How 15 Million Americans Could Lose Health Insurance in 2023

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The public health emergency declared when COVID-19 hit the U.S. in early 2020 is expected to end this coming spring. What does that mean for the vaccines and testing that Americans have been receiving for free, not to mention their access to broader health insurance coverage? Andy explores this question with physician and Medicaid expert Meera Mani, who explains why 15 million people could be at risk of losing care. Prem Shah, the chief pharmacy officer at CVS Health, then reminds Andy of the expanded role pharmacies played during the pandemic and how that could go away, too. The end of the public health emergency may be a bigger deal than you think.

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Follow Meera Mani @MeeraMani1 and Prem Shah @CVSHealth.

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Andy Slavitt, Prem Shah, Meera Mani

Andy Slavitt  00:00

This is IN THE BUBBLE with Andy Slavitt. So the pandemic is not over, but it’s gliding towards a more stable state. And with that, I think we believe that sometime in April, the public health emergency that was declared early 2020 will be officially over. What does that mean? That’s what we’re going to explore today with my two guests, Meera Mani, and Prem Shah. It is likely to have a profound impact on millions of people. Not just things like our access to vaccines, but things we get used to in the pandemic like access to telemedicine. And in probably the biggest issue you’ll hear about, there are 15 million people that could over the course of the year, lose their access to insurance. As the title of this show indicates, Meera is one of the world’s leading experts in Medicaid. She is a partner of mine at townhall ventures. I don’t know if I’ve mentioned tunnel ventures very much on the show. But you’re about to learn about tunnel Ventures by meeting Meera. She is a physician. She’s a PhD. She’s spent her career and life focusing on how to provide better solutions to underserved communities. Prem Shah oversees a pharmacy at CVS Health and that’s relevant because the pharmacy has become one of those points of the healthcare system that’s gotten a lot more freedom, but has have hospitals as of other places, that is also slated to go away. So this public health emergency ending may be a bigger deal than people who are not paying attention to give me credit for and I wanted Mira and prem to come on and explain exactly what’s going to change over the coming months, as has happened so we can all prepare ourselves for that. So here they are. All right, welcoming Crenshaw. And we’re Imani. And lo and behold, this is one of the few occasions when I get to do it in the bubble in person, because Meera is actually in the bubble with me. Welcome Meera, welcome Prem. So we got a lot to talk about today. And I think you guys can help us. As I said, in the introduction, January of 2020, the country declared a national health emergency. And at the time, I don’t know about you, but I don’t know that did anything other than scare me about the severity of what was going on. But in point of fact, there are reasons that national health emergencies are declared. Because they allow us to do things that under normal circumstances, you know, you’d want to go through Congress, you’d want to go through some other process, because after all, it is an emergency. And we’re used to thinking about national emergencies as hurricanes, tornadoes, but this little virus creeping through the country qualifies as well, for sure. So maybe you can inform us maybe start with you, Meera. And what are some of the provision some of the flexibilities that the country was permitted during the National Health Emergency and I say this with knowledge that this health emergency is going to come to an end, at some point in the next few months? And it’d be good for us to know that.

Meera Mani  03:46

Yeah, as you know, Andy, the clinical care that you actually receive is only a minor driver of your health outcomes. The majority of health outcomes are driven by what are known as the social determinants of health. So things like housing, food, income, education, clean air and water. So the point is, during the national health emergency, there were actually a number of provisions that were really important in these areas from a health perspective. So things like financial assistance, right rescue payments or tax credits to cover the cost of childcare, unemployment benefits if you lost your job. On the housing side, right mortgage relief, rent and utility assistance freeze on evictions, chances are if your housing insecure, then health is not your top priority, food assistance through the SNAP program for low income families or the WIC program for moms and young children, or even the pandemic EBT cards that were distributed both during the school year and summer break to make up for this free school meals that students would have received if they’d actually been in school. So you know, you back to like housing, food, financial assistance, things that are really important drivers of health outcomes that, you know, we were able to support. And I only bring this up because then we’re going to talk about what needs to stay after and it’s worth keeping the social drivers of health in mind with respect to what needs to stay after the National Health Emergency ends.

