The coronavirus pandemic has laid bare our health care system's vulnerabilities and lack of preparedness. It is imperative that we examine more closely the steps we have taken thus far, and what we have yet to accomplish in public health.
Over the past 6 months, COVID-19 has killed hundreds of thousands of people, sorely testing health care system capacities to manage critically ill patients around the world. In the United States alone, the pandemic has laid bare our own system's vulnerabilities and lack of preparedness. Scenes of overwhelmed emergency departments in the worst affected areas helped spur a public crisis response that included both widespread shelter-in-place orders and unprecedented government expenditures. These actions helped stave off the more apocalyptic possibilities, even as some areas still dealt with inadequate numbers of critical care beds, personal protective equipment, and mechanical ventilators.
Despite these efforts, the pandemic rages on, with the United States reporting the highest number of cases and deaths globally. As we contemplate how we will respond to this ongoing crisis, it is imperative that we examine more closely the steps we have taken thus far and what effects they have had on our healthcare systems. Below, we will summarize some of the most consequential policy responses of the past few months and consider the policy challenges that lie ahead.
Legislative Initiatives
The Coronavirus Aid, Relief, and Economic Security (CARES) Act was a $2 trillion relief bill signed by President Trump on March 27. The goal of the bill was to provide economic support to American workers, small businesses, and state and local governments.1 However, funding under the CARES Act quickly depleted, and the Paycheck Protection Program and Health Care Enhancement Act (COVID-3.5) was signed into law on April 24 as an extension of the former bill.
Key Features of the CARES Act |
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Expansion of telehealth opportunities |
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Medicare advance payments for emergency visits |
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Financial assistance for student loans/deferral of payments |
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Reimbursement for healthcare providers for lost revenue or expenses related to COVID-19 |
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Liability limitations and coverage of COVID testing and preventive services |
The Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act was passed by the U.S. House on May 15. This legislation plans to provide a $3 trillion expenditure including expanded unemployment benefits, hazard pay for front-line workers, student loan forgiveness, increased food stamp funding and direct cash payments of up to $6,000 per family.2 At the time of article submission, the Senate had no plans to take up the bill.
Regulatory Initiatives
Under section 1135 of the Social Security Act, the Centers for Medicare and Medicaid Services (CMS) may temporarily waive or modify certain Medicare and Medicaid requirements.3 The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law passed in 1986 that required anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay. CMS clarified that EMTALA requirements do not apply to drive-through testing sites for COVID, including those which are located on a hospital campus. Additionally, triage nurses may redirect patients coming into the ED to another area for a medical screening exam to cohort those with respiratory symptoms.
CMS also issued a number of waivers to encourage greater use of telehealth services. Key changes included geographic expansion of telehealth to include patients living in urban areas and waived HIPAA requirements to allow use of modalities such as Facetime and Skype to further increase accessibility. Additional waivers include expansion of the telehealth service list to include additional billing codes for emergency department evaluation and waiving patient cost sharing such as deductibles, coinsurance, and copayments. Lastly, there is a temporary waiver to allow physicians who are licensed in one state to provide telehealth services to a patient in another state, although this generally is still subject to the jurisdiction of states to address.
Future of COVID-19 Policy
Perhaps the most pressing COVID-related policy question is when and at what pace states or localities should reopen their economies. Unfortunately, this debate has become increasingly partisan. Political leaders face the dual challenges of balancing the healthcare risks related to a lethal pandemic versus what may become one of the worst economic depressions in history. These are usually framed as trade-offs: save jobs or save lives. But it is not at all clear that this is the case: premature lifting of public health measures followed by a COVID resurgence may cause more long-term economic damage than a slower, more methodical approach that initially keeps businesses shuttered longer.
The overarching goal of expert guidance on reopening is to drive R0 below one. R0 is the reproductive number of the virus: it refers to the number of people on average that one person with COVID will infect. If R0 is above one, each new generation of infected people will be larger than the last and the outbreak will spiral out of control. If R0 is less than one, each generation of infected people will be smaller than the last and the outbreak will eventually die out.
Criteria for Safe Reopening |
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Sustained reduction in cases for 14 days |
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Hospitals can treat all patients requiring hospitalization without resorting to crisis standards |
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The state is able to test all people with COVID-19 symptoms |
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The state is able to conduct active monitoring of confirmed cases and their contacts |
Another unsettled issue involves coverage for the uninsured. One of the most pressing questions at the beginning of this outbreak was what costs uninsured Americans infected by COVID would face and how providers and hospitals would fare if these patients were unable to pay. Since then, President Trump and various members of his administration have stated that the federal government will pick up this tab. But even with that commitment, many questions remain, including whether services such as post-hospital care for critically ill survivors and how they will be covered.
Finally, this unprecedented period of our history will likely end only with the successful development, manufacture, distribution, and administration of a novel coronavirus vaccine. We will not be able to make vaccines available immediately to every person, and the timeline for vaccine release remains unclear. However, some prioritization system for administration of vaccines will have to occur, and future debate regarding the topic of vaccination is certain and undoubtedly necessary.
References
- Snell K. What's Inside The Senate's $2 Trillion Coronavirus Aid Package. NPR. Published March 26, 2020.
- Werner E. House Democrats pass $3 trillion coronavirus relief bill despite Trump's veto threat. The Washington Post. Published May 16, 2020.
- CMS Makes Sweeping Regulatory Changes for COVID-19. American College of Emergency Physicians. Published April 28, 2020. Accessed June 5, 2020.