health insurance, Obamacare

A rise in insurer participation in the Affordable Care Act individual marketplace indicates that payers are anticipating a fruitful year ahead. The installation of a new president and ongoing Covid-19 pandemic appear to be driving this trend.

Over the past year, insurer participation in the ACA individual marketplace has grown and benchmark premiums have declined, according to a new analysis by the Robert Wood Johnson Foundation. The total number of insurance offerings sold on the marketplace is now 9,144, which is about 75% of the 2015 record high.

This suggests that insurers are anticipating increased enrollment as a result of federal policy changes and the impact of the Covid-19 pandemic, said Katherine Hempstead, senior policy adviser at RWJF and author of the analysis, in an email.

“The Biden administration has been emphatic about its commitment to the ACA marketplace,” she said. In particular, the administration has committed to preserving and expanding health coverage to help Americans during the pandemic.

In his American Rescue Plan, President Joe Biden called on Congress to subsidize continuation health coverage through the end of September and to expand and increase the value of the Premium Tax Credit. The latter move will help lower or eliminate health insurance premiums and ensure enrollees will not pay more than 8.5% of their income for coverage.

Further, Biden recently reopened the HealthCare.gov insurance markets for three months to enable Americans to sign up for coverage amid the ongoing pandemic.

Though these policy changes are temporary, there is a commitment on the part of the administration to try to make them permanent, Hempstead said.

Drilling down into participation among major insurers, Hempstead found that Anthem, UnitedHealth and Cigna currently comprise about two-thirds of the national commercial offerings on the individual marketplace. Centene, which dominates the Medicaid managed care organizations category, made its largest single-year increase, nearly doubling its marketplace offerings from 2020 to 2021.

In addition, participation by newcomers like Oscar and Bright Health has grown steadily. Bright Health is now in 10 states, and Oscar is in 19.

Another key analysis finding is that states that have yet to expand Medicaid saw increases in insurer participation. Increased participation in the ACA individual marketplace was particularly focused in Florida, Georgia, North Carolina and Texas, where the number of offerings increased by almost 50% in the last year.

“This is where the greatest number of uninsured people live, so it is the biggest opportunity for membership growth,” Hempstead said.

Looking ahead, it is clear that insurers are hopeful that a significant expansion in healthcare coverage is due, and they see the ACA marketplace as an increasingly important part of the coverage landscape, according to the analysis.

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A major concern during the Covid-19 pandemic has been that Americans, especially those with underlying conditions, will delay necessary care. New survey results show this concern is not unfounded.

As of last September, about 40% of Americans with one or more chronic health conditions reported delaying or avoiding care, according to a new report from the Urban Institute and Robert Wood Johnson Foundation.

Report authors analyzed data from the second wave of the Urban Institute’s Coronavirus Tracking Survey, a nationally representative survey conducted Sept. 11-28, 2020. The survey polled 4,007 adults, ages 18 to 64 years.

About 36% of Americans said they delayed or did not receive healthcare due to a fear of exposure to the coronavirus or because a provider limited services during the pandemic, the report states. Black adults (39.7%) were more likely than white (34.3%) or Hispanic/Latinx (35.5%) adults to report delaying or forgoing care because of concerns about virus exposure.

About four in 10 adults with one or more chronic health conditions (40.7%) said they delayed or avoided care because of the pandemic, as compared with 26.4% of adults with no chronic conditions.

In addition, more than half of adults with both a physical and mental health condition (56.3%) reported delaying or avoiding healthcare due to the pandemic. About 43% of this group also reported delayed or forgoing multiple types of care.

The impacts of delaying or avoiding care were acutely felt by those with chronic conditions, the report shows. An estimated 23.2% of these adults reported that going without or delaying care worsened a health condition, 21% said it limited their ability to perform daily activities and 15.2% said it limited their ability to work.

Further, the report shows the kinds of care that Americans were avoiding. Dental care was the most common type of care adults delayed or did not receive because of the pandemic (25.3%), followed by seeing a general doctor or specialist (20.6%) and receiving preventive health screenings or medical tests (15.5%).

“Tackling unmet healthcare needs requires effectively assuaging fears about exposure to the coronavirus,” report authors concluded. Providers need to reassure patients that they are following public health guidelines and that these precautions can effectively prevent virus transmission.

“More data showing healthcare settings are not common sources of transmission and better communication with the public to promote the importance of seeking needed and routine care are also needed,” the authors wrote.