Andy Slavitt  05:06

What are some of the major ones?

Meera Mani  05:07

So I think of them in two flavors, right, the things that we did to do a better job of managing COVID itself. And the second is to manage all of the health care that people needed. Even while we were dealing with the pandemic, the massive expansion in the availability of telehealth, or virtual care is the thing that jumps out at most people. So there was a slew of payment and coverage requirements that were eased up in order to allow folks to get care during the pandemic, virtually and safely. Mental health and care for addiction was an area where this type of flexibility was absolutely vital, given that issue just skyrocketed. And then I think I would say, our insurance coverage, making sure people had continuous access to the Medicaid program, for example, was one. And finally, of course, as prime would know very well pharmacy write things like reducing limits on refills, allowing home delivery, allowing vaccines for all ages, those are all really important provisions that were essential during the pandemic.

Andy Slavitt  06:08

So I’m hearing two things, basically, I’m hearing that we supported people with a slightly better safety net. And, you know, one could argue that our safety net doesn’t compare to most wealthy countries. And so maybe we were getting close to par with some of the things you talked about. And that it sounds like there’s a series of things I want to ask you prem to weigh in on this, from your perspective that we did to make healthcare more convenient and more accessible and closer to people’s homes. And maybe it was driven by the fact that we feared if more people went to the hospital, they’d be getting COVID risk. But whether it’s virtually or in the community, we were giving people seems like we’re giving people what they wanted anyway, which is more convenient. more accessible care.

Prem Shah  07:00

Yeah. I can’t imagine, I can’t believe it’s actually been three years since COVID. has started. And, and what I would tell you is, you know, throughout the pandemic, the prep Act, which Meena mentioned, you know, which is a temporary federal authority, really allowed pharmacist, uniform, nationwide authorities that created payment pathways, essentially, to help manage some of the convenience things we were talking about Andy. So think about ways that services really should be delivered in healthcare, around vaccination and testing and immunizations. The public health emergency really enabled that. So as you think about that expanding role of the pharmacist through legislation and establishing pharmacists, as providers under Medicare and public policy, I think these are just things that are absolutely critical.

Andy Slavitt  07:47

So is it the case that when the National Health Emergency ends, what will be different? Will they not be able to schedule a vaccination, will they not be able to get tested as easily? Again, assuming that Congress doesn’t change anything?

Prem Shah  08:03

Some of the provisions that allow for that care would change so for example, the testing would not be enabled without some of the changes that are there. On the vaccination side, right, we believe that some of that will continue. After the Ph. D, we believe that the commercial payers will pay for some of those services. And that will flow through as usual, what I’d say is we’ve also the consumer and the patient dynamic has also evolved, their expectations is that they’re going to be able to receive this care in the convenient way that the pandemic has allowed them to, whether that’s with vaccines and testing, so we have to continue to expand on those pieces as we go forward. And, you know, there’s more services that our pharmacists can provide. And on top of that, around, whether it’s blood pressure monitoring, or So smoking cessation, that we think are really adaptable, right, as it relates to this. So, you know, I just think this is a framework in which we’ve seen the benefits of what pharmacists can do in our communities across the board. And we want to be able to expand that, you know, as we go forward so that we don’t stop some of those things that, you know, consumers are now expecting as part of their day to day health care needs.

Andy Slavitt  09:13

Yeah, look at it’s not just pharmacists, from my perspective, the ability to get things done without having to go to the emergency room, and to go someplace closer to home, whether it’s virtually or in person is really important. I want to focus on another human impact, Meera, which is people’s ability to maintain their insurance coverage. One of the nice things I think you mentioned, if I heard you correctly, was that there was a provision that really prevented people low income people from losing insurance coverage during the national health emergency. And it sounds like that goes away. How big it down here. You’re right and how big a deal is that?

