicians who oppose the ACA hold exactly the opposite view. “Our healthcare system is in a shambles after the Obamacare fiasco,” Campbell said. “Even if Biden has a Democrat-controlled House and Senate, I still don’t think that there would be enough votes to pass sweeping changes to healthcare.”

Biden Could Choose Issues Other Than Expanding Access

There are plenty of proposals in the Biden healthcare plan that don't involve remaking the healthcare system.

These include making COVID-19 testing free, providing extra funding for community health centers, and stopping surprise billing. Proposals such as stepping up antitrust enforcement against mergers would involve administrative rather than Congressional action.

Some of these other proposals could be quite expensive, such as overhauling long-term care and paying for health insurance for laid-off workers. And another proposal ― limiting the prices of pharmaceuticals ― could be almost as contentious as expanding coverage.

“This proposal has been talked about for many years, but it has always met with strong resistance from drugmakers,” said Robert Pearl, MD, former CEO of the Permanente Medical Group and now a faculty member at Stanford School of Medicine and Graduate School of Business.

Pearl thinks the first item in Biden's drug plan ― to repeal a ban against Medicare negotiating drug prices with drugmakers ― would meet with Congressional resistance, owing to heavy lobbying and campaign contributions by the drug companies.

In addition, Pearl thinks Biden's plans to limit drug prices ― barring drugmakers from raising their prices above the general inflation rate and limiting the launch prices for many drugs ― enter uncharted legal waters and could end up in the courts.

Even Without Reform, Expect Lower Reimbursements

Although many doctors are concerned that Biden's healthcare reforms would reduce reimbursements, Pearl thinks reimbursements will decline even without reforms, owing in part to the COVID-19 pandemic.

Employer-based health insurance has been the bedrock of the US healthcare system, but Pearl says many employers have long wanted to get rid of this obligation. Increasingly, they are pushing costs onto the employee by raising deductibles and through premium sharing.

Now, with the pandemic, employers are struggling just to stay in business, and health insurance has truly become a financial burden, he says. In addition, states will be unable to balance their budgets and will try to reduce their Medicaid obligations.

“Before COVID-19 hit, healthcare spending was supposed to grow by 5% a year, but that won't happen for some time into the future,” Pearl said. “The COVID economic crisis is likely to continue for quite some time, forcing physicians to either accept much lower payments or find better ways to provide care.”

Like Berwick, Pearl believes healthcare will have to move to value-based payments. “Instead of producing more services, doctors will have to preserve resources, which is value-based healthcare,” he said. The primary form of value-based reimbursement, Pearl thinks, will be capitation, in which physicians agree to quality and service guarantees.

Even steadfast opponents of many of Biden's reforms foresee value-based payments taking off. “Certainly, there are ways to improve the current healthcare system, such as moving to value-based care,” said Orrico at the neurosurgeons group.

In short, a wide swath of observers agree that doctors are facing major changes in the payment and delivery of healthcare, regardless of whether Biden is elected and succeeds with his health agenda.

By Josh Ortega/Cronkite News | Sept. 24, 2020

WASHINGTON – The number of Arizonans without health insurance jumped to more than 800,000 last year, the third consecutive year of increases for the state, according to the latest data from the Census Bureau.

The number of uninsured also rose nationwide, but not as sharply as in Arizona. Nationally, the share of people without insurance rose from 8.9% in 2018 to 9.2% last year, the bureau said, while Arizona went from 10.6% to 11.3% in the same period.

And health experts in Arizona note that the latest numbers do not reflect the onset of the COVID-19 pandemic earlier this year, which likely makes for an even gloomier picture this year.

“Probably anything you look at that’s estimated, as far as our uninsured rate, is an undercount of where things are right now,” said Dr. Dan Derksen, associate vice president of health sciences at the University of Arizona.

Analysts attribute the rise to a number of factors, not the least of which is uncertainty about the availability of coverage under the Affordable Care Act after years of attack by the Trump administration.

Allen Gjersvig, director of outreach and enrollment services for Arizona Alliance for Community Health Centers, points to what he calls an “awareness and education problem” that has left some uninsured unaware that they might still qualify for affordable coverage under the ACA, or Obamacare.