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Care for chronic conditions has been severely disrupted amid the Covid-19 pandemic. To prevent further disruption, providers are increasingly partnering with IT companies.

Mount Sinai Health System and Current Health entered into one such partnership in December, with Mount Sinai implementing the company’s remote patient monitoring solution.

Their goal? To enhance care for cancer patients.

Current Health provides a wearable device to patients, which continuously monitors their vital signs, said Chris McCann, co-founder and CEO of Current Health, in a phone interview. The data is then transmitted back to the patient’s care facility. The solution alerts clinicians if the data indicate any abnormalities or potential care issues. At this point, the clinician decides whether the issue can be managed remotely or if the patient needs to be brought into the hospital.

Over the course of the Covid-19 pandemic, cancer screenings and treatment dropped drastically, which could lead to an increase in patient death rates, researchers warned.

A study published last year in JCO Clinical Cancer Informatics shows that at the peak of the pandemic in April 2020, screenings for breast, colon, prostate and lung cancer decreased significantly as compared to the same period the year prior. In addition, the number of mastectomies performed reduced consistently from April through July of last year, and colectomies similarly reduced between April and May.

“These problems, if unmitigated, will increase cancer morbidity and mortality for years to come,” the researchers wrote.

For Mount Sinai Health System, the drops in patient volume were striking. In April of last year, New York City was the global epicenter of the pandemic, and Mount Sinai, like other hospitals in the region, had to suspend elective procedures. The health system experienced a 25% decrease in volume in its ambulatory as well as inpatient settings in April, said Dr. Cardinale Smith, chief quality officer for cancer services at Mount Sinai, in a phone interview.

Even now, patient volume is 10% lower than what it was during the same time period last year, “which indicates to us that there are people who are likely staying closer to home to receive treatment,” she said.

This reluctance on the part of patients — to either risk coming into a health facility or traveling to a facility further away from them — was one of the reasons Mount Sinai looked into remote patient monitoring solutions for oncology.

The system decided to deploy Current Health’s solution, funding the implementation through a Federal Communications Commission grant. The rollout is currently in the pilot phase.

“What I’m hoping that we will see is that this gives us another way to monitor our patients and be able…to get them into a higher level of care when needed, and otherwise be able to really treat them in place so that they feel both safe and comfortable,” Smith said. “And also, so that we don’t overwhelm a healthcare system that is already being overwhelmed.”

Another reason for implementing the remote monitoring system was the growing digital divide among patients.

Mount Sinai clinicians saw that some of their patients, including people of color and the elderly, were less likely to use telehealth services, said Smith.

Smith hopes that the solution will help them care for those patients since Current Health provides the wearable devices and tablets that the patients need. The patients are trained on the devices, which are easy to use — even for the less-than-savvy tech user, Smith said.

Similarly, the health system educated and trained their clinicians on the new solution. As it is a novel mode of cancer care delivery, they needed to make sure they answered all their clinicians’ questions and concerns, she said.

The demand for remote monitoring solutions has exploded during the pandemic. Current Health, which received Food and Drug Administration clearance for its solution at the end of 2019, soon saw an explosion in demand, McCann said. The company experienced a 400% expansion of its customer base. This includes the addition of hospital customers like Mount Sinai Health System and Boston-based Massachusetts General Hospital.

“What [remote patient monitoring] does is it expands the criteria of patients who can actually be managed at home versus within a hospital and that has been a huge asset to us as a company — particularly in the [current] moment,” McCann said.

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Redox, a health IT company focused on interoperability, has partnered with Withings to make its remote patient monitoring solution compatible with nearly all EHRs used by healthcare stakeholders.

Withings’ remote patient monitoring solution, MED·PRO CARE, enables health professionals to monitor patients with chronic diseases — such as diabetes, hypertension or chronic heart failure — from afar, Alexandra Yembele, business-to-business marketing project manager at Withings, said in an email.

Redox offers a single, secure application programming interface endpoint that connects and integrates provider EHRs with healthcare products and services. Per the new partnership, MED·PRO CARE will become compatible with nearly all EHRs used by physicians and hospitals.

Clinicians will be able to order and ship Withings’ connected health devices directly to their patients through their EHRs, and data from the remote monitoring devices will be integrated into the clinicians’ medical record systems, Yembele said.