Meera Mani  09:51

Yes, it’s a huge deal. Andy Medicaid is a joint federal and state funded program that provides insurance coverage to disabled or low income Americans at this time, that’s about 90 million people in America that can’t get coverage from this program. At the start of the pandemic, the legislation by Congress made continuous coverage for current enrollees a requirement in order for states to receive the enhanced funding for their programs, which was partly what drove the expansion in coverage. Now, when the National Health Emergency ends, and states then revert back to eligibility determination processes, it’s estimated that up to 15 million people could disenroll from the program, have those, you know, 8 million would no longer be eligible. But there’s up to 7 million people that would lose coverage, despite being eligible. And this is due to administrative barriers, they don’t receive notices, because they moved, they don’t receive notices that they did they understood, or because their state doesn’t fully support phone or online documentation, and so on. So what

Andy Slavitt  10:53

I’m hearing is if we’ve got 300 million people in this country, 5% of the country, 15 million people, how’s my math 15 divided by my math never very good. But I think it’s something like 5% of people in this country could actually lose insurance coverage. And seeing our uninsured rate, jump from where it is today, which is 78% by five percentage point seems really problematic, particularly if these are low income people. And half of them if I heard you, right, roughly half of them may not be able to get coverage, because then they won’t be eligible, and they may or may not be able to afford it. But the other half, it sounds like there’s a real problem here would still qualify for coverage, but be disenrolled. Anyway,

Meera Mani  11:40

That’s exactly right. And even the half that are no longer eligible for Medicaid, in many states, they are eligible for other programs. So part of this is how good a job you do, but helping people find the right programs that provide coverage. And then the other half lose it simply for administrative reasons, simply because of all of the disruptions that I mentioned.

Andy Slavitt  11:59

So, I want to take a quick break. And then one of the themes I want to come back and talk about is, you know, both of you are essentially saying that there were some things done for emergency reasons, that if we take them away, people are gonna get hurt. And I want to talk a little bit about what we had to be doing about that. So we take a quick break and let it come back with me Romani, and prep shop.

Andy Slavitt  12:42

So it strikes me that these areas we’re talking about, there’s opportunity for us to ask the question, what can be done or what should be done? And I think there’s some I think what asked that question of both the government as well as what the rest of us can do, you know, prime, you refer to a couple of pieces of legislation in front of the Congress. So maybe we should start there. You know, a lot of staff members, listen to the bubble, because it really is the most fun thing to do with your time. I know when they’re on the rowing machine, and the hill basement, there blaring the show. So maybe you start with you Prem, what are some of the things that Congress should really think about? That would really have an impact on helping people get more convenient care? And then maybe I’ll ask you the same question with regard to the safety net, MedicAid, some of those issues?

Prem Shah 13:39

Yeah, look, I think first and foremost, I think COVID. And the pandemic has taught us that there’s a better way to deliver health care. And some of the things that the prep Act and the Ph. D afforded us was to be able to show a better health care experience for the communities in the way in which he delivered vaccinations and testing across all the pharmacies in the country, right over 200 million vaccine doses were delivered, be able to do it seamlessly. And if you think about the bill, and what that affords us, it took advantage of our ability to be able to, you know, what I would say HR 7213, allows us to continue to provide the access to patients to have better clinical care in their local communities. And it will also expand those services post a PhD. So that’s, that’s absolutely critical. And, you know, from my perspective, I think it’s about the we’re coming across this time in wherever you don’t have the capacity of healthcare resources, right? Every school you look at whether it’s medical schools or pharmacy schools, there’s just not enough folks in the community. So as you start are not enough clinicians to deliver care. So these bills will afford us the ability to leverage what we’ve learned during the pandemic, and really continue to drive it forward to improve the quality of care in our local communities, give consumers and patients a much better experience. So it’s absolutely critical and by We need to continue to drive these forward and take what we’ve learned during the pandemic and move that forward.