Gjersvig said “the vast majority” of the 809,000 uninsured people in Arizona could qualify for a tax credit that covers most of their monthly premiums, which could end up being less than $100 per month out of pocket. Some could even qualify for the tax credit and a reduction in deductibles and co-pay that Gjersvig said could cut out-of-pocket expenses to “less than $1 per month.”

“Based on Kaiser Family Foundation for 2018 data, we estimate that 323,000 or more Arizonans are eligible for no-cost coverage (AHCCCS) or low-cost coverage from the health insurance marketplace,” Gjersvig said.

The number of uninsured has crept up steadily for the past three years, after sharp drops after 2014 when the state expanded eligibility for coverage under the Arizona Health Care Cost Containment System, the state’s Medicaid system.

Currently, families earning up to 138% of the federal poverty level can qualify for Medicaid coverage in Arizona. The federal poverty threshold varies according to family size, but in 2019 it was set at $25,926 for a family of two parents and two children under 18 – so a family of four making about $35,000 would meet the 138% threshold.

Derksen said another factor behind the loss in insurance is the fact that U.S. health care remains “needlessly” complicated, with information so “fragmented” between different places that it requires navigators to help people understand the system.

That is not the case in other developed countries, which deliver health care at a much lower cost per capita, Derksen said. He pointed to an article in the Journal of the American Medical Association that said wasteful spending on fraud, abuse and administrative costs contribute to almost $1 trillion of the $4 trillion that is spent annually on health care in the U.S.

One resource Gjersvig recommends to people looking for insurance coverage is the Cover ArizonaCoalition through Vitalyst, a coalition of resources throughout the state that helps people navigate the healthcare marketplace in Arizona.

He also touted two national grants that he said have helped his organization work with more than 180 locations across the state to have certified application counselors help consumers navigate the health insurance marketplace.

Arizona’s 11.3% uninsured rate last year tied with North Carolina for ninth-worst in the nation. Texas had the highest rate of uninsured residents, at 18.4%, while Massachusetts was lowest, with a 3% rate.

With a pandemic raging and an election nearing, health care remains one of the top priorities for many Americans, Derksen said. He encouraged voters to consider all health care options this fall.

“It doesn’t have to be a binary choice of Medicare-for-all vs. the private sector,” Derksen said. “Those aren’t the only two choices.”

Open enrollment for coverage through the federally facilitated ACA Marketplace starts Nov 1 and runs through Dec. 15.

KAISER HEALTH NEWS | By Phil Galewitz | Oct 8, 2020

Health insurance costs for Americans who get their coverage through work continued a relentless march upward with average family premiums rising 4% to $21,342 this year, according to a study published Thursday.

The annual survey by KFF found workers on average are paying nearly $5,600 this year toward family coverage, up from about $4,000 in 2010 and $1,600 in 2000. (KHN is an editorially independent program of KFF.)

While health insurance costs rose a modest amount in 2020, as has been the trend in recent years, they soared 55% in the past decade — more than twice the pace of inflation and wages.

About 157 million Americans rely on employer-sponsored coverage — far more than any other type of coverage, including Medicare, Medicaid and individually purchased insurance on the Affordable Care Act exchanges. More than half of employers provide insurance to at least some workers.

“Conducted partly before the pandemic, our survey shows the burden of health costs on workers remains high, though not getting dramatically worse,” Drew Altman, KFF’s CEO, said in a statement. “Things may look different moving forward as employers grapple with the economic and health upheaval sparked by the pandemic.”

The survey was conducted from January to July as the coronavirus pandemic took hold and upended the nation’s economy. Many of the details of the employers’ plans that the researchers examined were set before the virus hit.

Since 2012, the cost of family coverage has increased 3% to 5% annually. It’s been more than 15 years since these costs were rising at double-digit rates.

Employers help shield workers from much of the cost of their health insurance premiums, though employees often feel the impact via higher deductibles, copayments and lower wages.

On average, workers pay 17% of the premium for single coverage and 27% for family coverage, the survey found. Workers at smaller companies pay 35% of the premium for family coverage, compared with 24% for larger companies, the survey found.

The average annual deductible for single coverage is now $1,644, up 25% in the past five years and 79% in the past decade.

