E15: Health Coverage in a Pandemic / Donald Berwick, Karen Pollitz

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“COVID-19 is the great revealer. It’s showing every crack and fault in the healthcare coverage system.” – Dr. Donald Berwick

In today’s episode, co-hosts Dr. Celine Gounder and Ron Klain speak with Dr. Donald Berwick, former administrator for the Centers for Medicare and Medicaid Services and senior fellow for the Institute for Healthcare Improvement, about how COVID-19 has exposed the vulnerabilities of the U.S. healthcare system to a public health crisis. They also discuss how the Affordable Care Act has provided a safety net for many Americans during these uncertain times, and how coronavirus relief bills, the CARES Act, attempt to address further gaps in the system. Finally, they discuss how both rural and urban hospitals will be affected by the pandemic from an economic standpoint.

They also speak with Karen Pollitz, a senior fellow at the Henry J. Kaiser Family Foundation and a four-time cancer survivor, about how important it is to have health insurance coverage when a crisis strikes, and how terrifying it can be to lose coverage during these times. Karen also explains options for those who have lost coverage and are struggling to figure out how to cover themselves and loved ones during this unpredictable time in our country, and how to weigh their options, depending on individual circumstances.

Listener Q&A: How does contact tracing and quarantine work for a disease where many cases are asymptomatic and many do not even realize they are sick?

This podcast was created by Just Human Productions. We’re powered and distributed by Simplecast. We’re supported, in part, by listeners like you.

Celine Gounder: I’m Dr. Celine Gounder.

Ron Klain: and I’m Ron Klain,

Celine Gounder: and this is “Epidemic.”

Ron Klain: Today is Tuesday, April 28th. We’re nearing the end of one of the deadliest months in American history. More than 50,000 Americans will die from COVID this month. That’s more than die from a heart attack or from all cancers combined, during the month of April.

Since mid-March, in addition to the healthcare consequences, there have been devastating economic consequences from the coronavirus epidemic. For many Americans who lost their jobs, they also had their health insurance put at risk.

Celine Gounder:  What are the uninsured supposed to do now when having health insurance is more important than ever?

COVID has exposed just how vulnerable the US healthcare system is in the midst of a public health crisis.

Ron Klain: In today’s episode, we’ll hear about how the Affordable Care Act provides a safety net for many during these times and how corona relief bills like the CARES Act are trying to address other gaps.

Celine Gounder: We’ll also hear from an expert about what to do if you’ve lost your health insurance and how to weigh your options.

Ron Klain: Our first guest is Don Berwick. There are few people in this country who know more about how Americans get health care, than Don Berwick. He used to be the administrator for the Centers for Medicare and Medicaid Services.

That means, uh, he used to be the person who ran the Medicare program and the Medicaid program in the United States. He’s also the President Emeritus and the senior fellow of the Institute for Healthcare Improvement. So Don, thank you so much for joining us on our podcast.

Don Berwick: It’s a pleasure, Ron. Thank you.

Ron Klain: More than 26 million Americans have filed for unemployment, having lost their jobs as a result of the pandemic.

Celine Gounder: What is that going to mean for their health insurance when most working people in this country get health coverage through their jobs? You know, how can they keep their current coverage or get new coverage?

Don Berwick: Yeah, COVID- 19 is the great revealer. It’s showing every, every crack and fault in the healthcare coverage system. People who lose their jobs, who had prior healthcare benefits, they are eligible for getting access to the exchanges. But, uh, the costs will still fall to them. Uh, there are very high cost of health insurance coverage and there are a lot of people who will not have access that way.

Ron Klain: So Don, let me ask you two follow up questions on that. First of all, isn’t it the case that, uh, anyone who loses coverage cause they lose their job has access to the exchanges?

Don Berwick: Well, yes. First, people who did have employer insurance and lost it do have in essence, a special enrollment period. The problem is how easy will it be for them to get access to that benefit?