Andy Slavitt  15:04

So, okay, Prem, what if you don’t care about health care, but you care about inflation? What’s going to be the impact and inflation of saying, hey, a lot of the care you’ve been receiving locally, whether it’s in pharmacies or other convenient locations, you’re not to go back out to go back to the hospital with limited nursing staff and see physicians for those services. We have shortages there anyway. So isn’t this a recipe to increase healthcare inflation? And therefore everybody’s inflation?

Prem Shah  15:30

Yeah, absolutely, I think you’re going to decrease the ability to have access to care for consumers and patients across the country in a convenient fashion. And if they don’t get, you know, what I’d say is preventative services in a in a way that’s tangible to them, or they have to wait for those preventive services that can lead to increased hospitalization and ER visits and other things that cost much more to the healthcare system than, you know, some of these preventative services that, you know, HR 7213 would afford?

Andy Slavitt  15:59

Well, that’s the argument I’ve been making on the Hill about telemedicine is if you have the ability to access services, by picking up your phone and accessing any available counselor or care provider, it’s going to by the definition, help you solve the supply and the inflation crisis. Versus if you have to go into someone’s office and they’ve got to have an appointment available, it’s going to be much more expensive. So you know, I don’t know, I think mirror that like even if you’re just looking at this from purely an economic lens, like creating this, I’ll call it new forms of competition, lower cost forms of competition, more convenient ways to get care that we experienced to the national health emergency, it feels like there’s an economic imperative to me, too.

Meera Mani  16:46

I think you could argue that, you know, on the hospital side, the care that was diverted away from the hospitals, was cared that could have been safely delivered outside of the hospitals in other locations anyway, we just never got around to it until our hand was forced, right? So right there, you have a difference in cost associated with that care, delivery. And more importantly, you preserve the hospital for the kinds of things and hospitals really need to be there to serve us.

Andy Slavitt  17:11

So maybe I wouldn’t have to wait six hours in the emergency room, if you took some of the things that were missing in the emergency room before and saw them in our community locations.

Meera Mani  17:21

That’s a great example. I’d also say that the other economic argument, if you would, is that by delivering this convenient care, particularly for disadvantaged communities, many of whom have worse health outcomes to begin with, you’re also taking care of what actually is described as rising risk, which is people that have not been engaged in care, but are really going to have, you know, blow up incidents, and therefore a high cost of care in the years that follow. And so by meeting them where they are, you help defer those costs.

Andy Slavitt  17:53

So I’m asking about these economic issues, because in some respects, I think you’ve got half the people in Congress, who believe everybody should have more access to health care. And then you got another half of the country kind of rich, which feels understandably, by the way, in some respects, that we spend too much on health care. And it’s not a good investment and everything we spend on health care doesn’t get, you know, it’s lost to the economy. But I was I wanted to understand to the extent we’re talking about things that are also not only good for people’s health, but are also productive, productive for us as a country and therefore, good policies. I’m gonna ask the same question, do you mirror that I asked to Prem? What should Congress do about the situation where people losing Medicaid coverage? Or any one of the other issues that are impacting people can they act can states act? What’s the right recipe because it feels to me like, if you’re telling me we’re rolling towards something where 15 million people are gonna lose insurance coverage, I want to get the country’s attention to that.

Meera Mani  19:02

Rightly so, Andy, I think there’s two things in there right of those 15 million people, right, about half right made the maybe a small slice that are truly ineligible for coverage, right, which is just put them to the side for a minute, because I know there’s strong polarized views about what to do there. But just take the people that everybody according to current regulations should have access to coverage for right, I think there’s two things one is help people find the right coverage, that they’re eligible for full stop. And then for those that are losing it for administrative reasons, that’s just unconscionable. And, you know, that’s where actions related to make it make it easy to enroll, right, just like we have in other parts of our life, make it easier to provide documentation online or phone right. Don’t send renewal notices to the wrong addresses and expect people to respond don’t send them notices and languages they don’t understand.