Workers with coverage are exposed to higher costs when using the hospital since 65% have coinsurance, which means they are responsible for a fixed share of the charge, and 13% contribute a copayment, or fixed fee per visit or service. The average coinsurance for hospital admission is 20% and average copayment is $311 per hospital admission.

Workers are protected for catastrophic costs through limits set on their out-of-pocket spending in provider networks, although those amounts vary by employer: 11% face a maximum of less than $2,000, while 18% are in a plan with a maximum of $6,000 or more.

The study also noted that large employers have made it easier for workers to access care by adopting coverage for telemedicine in recent years. Nearly 9 in 10 companies that have 200 or more workers and offer insurance covered these medical appointments done via telephone or computer this year, up from fewer than 3 in 10 in 2015, according to the research. During the pandemic, telemedicine usage has increased markedly as people sought care from the safety of their home.

The KFF study is based on a telephone survey of 1,765 randomly selected nonfederal public and private employers with three or more workers from January to July.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

SHOTS | Health News from NPR | By Will Stone | Oct 7, 2020

Even when there isn't a pandemic, finding the right doctor can be tough in rural eastern Ohio. Reid Davis, 21, and his mother Crystal live in Jefferson County, which hugs the Ohio River near West Virginia. Their home is surrounded by farms, hayfields and just a few neighbors.

"To the nearest hospital, you're talking about 50 minutes to an hour," Reid Davis says.

Davis' mother has rheumatoid arthritis, a severe autoimmune condition, for which she sees a specialist. That doctor prescribes an injectable medication and also works on her joints to ease inflammation and pain, he says.

But when the pandemic began, that doctor stopped seeing patients. Nearly six months went by, and only recently was Crystal Davis able to resume in-person visits.

In the meantime, her condition got worse.

"There have been days where she's just been unwilling to get out of bed because of pain," Davis says.

There were only a few other rheumatologists within a two-hour drive and none of them were accepting new patients at the time.

Even before the pandemic, the health care systems that serve rural Americans were in decline: rural hospitals were closing their doors, and the medical workforce was shrinking. This year, as the coronavirus outbreak has made its way from major cities to rural America, threats to the rural health care infrastructure have only increased.

A new nationwide poll shows that one in every four rural U.S households have been unable to get medical care for serious problems. Among those households that had trouble getting care, more than half reported that a family member experienced negative health consequences as a result.

The poll was conducted by NPR, the Harvard T.H. Chan School of Public School and the Robert Wood Johnson Foundation.

"The crisis is really widening the fractures that have already existed in rural communities," says Brock Slabach, senior vice president of the National Rural Health Association, based in Kansas.

New coronavirus infections in rural America are now at record levels, with 54% of rural counties in the "red zone," defined as places with an infection rate of 100 or more new cases per 100,000 residents.

Only 14% of the U.S. population lives in rural counties, but last week 20% of new cases and 23% of COVID-19-related deaths were in rural counties, according to an analysis by The Daily Yonder, an online newspaper that covers rural America.

Rural Americans contacted for the NPR poll — from Montana to Georgia to upstate New York — discussed problems getting treatment for many types of health problems, including the virus.

In the U.S., one of the biggest obstacles to getting health care is the simple fact of not having health coverage, and people living in rural areas are more likely to be uninsured compared to other Americans. Not having insurance can also mean higher out-of-pocket payments for treatments or medications, on top of other pandemic-related financial stresses.

But the poll also revealed many non-financial obstacles. In interviews with NPR, rural respondents talked about being forced to cancel surgeries and procedures, waiting months for appointments, putting mental health care on hold, or spending hours on the road in search of specialists. Some talked specifically about their struggles to get a coronavirus test. Because of these problems, many were experiencing increased pain, anxiety or financial hardship.

Over the past 15 years, 174 rural hospitals have closed in the U.S. and the pandemic may be accelerating the trend. So far, 15 rural hospitals have closed in 2020, casualties of the pandemic-related shutdowns that forced hospitals to cancel elective surgeries, an important source of their revenue. Because of the pandemic, some people also avoided going to the hospital, even for life-threatening emergencies. Among the rural hospitals that remain, more than half don't have an intensive care unit, according to Slabach.

"As the hotspots grow, where do these people go? A lot of them have serious illnesses," says Harvard professor Robert J. Blendon, a co-director for the NPR poll.