What do they have to prove? What kind of documentation can we make that easier for them? And there’s some concern that some of those people may not have. Uh, an easy route to actually signing up for the insurance they need. There are other people though who lose insurance cause they’re not in the commercial insurance market with employers who do not have access to that special enrollment period.

And that’s the extension that we’re asking.

Ron Klain:  And then secondly, I wonder if you could also talk about the proposal that some Democrats unveiled yesterday, to improve, expand, COBRA as a way of people getting their healthcare coverage.

Don Berwick: COBRA is a form of safety net. We’ve used it before. COBRA has been improved and expanded, and I think subsidies offered, I believe, after the, uh, after the 9/11 attacks, uh, and in the 2009 recession.

However, COBRA is, it’s not a real long-term solution. It lasts only for a shorter period of time and it’s very expensive. COBRA coverage, it’s really a burden. Exactly how generous Congress may be to help people get COBRA is going to really matter.

Celine Gounder:  So you’ve lost your job and now you’ve applied for unemployment insurance. Is that unemployment insurance going to be enough to pay  for buying coverage on the exchanges or to pay for COBRA?

Don Berwick:  There are some subsidies available, but, uh, given the cost of health insurance and the, the economic circumstances, people are gonna find themselves. I think those subsidies may prove inadequate.

The Kaiser Family Foundation says that individual coverage, I think in 2019 was about $7,200 a person for a family, it was over $20,000 that’s a big burden and even people who we would call quite middle-class will have a lot of trouble paying for that kind of coverage. Among the adjustments we really need to be making in the COVID period is to make sure that the subsidies and the exchanges are available and increased. I think that’s an important part of increasing security.

Ron Klain:  Let’s go back to the Affordable Care Act for a second. One thing that people don’t focus as much on but really was a critical aspect of that was the expansion of Medicaid. That was part of the Affordable Care Act, but in the end it was dependent on states to make the choice to take advantage of that opportunity.

How will COVID play out differently in the states that made the election to participate in this expanded Medicaid program versus the states that made the choice not to participate in that program?

Don Berwick:  When the Supreme Court decided that Medicaid expansion could not be mandated, it gave to the state the choice whether or not to take advantage of the expansion with federal dollars.

Uh, today, uh, still 14 states have not expanded. For the states that have not expanded access to Medicaid. Number one, they’re going to be people who will not have coverage. They’re not going to be eligible for the exchanges and they won’t have coverage through Medicaid with big federal matches. Um, the consequences of those individuals are dire.

They’re still gonna show up in hospitals and the states are going to feel the burden. Instead of relying on federal support, which is available to them, if they expanded, they’re now going to have to carry that burden themselves. That’s why most hospitals and other healthcare caregivers are really urging the non-expansion states to become expansion states as fast as they possibly can.

Ron Klain: And Don, we’ve heard a lot about the economic consequences of the pandemic, but what about costs to treat people with COVID to test people with COVID? How’s that going to affect both the healthcare system and our economy?

Don Berwick: Right now, the three COVID bills include provisions to expand coverage for testing for COVID, but that’s, that’s just the beginning of the story.

The cost of caring for COVID, even for someone that isn’t seriously ill can be massive. And should someone end up in a hospital, you’re looking at bills of 20, 30, 40, $50,000 or more, uh, in a population which still has high levels of uninsurance and under-insurance. There’s going to be a real, real dire effect on people’s economic wellbeing, let alone their health.

This is again, another example of how the COVID pandemic is underlining the defects in the American healthcare insurance system itself. We have a patchwork that leaves so many people out. And leaves so many people with insufficient coverage.

Celine Gounder:  So in other words, what you’re saying is that the coronavirus relief bills have done more with respect to maybe economic concerns, but not really in terms of addressing people’s immediate health coverage and access needs. You know, not just in terms of treatment, but in terms of. Well, you know, all the other issues that they may be facing right now.

Don Berwick: I think of it as kind of three levels. One is the immediate urgent response to getting care to people who need it in the COVID crisis. The second is in the midterm, we’re now showing the consequences of people not having access to the healthcare coverage they need.