Andy Slavitt  19:52

It feels like we’re inflicting our bureaucracy on poor people. It’s like if we said to wealthy people, you don’t get access to your tax credit that you’re deducting unless you go find it. And then as you go document it, we generally give people with capital, we remove the hoops to allow them to get the things that they by law have access to. But it seems like we’re doing the reverse with low income people, we’re basically saying that the burden of proof is on them, not the state or the federal government to do the things they need to do to get health care, it feels like either that’s been done very cynically in order to save money. Or we ought to be able to change the law or the way the law is implemented in such a way that we reverse the burden of proof. And in other words, you tell me why I shouldn’t get coverage, instead of you taking my coverage and making me prove why I should get it. Is that too simplistic way of looking at it?

Meera Mani  20:59

No, I think that’s succinctly and clearly said, Andy, I think that, you know, there’s ways in which you certainly make it simpler to prove that you are eligible for coverage. And to be fair, there’s a there’s a lot of work underway in a number of states that’s trying to do just that it’s not uniform, right. So the experience you have across different states is varied. But you’re exactly right in the burden of proof for low income people.

Andy Slavitt  21:23

Let’s take a final break, I’m going to come back and see if I can sum up a little bit of something that Prem raised, which is what did the last few years teach us about what a better healthcare system might look like? I’m gonna ask some pointed questions of Meera and Prem, let’s take a quick break, we’ll be right back. Back with Prem Shah, and Meera Mani, and I think you guys have spent the last 20 minutes 30 minutes or so talking about some of the adjustments that we started to get used to, that were put in place simply as a result of the pandemic. And simply because it was an emergency, telehealth more convenient care and options in pharmacies and other things being brought out of the hospitals flexibility that the hospitals had, then a whole bunch of other things that are safety net to help people from falling through the cracks. And the thing that I think was most different about it is if I walked in to CVS pharmacy and said, I need a vaccine, I need a test. The one thing you never asked me for was money. So I know that most healthcare decisions that people think about and worry about all the time, they worry more about paying for it, oftentimes than they do getting the right care. So construct for me, if you would maybe Prem we’ll start with you. What if you go up 30,000 feet and say, We need to extract some lessons about what a better US healthcare system could look like? What are the things on the top of your list?

Prem Shah  23:29

Yeah, it’s such a great question. And it’s something that our team thinks about every day across our company. And here I’ll say a couple of things. The pandemic made it really, really clear that the way we deliver care, even in pharmacy, there was a tremendous opportunity to make that care better. And I’d say one of the things that pandemic did was really drive forward, more efficient ways to deliver care. So for example, pre pandemic, the scheduling of vaccinations, we delivered a, you know, millions of vaccines, even before the pandemic, across the pharmacy industry. But after the pandemic scheduling of those vaccines scheduling of the testing that occurred around COVID, were critical changes and what we’ve done, we’re going to take those, you know, across our industry and really make that table stakes as it relates to our pharmacy experience. The second piece around affordability, it’s been something that’s been real and relevant in healthcare for a long, long time. And if you think about prescription drugs, you know, our desire is to always make access and more affordable care for patients. We know that patients who take their medication stay and can afford their medication stay more adherent to their medications, which ultimately improves health outcomes and manages healthcare cost. We also have seen over the course you know, even before the pandemic, the rise of High Deductible Health Plans, what that means is patients paying more to get their services before their insurance kicks in and those higher out of pocket costs and you know, requires a need for more ways in which consumers can save money are becoming more and more prevalent. And so, you know, in our pharmacy processes, we continue to evaluate prescription costs. And we identify ways in which we can help members and patients save money, either through loyalty programs or manufacturer coupons that may exist, as well. You know, and I’ll say that studies have also shown that the coordination of care, and the use of these preventative care services also helped to, you know, lower costs, but I’ll just say the, you know, to sum it up, I think technology is going to play a critical role going forward, how we deliver that care, how do we put it the control of their care back in the patient and consumer, we have to continue to make, you know, take the administrative burden out of delivering care, whether it’s in pharmacy or health care services, and we have to make it more convenient, and drive more preventable services. We know that when patients and consumers receive those preventable services, you know, that lowers the cost, the total cost of health care across the board.