“This partnership allows Withings to work with major and respected hospitals as it makes MED·PRO CARE now compatible with most EHRs,” she said. “For Redox, they have a new commercial partner to offer through their solution.”

The remote patient monitoring solution can be accessed through tablets and computers and allows clinicians to track several vitals using Withings’ range of health devices, which includes wireless blood pressure monitors, connected scales, activity trackers and sleep monitoring devices. The solution allows physicians to define a set of thresholds and alerts them when their patients have irregular readings.

Further, Withings’ connected health devices and remote monitoring tools, such as its connected thermometer that enables people to take temperature readings without skin contact, can be helpful in assessing symptoms of Covid-19, Yembele said.

“[Withings] is also currently participating in a few studies to further prove the benefits of using our devices to monitor Covid-19 patients remotely and prevent any complications or any unnecessary hospitalizations,” she added.

Hospital bed capacity has become a highly sought after resource amid the pandemic, as Covid-19 cases surge with no end in sight. Using data from University of Washington’s Institute for Health Metrics and Evaluation, the American Hospital Association occupancy projection tool predicts that 78% of the hospital beds in the U.S. will be occupied by Covid-19 patients by Feb. 1.

To keep beds free for those with severe Covid-19 illnesses, hospitals are increasingly turning to remote monitoring solutions and hospital-at-home programs to care for other patients.

“Throughout the pandemic, we’ve seen the importance of and rise in remote patient monitoring,” Yembele said.

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Even before there was a vaccine, some seasoned doctors and public health experts warned, Cassandra-like, that its distribution would be “a logistical nightmare.

After Week 1 of the rollout, “nightmare” sounds like an apt description.

Dozens of states say they didn’t receive nearly the number of promised doses. Pfizer says millions of doses sat in its storerooms, because no one from President Donald Trump’s Operation Warp Speed task force told them where to ship them. A number of states have few sites that can handle the ultra-cold storage required for the Pfizer product, so, for example, front-line workers in Georgia have had to travel 40 minutes to get a shot. At some hospitals, residents treating Covid patients protested that they had not received the vaccine while administrators did, even though they work from home and don’t treat patients.

The potential for more chaos is high. Dr. Vivek Murthy, named as the next surgeon general under President-elect Joe Biden, said this week that the Trump administration’s prediction — that the general population would get the vaccine in April — was realistic only if everything went smoothly. He instead predicted wide distribution by summer or fall.

The Trump administration had expressed confidence that the rollout would be smooth, because it was being overseen by a four-star general, Gustave Perna, an expert in logistics. But it turns out that getting fuel, tanks and tents into war-torn mountainous Afghanistan is in many ways simpler than passing out a vaccine in our privatized, profit-focused and highly fragmented medical system. Gen. Perna apologized this week, saying he wanted to “take personal responsibility.” It’s really mostly not his fault.

Throughout the Covid pandemic, the U.S. healthcare system has shown that it is not built for a coordinated pandemic response (among many other things). States took wildly different Covid prevention measures; individual hospitals varied in their ability to face this kind of national disaster; and there were huge regional disparities in test availability — with a slow ramp-up in availability due, at least in some part, because no payment or billing mechanism was established.

Why should vaccine distribution be any different?

In World War II, toymakers were conscripted to make needed military hardware airplane parts, and commercial shipyards to make military transport vessels. The Trump administration has been averse to invoking the Defense Production Act, which could help speed and coordinate the process of vaccine manufacture and distribution. On Tuesday, it indicated it might do so, but only to help Pfizer obtain raw materials that are in short supply, so that the drugmaker could produce — and sell — more vaccines in the United States.

Instead of a central health-directed strategy, we have multiple companies competing to capture their financial piece of the pandemic healthcare pie, each with its patent-protected product as well as its own supply chain and shipping methods.

Add to this bedlam the current decision-tree governing distribution: The Centers for Disease Control and Prevention has made official recommendations about who should get the vaccine first — but throughout the pandemic, many states have felt free to ignore the agency’s suggestions.

Instead, Operation Warp Speed allocated initial doses to the states, depending on population. From there, an inscrutable mix of state officials, public health agencies and lobbyists seem to be determining where the vaccine should go. In some states, counties requested an allotment from the state, and then they tried to accommodate requests from hospitals, which made their individual algorithms for how to dole out the precious cargo. Once it became clear there wasn’t enough vaccine to go around, each entity made its own adjustments.