And this is a time when maybe we need to get really serious about looking at the flaws in the current insurance packages, improvements in the Affordable Care Act, and reversing some of the terrible cutbacks on Medicaid supports. And then in the longer run we face really the big question for our country. We’re going to finally be a country in which everybody has health insurance that they can count on in crisis or not.

Ron Klain: So Don, I want to flip a little bit from talking about this from a perspective of individuals and their coverage to impacts on the healthcare system itself. What’s going to happen to hospital budgets, hospital funding, hospital resources as a result of this? And if you could talk particularly about both urban hospitals and smaller rural hospitals and how all this is going to hit them.

Don Berwick: Well, let’s start with the urban hospitals. They are taking it on the chin in the cities that now or will have a COVID pandemic hit them. Um, their costs are enormous. Uh, and meanwhile their revenue is going down because hospitals rely on elective procedures and of course, non-COVID care revenues in a fee for service environment to pay their bills. They’re losing that. I talked to a hospital leader in a system in New York just last week that anticipates they’re going to lose $300 million a month. Uh, Congress has stepped up somewhat in the third COVID legislation, but I would say that’s a very short-term solution.

Hospitals are going to be reeling for quite a while. And I, you know, I, I don’t want to be glib about it, but the actual answer to the distress that hospitals are in today, in addition to direct relief, is to get to universal health coverage as an American standard so that they hospitals can count on the fact that people who show up can pay, without going bankrupt. And the people who show up can know that they can pay without going bankrupt.

Rural hospitals and critical access hospitals may be the only game in town. They’re always vulnerable. Medicare and Medicaid does offer some extra help to those hospitals, financially. They get a little bit of a boost, but not enough. And I think we need to take a step back and ask about what kind of rural health system we need. Right now, there’s emergency relief for those places, but I think we need a long-term plan for really robust rural health in this country. Which in my mind includes treating them not just as hospitals, but as community health resources.

Celine Gounder: Don. There’s been a lot of discussion recently about how to lift social distancing measures and, as we’ve all heard, New York governor, Andrew Cuomo, has for example, discussed a more regional approach. Uh, this is something I know you’ve also written about, you know, how do you balance regional versus national approaches. Understanding that viruses don’t respect manmade borders.

Don Berwick: I think we do need regional responses to 21st century health threats with national guidance and resources. Our regions differ from one another in the needs and the ways they need to react, and there can be more agility in regional response than maybe in a complete national response.

So I say, very, very strong federal support and strong federal plans for regional response. No individual healthcare institutions, no single hospital, even hospitals system can actually meet the needs that emerge in a pandemic. You need to have highly coordinated endeavors with data sharing and resource sharing and joint planning. Now is the time to invest.

Ron Klain: So Don, let me build on that. I mean. Talk about how states, in the absence of clearer federal leadership, can start to coordinate some of this data sharing some of the supply chains management, maybe even thinking about how to manage hospital capacity across systems within their States. How can some of these things, that we’d love to see Washington lead on, maybe that leadership isn’t there. How can states fill in the gaps here on some of these things?

Don Berwick: Well, I’ll take your premise, but not without a little protest in the sense that we really need national leadership. States can’t print money. They can’t run deficits. They can’t, uh, they can’t do what’s needed to, to move resources around the way the federal government can. And the lack of federal leadership is devastating to the kind of response we need in pandemics, and large scale threats like this. But states are stepping up. We look at what’s happened in states that, that really took the lead in and followed the manual, so to speak, for how you respond to a pandemic. Uh, what happened in Ohio, in my own state, Massachusetts, and I’d say in Washington. You saw governor step up, say what needed to be said. Speak with honesty and states can do it. And being able to work with your neighboring states in good consortium arrangements really matters.