Unlike major metro areas where hospitals have lots of beds, many smaller hospitals in geographically isolated places are not equipped to handle COVID-19 patients and other emergencies at the same time, Blendon says.

"People are hundreds of miles away and many rural hospitals have been deciding, 'Can I take anybody else but COVID?' " he says.

Long waits mean pain, delayed surgeries, and dental problems

The poll looked closely at two especially vulnerable groups: rural households that include someone living with a chronic illness, and rural households that include someone at high risk for a serious case of COVID-19 (due to age or underlying health conditions). In both groups, about a third of the households reported problems getting medical care.

"It's really scary that there's a very large number of rural households at risk at this point, and we haven't figured out a better way to provide care for them," says Mary Gorski Findling, a researcher with Harvard's polling team.

"The rural health care workforce was already disproportionately small," says professor Carrie Henning-Smith, who studies rural health at the University of Minnesota.

The pandemic disrupted a root canal for Stephen McDonald, and he ended up losing the entire tooth, and incurring additional costs.

McDonald lives about 70 miles outside of Missoula, Mont., and was left stranded after many doctors and dentists temporarily shut down their offices in the spring. His dentist had begun the root canal, but had to call off the follow-up appointment.

With limited options in his area, McDonald had to make do with the temporary filling.

"During that period of waiting, my tooth cracked and the tooth was no longer salvageable," McDonald says.

Even to remove the cracked tooth proved difficult. A local dentist couldn't see him, so McDonald went to a different dentist an hour away.

But that dentist could only extract a portion of the cracked tooth.

"Because of the procedures they had to follow for COVID, they weren't able to extract the rest of the tooth, so I had to go to an oral surgeon," he says.

While many health care providers tried to cope by using telehealth, it doesn't cover urgent problems that require hands-on treatment. In addition, the NPR poll found that a third of rural households have serious problems connecting to the Internet.

Slabach says ensuring people have adequate broadband connections would help, but even that wouldn't be enough.

"Many of our rural citizens are older, poorer and sicker, and so they don't have iPads. They don't have the necessary means, perhaps, to communicate," Slabach says.

Cynthia Davis, who lives in central Missouri, says she had lots of trouble using telehealth.

"I've got a small phone so I had a three-inch screen to do these online video appointments," Davis says of her efforts to use telehealth. "That did not work well, and even the phone would not work half the time."

Along with obstacles to health care, many rural households are under immense financial pressure during the pandemic, according to the NPR poll. More than 40% reported they are facing serious financial problems.

For Black and Latino households, the economic toll is especially stark in rural America. More than 80% of those households are facing serious financial problems, compared to only 36% of white rural households.

More than 40% of rural families also said at least one person in their household had lost a job, been furloughed, or had wages or hours reduced. In addition, more than half of families also shared that they are having serious problems caring for their children.

Even as more clinics and doctors have resumed in-person appointments, some patients are encountering long wait times because there are not enough providers in rural areas to handle the backlog of patients.

In Arkansas, Elizabeth Booher says she scrambled to get her husband to the right doctors, when he started having severe abdominal pain in early August.

Until last week, she kept hearing that the earliest he could get surgery was late October.

"He's lost a ton of weight because he can't eat," Booher says. "I feel like this is being elongated because doctors have been closed, and now they're just trying to play catch up."

Brett Corbett of Glens Falls, N.Y., says that last spring all of his doctor's appointments were called off. Corbett is in recovery for substance use disorder.

"All my mental health appointments got cancelled across the board," Corbett says. "It's December before anyone can get a doctor's appointment around here."

Even with so much attention on the coronavirus, some living in rural America are barely able to find tests.

Sunshine Peebles, who lives an hour outside Syracuse, N.Y., worried she might have COVID-19 when she spiked a fever.

"There's a lot of people who have access to free testing, where I am in upstate New York, that's not an option," Peebles says.

Peebles can't afford health insurance and says money was tight because her family's small construction business was out of work because of the pandemic.

"I should have gone sooner. I just couldn't wait any longer. I had to go to an urgent care," she says.

She had to pay $150 out of pocket. Luckily, her test result came back negative, but she knows others in her community have encountered similar problems.

"I think it's a big dilemma for people who live in the more rural areas," she says.