Some doses are being shipped by FedEx or UPS. But Pfizer — which did not fully participate in Operation Warp Speed — is shipping much of the vaccine itself. In nursing homes, some vaccines will be delivered and administered by employees of CVS and Walgreens, though issues of staffing and consent remain there.

The Moderna vaccine, rolling out this week, will be packaged by the “pharmaceutical services provider” Catalent in Bloomington, Indiana, and then sent to McKesson, a large pharmaceutical logistics and distribution outfit. It has offices in places like Memphis, Tennessee, and Louisville, which are near air hubs for FedEx and UPS, which will ship them out.

Is your head spinning yet?

Looking forward, basic questions remain for 2021: How will essential workers at some risk (transit workers, teachers, grocery store employees) know when it’s their turn? (And it will matter which city you work in.) What about people with chronic illness — and then everyone else? And who administers the vaccine — doctors or the local drugstore?

In Belgium, where many hospitals and doctors are private but work within a significant central organization, residents will get an invitation letter “when it’s their turn.” In Britain, the National Joint Committee on Vaccination has settled on a priority list for vaccinations — those over 80, those who live or work in nursing homes, and healthcare workers at high risk. The National Health Service will let everyone else “know when it’s your turn to get the vaccine ” from the government-run health system.

In the United States, I dread a mad scramble — as in, “Did you hear the CVS on P Street got a shipment?” But this time, it’s not toilet paper.

Combine this vision of disorder with the nation’s high death toll, and it’s not surprising that there is intense jockeying and lobbying — by schools, unions, even people with different types of preexisting diseases — over who should get the vaccine first, second and third. It’s hard to “wait your turn” in a country where there are 200,000 new cases and as many as 2,000 new daily Covid deaths — a tragic per capita order of magnitude higher than in many other developed countries.

So kudos and thanks to the science and the scientists who made the vaccine in record time. I’ll eagerly hold out my arm — so I can see the family and friends and colleagues I’ve missed all these months. If only I can figure out when I’m eligible, and where to go to get it.

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.

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More than 30 years ago, Dr. Paul Farmer and Dr. Jim Yong Kim travelled to Haiti to provide care for the poor and underserved. The lessons they learned about public health, poverty and social justice can be applied in the U.S. today, as the Covid-19 pandemic accelerates, ravaging low-income communities across the country.

In 1983, Farmer and Kim, along with activist Ophelia Dahl, went to Haiti to bring high-quality medical care to rural Haitians. A new film, called “Bending the Arc,” depicts their story and the challenges they faced setting up health clinics in remote parts of the country. Through their failures, the group realized they had to change the way they were delivering care. They began to train Haitian villagers as healthcare workers and developed a successful community-based care delivery model. The model has since been applied in other countries, including Peru and Rwanda.

Farmer and Kim, who later created Boston-based nonprofit Partners In Health, believe that there is knowledge to be drawn from their experiences abroad for the U.S. healthcare system.

One lesson they learned is that public health experts have a “frustrating” tendency of having low aspirations for the poor and are very nihilistic about the likelihood of improving their health and circumstances, Kim said at a virtual panel discussion for the movie.

“The thing that I couldn’t believe was that [nihilism] kicked in here in the United States once Covid started,” he said. “We couldn’t believe that public health experts in the United States were giving up on things that, for example, are well in place in Rwanda, are well in place in Korea, in Hong Kong, in Taiwan, in China — well in place in lots of places that have been successful at suppressing the virus. We just gave up.”

And the people who are suffering the most as a result are the poor, the Native Americans, Black people and other communities of color, he added.

Public health crises involving infectious diseases tend to follow a panic-neglect cycle. The U.S., still in the panic phase, appears to be attacking the Covid-19 problem with fiscal stimulus and just hoping for a vaccine, Kim said.

What the country needs to do is invest in public health and the proven strategies of testing, contact tracing and supported isolation — where those who need to isolate are given the resources they require — because even when there is a vaccine, on-the-ground public health strategies will be necessary to distribute it, he added.

“I hope I’m wrong, but what I think we may [see] is — if the vaccine is successful, we’ll go right back to neglect,” Kim said. “We won’t build the public health systems [we need].”

The panic-neglect cycle needs to be broken, Farmer said, and there is a chance to do it now amid the Covid-19 pandemic.