There’s a challenge here, by the way, which I’ll mention for hospitals as well. You know, we have a system in our country where hospitals are competitive with each other. There’s a bit of a cultural change we’re going to need, to tell hospitals that they’re a part of something bigger than themselves. And that’s going to take state and political leadership as well.

Celine Gounder: Don, you’ve also written about how public- private partnerships might serve as the foundations for more comprehensive preparedness. What might that look like?

Don Berwick:  It’s very interesting to see the difference in response from a government-run healthcare systems where the government actually controls the delivery, such as in say, Singapore, maybe in the UK and in the US and other countries where the delivery systems are, are private, maybe nonprofit, neither party, the government, nor the delivery systems can solve this alone. Need the government to call to arms, to offer resources to insist on standards for say, data exchange, to make sure that supply chains work across boundaries, but you also need individual organizations on the private side to come together. There’s going to have to be a hard conversation between the governmental funders and the private sector about where resources really are needed in order to allow this regional planning to occur.

Celine Gounder:  In the entrance of the Hubert Humphrey building, the headquarters of the Department of Health and Human services, Senator Humphrey’s words are chiseled in stone, and I quote, “the moral test of government is how it treats people in the dawn of life, the children and the twilight of life, the aged, and in the shadows of life, the sick, the needy, and the handicapped.” Are we living up to that moral test today?

Don Berwick: We are not.

When I take a Senator Humphrey, vice president Humphreys words and inspect, interrogate, our nation right now to say, are we doing that? Are we really reaching out to the people who need the help the most? Because it’s our job to do it. I think it’s a moral issue. There’s a lot of pragmatism that you have to attend to, but this is a moral question.

Are we responsible for each other or not? Are we going to make sure that people who are having a rough time, have their journeys eased? And are we going to do that as a nation, with duties to each other? I think that question has to be called and right now I’m afraid the answer isn’t what I hope it will be for our country.

Ron Klain:  Don, those are powerful and wise words to end on. We appreciate you sharing your expertise with us. Thank you for joining us for the “Epidemic” podcast.

Don Berwick: Thank you, Ron and Celine.

Celine Gounder: Thank you.

Ron Klain: Our next guest is Karen Pollitz. She’s a senior fellow at The Henry J Kaiser Family Foundation. She explains some healthcare options available to those who’ve lost coverage and are struggling to figure out how to protect themselves and their families in these unpredictable times.

Celine Gounder: Karen Pollitz is a four time cancer survivor. Karen understands all too well how important it is to have health insurance when a crisis hits. Karen, would you mind sharing with us your experience as a cancer survivor?

Karen Pollitz: Sure. The first one happened almost 25 years ago. Very unexpectedly. My daughter was just in diapers, and I’m, uh, on my baseline mammogram, found out that I had breast cancer. Um, and I was revisited by that two more times. Um, and then uterine cancer last year.

So. This has been my own personal tour through our health insurance system and our healthcare system. I’ve been very lucky. I’ve had terrific doctors. The insurance part of it was kind of, um, eye opening as well. I’ve had to deal with, uh, denied claims and surprise medical bills and you know, pre-authorizations and network issues.

So I’ve, I’ve kind of learned a lot about how health insurance system works along the way. I, I, it has, uh, made me fervently believe that good health coverage is your ticket to healthcare, but making coverage work for you is not always easy or straightforward. And when you have to deal with insurance problems while you’re sick, it’s even more challenging.

Celine Gounder: Was there any particular instance that was especially difficult or frustrating to navigate through.

Karen Pollitz:  The kind of knucklehead claims stuff I think was always the most frustrating. My very first my very first surgery though, I had to get it all preauthorized through the insurance. You know, I went in, I had the surgery. It was, you know, it was scary. I was in my thirties. I had a baby. I thought I was going to die. You know, but got through that and came home. And about two weeks later uh, got a statement from our health plan that said, the claim for my surgery had been denied. And I remember just sitting down on the kitchen floor with that notice and starting to cry and thinking, I’m going to die. My family’s going to lose their house. So it, uh, and later I could kind of collect myself and figure out what to do and, and this is how I learned how to, you know, kind of contest denials and ask the right questions. But, um, you know, it really, it really kind of took my legs out from under me at the time. It’s just. It’s just very scary to have to add that, um, you know, that frustration to, uh, to an illness that’s already terrifying.

