Former Vice President Joe Biden is beginning his transition to power as the novel coronavirus is breaking somber records in the U.S. — and hospitals in some areas find themselves stretched to the brink once again. Bolstering the federal response to the pandemic is the sector's No.1 ask for the incoming president.
On the current trajectory, Biden is poised to assume office when the deadly pandemic may reach unprecedented heights in terms of the number of cases, hospitalizations and deaths.
Many hospitals and health systems across the country are warning that the virus threatens to overwhelm their clinicians and resources, spurring a call to action as administrators and officials all but beg the broader public to wear masks and socially distance to contain the spread.
Although the pandemic will undoubtedly be the top priority for a Biden administration come Jan. 20, there are other key issues to tackle in the early days.
Healthcare Dive spoke with numerous influential hospital leaders to discuss the most important items they want the president-elect to address in his first 100 days in office.
Pandemic response, continued relief
Following a largely hands-off Trump administration response, coronavirus cases are once again surging in the U.S., with total cases surpassing 10 million on Monday. Providers, following a brief reprieve with the virus after state lockdowns earlier in the year tamped down on new cases, are now once again facing the grim potentiality that the rising caseload could push them beyond their resources.
Many are calling on the newfound Biden administration for quick aid as a result.
"A critical concern now is making sure our hospitals have the support they need to respond to the new wave of COVID-19 infections," said Beth Feldpush, senior vice president of policy and advocacy for America's Essential Hospitals, a trade association for safety-net hospitals.
Hospitals want more federal funding, particularly as many may be forced to curb lucrative electives cases to preserve resources and personnel amid rising COVID-19 cases. Hospitals are hoping this issue of funding can be accomplished in the last months of President Donald Trump's term during the lameduck session, though many view it as a major hurdle.
"There's a chance that we could see a [small] COVID relief package. But I think that's really going to be challenging. I think that's all that we can expect other than federal funding to keep the government open, and, frankly, I think that's going to be challenging," said Joyce Rogers, chief government affairs officer for Advocate Aurora, a major regional health system that spans Illinois and Wisconsin.
The federal government allocated $175 billion to hospitals and providers thus far, which included Medicare loans that need to be repaid. Hospitals leaders are also hoping the deadline to repay is again extended — or forgiven entirely — as facilities continue to battle the pandemic.
They also want more clarity on the reporting rules surrounding congressional grants, money that does not have to be repaid, partially from the Coronavirus Aid, Relief, and Economic Security Act. The issue is complex but important, as it ultimately dictates whether some systems would have to return funds.
Biden has already named a pandemic task force made up of experts who aim to help him tackle the crisis through the transition. Hospitals seemed encouraged by this move and the likelihood of much more robust response to the pandemic.
"We look forward to a coherent COVID strategy and proper attention to the ongoing management, because things are getting worse and they're not going to get any better before Jan. 20 in all probability," said Chip Kahn, CEO of the Federation of American Hospitals, a group that represents for-profit hospitals.
Bolstering healthcare coverage
The pandemic spurred a historic number of job losses as the economy was all but halted to try to trap the spread of the virus. For most insured Americans, health coverage is tied to their jobs, so losing employment means possibly losing health insurance during a period of potentially great need.
However, many employers continued to offer health benefits even as they furloughed employees, recognizing the severity of the situation.
Still, hospital leaders say they can build on the gains made under the Affordable Care Act — assuming it's not overturned by the U.S. Supreme Court — to improve coverage overall.
"All those things that make coverage more seamless and easier would be a priority," Kahn said.
The American Hospital Association also backs increasing access to coverage. Coverage is critical for hospitals that would otherwise be left to treat the uninsured without reimbursement.
Kahn said some key areas of focus include enhancing the subsidies available to those who shop for insurance on Healthcare.gov and subsidizing COBRA coverage, the insurance extended to employees when they lose their jobs, which can be expensive.
Hospitals, however, do not support Biden's agenda to create a public option plan or lowering the eligibility age for Medicare as that would potentially move the prized privately insured patients into Medicare, which typically pays less.
Increased access to Medicaid
Biden's healthcare agencies should roll back Trump administration actions that undermined the Medicaid program, hospitals say. Medicaid has faced an onslaught of policies over the past four years that experts say has restricted access to the safety net coverage or threatened the integrity of the program, which covers some 75.5 million people and has seen enrollment skyrocket in the coronavirus recession.
Notably, CMS has given states unprecedented flexibility to deviate from standards in program design and eligibility, sometimes in exchange for capped funding, and encouraged states to adopt programs linking Medicaid eligibility to work or volunteering hours.
The Trump administration has also proposed a rule establishing new reporting requirements for supplemental payments to Medicaid providers, and limiting what they can be paid. That Medicaid Fiscal Accountability Rule was popular within the administration, but CMS withdrew it in September following provider backlash.
Policies like that rule, along with other Trump-era moves limiting the number of people eligible for Medicaid, should be eschewed by Biden, Feldpush said.
Biden has backed increasing the federal match rate for Medicaid. During the pandemic, the federal match rate was increased temporarily. If the public health emergency is not extended through January, the increased FMAP will expire, right at a time when the rolls are expected to have greater enrollment due to the depressed state of the economy. As such, providers want to see the federal match increased as states' financial conditions are likely to deteriorate. States will likely turn to Medicaid first in cutting their budgets, as it's usually one of the biggest programs.
Additionally, under his public option plan, the roughly 4.8 million adults in states that elected not to expand Medicaid would be automatically enrolled into coverage.
That would be a net positive for hospitals, as it would cut down on rates of uncompensated and charity care.
The new administration should reverse Trump-era policies that have cut back on funding for facilities serving a large proportion of low-income or vulnerable patients, Feldpush said. That includes cuts to outpatient clinic visits and Part B drug payments to hospitals in the 340B drug pricing program.
Biden's CMS administrator could reverse the 340B rate cut of 23%, but Biden himself hasn't mentioned it as a priority, according to consulting firm PwC.
Hospitals also want to continue the march toward more value-based care arrangements and move away from getting paid for volume, which was particularly crucial during the early days of the pandemic as volume was hit.
"The Biden administration is expected to continue the federal government's move toward value-based care, a pardigm shift that began under George W. Bush," PwC noted.
Leaders also want to see legislation that would push back the 2% Medicare sequester cuts, another issue they're hoping to address during the lameduck.
Providers have turned to virtual care in droves this year as the pandemic stifled in-person use of non-emergency services and the Trump administration temporarily removed barriers to the service. Hospitals were no different, with some facilities seeing use jumps in the multiple-thousand-percentage-point range by the middle of the year, giving them a valuable pathway to recoup lost revenue.
Along with connecting patients with providers for use cases like post-surgery followup, hospitals also see the benefit of virtual care in looping in remote specialists for services like teleICU or telestroke.
"We believe it's a game changer," Rogers of Advocate Aurora said of telehealth. The system is going to push to make the telehealth waivers that were enacted as part of the public health crisis permanent. "That's one of our top priority issues that we're going to push on," Rogers said.
More specifically, Rogers wants to see the number of providers allowed to provide telehealth expanded beyond the scope of the national emergency.
Virtual care generally has bipartisan support, though many of the changes providers are stumping for would require congressional intervention.