Strengthening the public health response to the pandemic, for example, can help address inequities related to social determinants of health, like job loss. In Navajo Nation, a number of the new recruits for contact tracing jobs are from the casino industry, which has seen closures and layoffs amid the pandemic, Farmer said.

Further, community support, similar to the model developed in Haiti, is needed as the pandemic rages on. Kim and Farmer’s nonprofit found that about 20% of the people they got in touch with via contact tracing needed resources, like food, to help them isolate properly. So the nonprofit started hiring resource managers to assist those in need, Kim said. This had the added benefit of creating jobs.

In addition, contact tracing and supported isolation was successful in places like West Africa during the Ebola epidemic, and they can be effective in the U.S. now. Some of what we have learned in one place can also be useful in another, Farmer said.

“We’re facing a once-in-a-century — if we are lucky — a once-in-a-century pandemic,” he said. “It has resulted in a massive disarray that all of you can see and feel, and with 250,000 dead, you can bet a lot of people are feeling this in a very personal way. Now we’re saying: here’s how to transform the illness care system into a healthcare system that does not neglect the critically ill and injured, but there is a lot more [we can do] to make us healthier overall.”

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Photo: Natee Meepian, Getty Images

Utah-based Intermountain Healthcare and South Dakota-based Sanford Health plan to merge in 2021, creating a 70-hospital system.

If approved, the merger would combine the 24-hospital Intermountain Healthcare and 46-hospital Sanford Health to create a massive organization. In addition to the 70 hospitals, the combined organization would include 435 clinics and provide senior care in 233 locations. Both organizations offer health plans, and together, they would insure about 1.1 million people.

This continues the recent trend of provider consolidation and will likely continue as Covid-19 has severely hit hospital finances heavily reliant on elective procedures forcing them to look for scale. Earlier this month, two North Carolina-based systems, Atrium Health and Wake Forest Baptist Health combined to create a 42-hospital system expected to generate more than $32 billion annually.

The combined system would generate about $15 billion in total annual revenue, a Sanford spokesperson said via email. Intermountain’s total revenue for the first three months of 2020 was $2.3 billion and it incurred a $1 billion loss, while Sanford’s total revenue for the first six months of 2020 was $3.1 billion and it gained a profit of $95 million, recent financial filings of the two organizations show. But, it’s important to note that Intermountain’s loss is mostly attributable to losses on investments, “much or all of which was probably made up by June or July as the markets recovered,” Allan Baumgarten, an independent health markets analyst, said via email.

Intermountain Healthcare’s president and CEO, Dr. Marc Harrison, will serve as the combined system’s leader, which will employ more than 89,000 people.

Kelby Krabbenhoft, Sanford Health’s president and CEO, will serve as president emeritus of the new system. The existing board of trustees from both systems will also join to form a combined board.

In an Oct. 26 news release, Dr. Harrison said that the two nonprofit organizations have a “shared vision of the future of healthcare” and aligned values.

“This merger enables our organizations to move more quickly to further implement value-based strategies and realize economies of scale. Through coordinated care, increased use of telehealth and digital health services, we will make healthcare more affordable for our communities,” Dr. Harrison said in the statement.

In turn, Sanford hopes to “improve the health and well-being of the communities we serve and strengthen our impact in healthcare delivery and value,” Krabbenhoft said in the news release.

Baumgarten provided a variety of reasons for why hospitals are going down the M&A road.

“Hospital systems are still setting growth as their chief strategic goal — in multiple dimensions: total revenues, geographic reach, facilities and patient counts,” Baumgarten said via email. “Some are rethinking the size of their footprint in inpatient facilities and making new investments in small facilities (such as Ascension). Some are rethinking their strategy for locating outpatient services (like Fairview and HealthPartners) and concluding that it’s not efficient to have a clinic every five miles and are closing some of those facilities.”

If all goes to plan, the combined health system will be headquartered in Salt Lake City, with corporate offices in Sioux Falls, South Dakota. For the time being, both organizations will operate under their current names. The merger is expected to close next year, pending federal and state approvals.

The latest merger news from Sanford Health, the largest nonprofit rural health system in the nation, comes after a failed attempt last year.

The system announced plans to merge with West Des Moines, Iowa-based UnityPoint Health in June 2019 but by November, the plans fell through, according to the Sioux City Journal.

Photo: Natee Meepian, Getty Images

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