Celine Gounder: How did you have your health insurance? What was the source of your health insurance at the time?

Karen Pollitz:  My insurance was through my husband’s job. Um, it’s actually still through his job, although we all have changed jobs by then.

Um, you know, it’s a big group health plan. It’s a generous plan. Um, at the end of the day, it covers everything. Uh, really it’s, I have great insurance now. Um, but I have learned that, you know, don’t take no for an answer, uh, from your health plan. Um, but I’ve also learned why they call it a health benefit. You know, it has, it has enabled me to get the care I need without having to spend tens of thousands of dollars out of pocket.

Celine Gounder: So unfortunately, a lot of people are losing their jobs right now in the midst of the pandemic, and that means that they’re losing their health insurance. What would it have meant if you’d been going through treatment for cancer during this pandemic and you lost your job?

Karen Pollitz: Oh wow. I don’t even like to think about that.

It would have been terrifying. Um, each time that I’ve had cancer, the bills have reached into the six-figures over a hundred thousand dollars. Um, you know, nobody has that kind of cash lying around and I just, I just don’t know what I would have done. I’ve also had two kids, those that sort of inexpensive, um, you know, tour of the health care system, giving birth to them.

Uh, you know, my husband, uh, he’s a teacher now, but he’s been hospitalized with pneumonia a couple of times. So I think we have learned, um, that there’s a reason health insurance is expensive because it protects you from healthcare costs and those are expensive. And if you lose that, you’re in trouble. In every case, I was able to, uh, you know, at the first sign of a symptom, get in, uh, get checked out, get a biopsy.

Um, all of my cancers have been early-stage cancers. That tends not to be true when you are uninsured. Um, you know, people let it wait so. I’m here today in part because we’ve always had good health insurance, and I don’t know that that would be the case if we hadn’t.

Celine Gounder:  So now I kind of want to get, have you talked through, you know, if somebody lost their health insurance today, how, what they should look into in terms of options. So things like COBRA and the marketplace plans and Medicaid and so on, but it’s going to be different for different people depending on what their health issues are and their needs are.

 So let’s start with your own scenario. So let’s say you lost your job in the middle of this COVID pandemic. You were going through treatment for cancer.  What would you have done in terms of getting some sort of health coverage, and how would you have approached that?

Karen Pollitz: So for my own family and our situation, if my husband got laid off now, um, I guess, well, I would have the opportunity first to join my health plan at work.

Um, I’m actually covered under Dave’s plan, but my employer, Kaiser Family Foundation offers coverage. So I would have a special enrollment opportunity if we lost his coverage to join, um, Kaiser Family’s health plan. And, um, that’s probably what I would do.

I think my next choice would be COBRA. We do still have some savings. We can afford to take money out of the house, um, and pay the COBRA premiums. COBRA’s really expensive. Uh, on average it’s going to be about 600 bucks a month for an individual, and it could be a lot more than that. COBRA costs what your health plan costs, but your employer ceases to contribute to the monthly premium, so you have to pay the whole thing yourself.

That’s a deal breaker for a lot of people who’ve lost a job. But if you are in the middle of treatment and if you do have some resources and you can afford COBRA, it’s worth considering because it means you keep your plan. You don’t have to restart your deductible. You don’t have to enroll in something new. You don’t have to find a new set of doctors who are in network that said, most people who lose their jobs can’t afford $600 a month for insurance. So fortunately, there are other options. The Affordable Care Act really did change, uh, what options are available for people when they lose their job-based coverage.