Andy Slavitt  25:56

So what I take away from that is more prevention, more convenient locations for care, more affordable care. And look, the more affordable care was a bit of a loaded topic, because the question is, who pays and how much did they pay? We’ve had shows, and we talked about the inflation Reduction Act talking about how we reduce the cost of prescription drugs. But it’s also the case that, you know, when we do pay for prescription drugs, it’s either going to be us as individuals, maybe our employers or taxpayers that are going to pay the bill. And I think there is, you know, it when we go through health reform questions, a lot of that, really, it’s about how much burden to put on individuals, and how much burden to put on taxpayers. It is going to you a bit on this particular question before we get to the bigger question, mira, like, the more way I look at it, as the more of the burden is put on taxpayers, the more we treat everybody the same in this country, the more everybody has access to similar things, the more we say, you know, you individually have to pay, whether it’s a deductible, Prem talked about, or CO payment or more premiums. The more we’re saying this is healthcare system for the wealthy.

Meera Mani  27:10

Yeah, I think that, you know, this, there is obviously nuances to it right, I think the flip side of what you what you said, I think, you know, would, you know, would have merit, I think the flip side of it is, you know, we’re at a point where health care costs are set to outpace GDP growth in the next few years. And you know, what this is also at a time, we’re seeing a whole new set of care pathways. So I think the idea of just being, you know, studious about it, and learning what’s working well versus what’s not. And making sure that the new care that’s provided is actually in service of high quality and is holistic to what the person needs, I think is going to be critically important. I think there’s also the thing to keep in mind with respect to what happened during the pandemic is that we had to get certain things done at all costs. And that kind of pandemic pricing in this environment is just not sustainable. And it could even create disincentives, right. If I assume that someone else will just step in to do it for free.

Andy Slavitt  28:06

That’s true. But we had a lot of people who were pandemic profiteers that took advantage of that, and what companies it’s all tests and masks for just unconscionable prices. So you’re right, when you lose these controls, some of those things go away. What would you add anything to Prem’s list of your 30,000 foot list of aha, takeaways and things go, You know what, that actually worked better under a national health emergency, and we, too, as a country, begin to adapt our healthcare system. So those kinds of things are permanent?

Meera Mani  28:39

Yeah, I’d say that. Most people would argue that the care that we moved away from hospitals probably deserved to be out of the hospital in the first place. Right. So that feels like something we ought to maintain. I think on telemedicine, right. I think some of the convenience, particularly and the access that facilitated for mental health and for addiction care, I think is just vital to maintain in this environment. I would love to continue to see expansion, at least reduced barriers and expanded coverage for the social care, right, the kinds of benefits that drive health outcomes, but I’m not getting paid for in a systematic way today.

Andy Slavitt  29:17

Good. Let’s just leave it there. Let’s leave you with the last word Mira. And I think let’s get Congress both with an opportunity now, but certainly over the next couple of cycles to have the kind of Congress that is focused on steadily improving our healthcare system. We had a great experiment over the last few years as one way to look at it. And a lot of these things worked a lot of these things people liked, and when they go away, I just have this feeling that people are not going to be as happy with our healthcare system. And so, you know, pressure on to Congress and to the rest of us to keep making our system better. Thank you both for being in the bubble.

Andy Slavitt  30:10

I’m very excited for our show Wednesday, we’re gonna give you the most usable guide to what the economy is going to look like in 2023. With the great economist Justin Wolfers, that is on Wednesday, Friday. We have a really interesting show about big tech, the technology platforms, democracy, the First Amendment where it’s gone wrong, where it’s can be salvaged. That’s going to be a great show. And then we’re gonna get to the holiday season the following week. We’ll tell you about those shows later in the week. Okay, have a great week. We will talk to you on Wednesday.

CREDITS  30:54

Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Kathryn Barnes, Jackie Harris and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.

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