First in most states is Medicaid. People who’ve been working, um, and who are used to having job-based coverage may not think about Medicaid. Medicaid has really been transformed. It, it is now the public plan for people who, um, who have a sudden drop in income, um, and who need health insurance. It in most states, not every state has elected to do this, but in 36 States and the district of Columbia, Medicaid is now available for people, um, who have a sudden drop in income who have income down below, um, 138% of the poverty level. That’s about, I dunno, 15, $16,000 for a single person. So, um, uh, it’s free health insurance. It doesn’t have big deductibles. Um, uh, it’s, it’s comprehensive. It is really something that you should look at and, um, you know, that may get you through this crisis.

And then finally, um, people should look in the marketplace. When we don’t have job-based coverage. When we don’t qualify for a public plan like Medicaid or Medicare, we buy insurance on our own. That often can be, you know, prohibitively expensive as well. But in the marketplace, you can get help paying the premiums if your income has dropped. So if your income is between the poverty level and four times the poverty level, that’s about a little over 12,000 to about $50,000 a year for an individual. Um, you can go to the marketplace, you can pick out a plan for yourself, or you can also get family coverage. And, um, and the federal government will help you, uh, through premium tax credits to reduce what you have to pay every month. Uh, depending on your income, you may also get help with deductibles. Loss of job-based coverage gives you a special enrollment opportunity. So you have 60 days from the date that you lost your job-based coverage to go to the marketplace and apply and sign up for a new health plan.

Celine Gounder: My husband and I got through insurance through his job and he lost his job a couple of weeks ago, and we’re now having to figure out what we’re going to do now. We don’t have any children. We’re healthy. We don’t have any chronic medical conditions. Don’t take any prescriptions on a regular basis. How might we weigh our different options, maybe differently from you?

Karen Pollitz: You have the same options. So I think you just need to, you know, kind of take out a piece of paper and make a couple of lists.

You’re going to care about what the monthly cost of coverage is because, you know, you just lost one of your incomes. So, um, you know, you can compare the costs of different marketplace plans. You can compare the cost of COBRA. You’re going to want to look at the kind of content of coverage. What are the covered benefits? Whether you’re in the marketplace or COBRA or even Medicaid. Those should be pretty similar, but there can be some differences. You’re going to want to look at the deductibles, the copays, sort of what does it cost you out of pocket when you receive covered services under the plan?

Generally, there’s an inverse relationship the higher the deductible, the lower the premium. When you take a higher deductible plan, what happens if you get sick? We are having this pandemic, as you may recall, you know, there’s a chance, right, that, um, any of us could land up in the hospital this year.

The network of doctors and hospitals, um, is also gonna matter under any given plan. Uh, you know, do you have a regular doctor who you see, uh, the hospital that’s, you know, kind of closest to your community? Is that covered in network? So those are, those are all things that I think people need to take a look at.

Celine Gounder: So it is a, it is a really important point that we are in the middle of a COVID pandemic. Are there certain plans we need to worry about not providing coverage for COVID specifically?

Karen Pollitz: So, I mentioned short term medical plans. I don’t think you’re going to hear too much about these, but in most states, these are still for sale. These are kind of pre-Obamacare, pre-ACA type, non-group plans. They’re even easier to find now in some states. the Trump administration wrote some new  regulations a couple years back to really promote the sale of these plans. They’re a lot cheaper. Um, you can get some of these short- term plans for, you know, under a hundred bucks a month, but they’re cheaper for a reason.

Uh, they won’t sell to you if you’re already sick. So they will turn you down if you have a serious preexisting condition, and if you’re healthy and you buy one of these plans and then you get sick, there’s a really good chance that they will still figure out a way to not pay that claim. They will heavily research at that point, your medical history, go back, look at symptoms, prior lab tests, medical records, anything they can find to see if there’s an argument to be made that whatever it is that you have now is related to a preexisting condition, and then they won’t pay for it either. So these plans don’t offer secure coverage. It’s hard when money is tight to not price shop for health insurance. You know, paying most attention to the premiums.  But, you know, this isn’t just an orange or a shoe or something. You know, you’re buying insurance in case you get sick, not in case you stay healthy.

Celine Gounder: How did the Affordable Care Act make meaningful coverage options available for situations just like this?

Karen Pollitz: It completely changed Medicaid. Medicaid used to be kind of a welfare based program. You had to be receiving other low income benefits to qualify for it. And now it is, it’s just a public plan that is available for people with low incomes, in most states. So, uh, that was a huge, big change. Tens of millions of people have been able to get coverage through the Medicaid program.

The Affordable Care Act completely changed the non-group market. You could only buy coverage if you were in perfect health. Um, if you didn’t have a preexisting condition, if you developed a condition, the insurer could find a way to call it preexisting and still not pay for it. They could cancel you. And the benefits were generally pretty skimpy.

The Affordable Care Act said that all non-group coverage has to take everybody now, treat them the same, charge them the same premium, regardless of their health status. Always cover major medical benefits, uh, hospitalization, mental health care, prescription drugs, and, um, and that of course, made non-group coverage more expensive because then it was more protective. And so to make it affordable, the Affordable Care Act added, um, income- related subsidies. So, um, the Affordable Care Act, uh, made it more likely that no matter what your circumstances or how your circumstances change, there will be an option for you to get coverage that you can afford.

That is, um, you know, that offers comprehensive protection. It’s not airtight. There are gaps. The Supreme Court said that the Medicaid expansion is a state option, and we still have 14 States that refuse to open their Medicaid program for low income adults. The subsidies, um, uh, are not as comprehensive as they could be.

So, um. Uh, some people find that even with the tax credits, it’s still costs more every month to buy a marketplace plan than they really feel comfortable affording. Um, you know, and there are people that aren’t eligible for subsidies, for other reasons, including undocumented immigrants and other categories of people. So there are still gaps in coverage.

Celine Gounder: So let’s say you get sick with pneumonia. Maybe it’s COVID, maybe it’s not. But how much does it cost to hospitalize someone with pneumonia and how much of that is a patient having to pay for themselves.

Karen Pollitz: We looked at a database of a large employer health plan claims from the past couple of years. And we found that on average, um, an inpatient stay for pneumonia costs in the neighborhood of $20,000. It’s a lot of money. And for people with job-based coverage, a big chunk of that comes out of pocket. Job- based plans, they mostly have high deductibles. Now the average is close to $1,700. Um, some people have lower, and what we saw that was in this data search was that on average people had to pay about $1,300 of that $20,000 bill.

Celine Gounder: Why is employer sponsored insurance or job-based coverage not really a great model here?

Karen Pollitz: As we are learning, um, people can change and lose jobs. Uh, and when you do, your health plan goes up in smoke with that. Looking forward, are there better ways to organize our health coverage? We don’t know for sure how many people have lost job-based coverage in the last month, but we do know over 20 million people lost their jobs. And so a good number of them lost, um, lost their job-based coverage along with that.

Celine Gounder: You know, is this, is this a teachable moment, so to speak, where this pandemic is really shining a light and revealing some major vulnerabilities in our system?

Karen Pollitz: I think it is incumbent on our leaders and on our policy thinkers to really consider what, what we’re learning about the weak places in our health coverage system today. There are all kinds of proposals, you know, expanding eligibility for the current Medicare program. You know, that’s the closest thing we have to universal coverage now. Doesn’t kick in until you’re 65, but you know that that is the public plan that, that people look forward to reaching when they’re 65 and once you’re in, they don’t take it away. You’re, you just always have it. So, and it covers every doctor and every hospital and you know, so some, some are looking at that or maybe building another public program that’s based on Medicare.

Um, uh, there are other, you know, kind of proposals to strengthen the marketplace and make that available for everyone. So, I think there are a lot of directions that we could go from here. Um, but this crisis has taught us that the status quo leaves, um, tens of millions of people at risk.

Celine Gounder: I think you made some pretty complicated things, accessible and understandable to people who are trying to navigate this themselves. So, you know, that’s really very timely right now, especially. Um, so thank you.

Ron Klain:  It’s important for all listeners to know. Two things. First of all, the legislation passed by Congress, the CARES Act promises every person in the country free testing for coronavirus.

So whether or not your healthcare coverage pays for it, or you have health coverage or you don’t, your test is free under federal law. Secondly, if you’ve lost coverage for the 30 days after you lose coverage, you have a right to go on to the Obamacare website, www.healthcare.gov and get coverage under the Affordable Care Act.

So coverage is there if you’ve lost your coverage due to losing a job and losing job-related healthcare coverage.

Every week we answer a couple of listener questions. Today’s question is from Phillip Sutherland.

Phillip Sutherland: Hello. I’m Philip from Milwaukee, Wisconsin. And my question is, how does contact tracing and quarantine work for a disease where perhaps 25 to 50% of cases are asymptomatic, or at least so mild that the person doesn’t even realize he or she is sick?

Celine Gounder:  Phillip, when I realized that COVID could be spread by people with no symptoms or only mild symptoms, I realized that this was going to make our job a whole lot harder.

In a sense, we’re looking at preventing invisible spread of the disease. If we had an unlimited supply of tests, we would test everyone every 14 days, which is the maximum incubation period of the virus. We would test everyone regardless of whether they had symptoms or not. We would then isolate everyone who tested positive and trace each contact chain to the end and keep repeating this for several weeks until we’d suppress the virus.

But we have nowhere near that kind of testing capacity. So you’re right, we’ve got some big gaps, a big blind spot here. We’re going to miss some people with COVID who are spreading the virus in the community. And this is why life can’t safely return to normal after social distancing measures are lifted.

Workplaces and school should continue remote telework as much as possible, and consider staggered schedules to reduce the density of people in public spaces.  It will still be important to wear masks and be rigorous about hand hygiene and we’ll need to be a lot more aggressive about keeping shared spaces clean.

Ron Klain: You know, Celine, I agree that contact tracing for this kind of a virus isn’t going to be perfect, but it’s a lot better than being completely blind, which is what we are now. So we need to get the testing in place. We needed the contact tracing in place. Because we’re going to know a lot more that way than we know right now.

So thanks to Philip for your question. We love getting questions from our listeners. If you have a question that you’d like us to answer, send us a voice memo, keep it under a minute and email the voice memo to us at hello@justhumanproductions.org. That’s hello@justhumanproductions.org

Celine Gounder: “Epidemic” is brought to you by Just Human Productions. Today’s episode was produced by Jordan [Last name] and me. Our music is by the Blue Dot Sessions. Our interns are Sonya Bharadwa, Annabel Chen, Isabel Ricke, and Claire Halverson. If you enjoy the show, please tell a friend about it today. And if you haven’t already done so, leave us a review on Apple podcasts.

It helps more people find out about the show. You can learn more about this podcast, how to engage with us on social media, and how to support the podcast at epidemic.fm that’s epidemic dot F M. Just Human Productions as a 501 (C)(3) nonprofit organization. So your donations to support our podcasts are tax deductible.

Go to epidemic.fm to make a donation. We release “Epidemic” twice a week on Tuesdays and Fridays, but producing a podcast costs money. We’ve got to pay our staff, so please make a donation to help us keep this going. Also check out our sister podcast, American Diagnosis. You can find it wherever you listen to podcasts or at American Diagnosis.fm. On American Diagnosis, we cover some of the biggest public health challenges affecting the nation today. In season one, we covered youth and mental health. In season two, the opioid overdose crisis and in season three, gun violence in America. I’m Dr. Celine Gounder

Ron Klain: and I’m Ron.

Celine Gounder: Thanks for listening to “Epidemic.”

Guests
Donald Berwick Donald Berwick
Karen Pollitz Karen Pollitz
Hosts
Dr. Celine Gounder Dr. Celine Gounder
Ron Klain Ron Klain