The Health 202: The Trump administration is pulling Medicare and Medicaid levers to combat coronavirus

Under a special allowance — made possible by Trump’s emergency declaration Friday — states can now seek permission from the federal government to ease the pathway to care for their Medicaid patients during the pandemic. 

By applying for what are known as “Section 1135 waivers,” states can get permission to skip steps normally required to enroll people in Medicaid or bring more health providers into the program. The idea is this: It’s so vital to ensure low-income people have health coverage and access to care during an emergency that it’s worth suspending normal processes.

Florida already received permission to tweak its Medicaid program from the Centers for Medicare and Medicaid Services, less than a week after the state submitted its request. California announced yesterday afternoon it has also requested a waiver to loosen rules around the use of telehealth and where care can be provided in Medi-Cal, its Medicaid program.

“To get Californians the care they need during this crisis, we need to change how that care is delivered and communicated,” California Gov. Gavin Newsom (D) said in a statement.

Many more states — perhaps all 50 — are expected to seek this emergency permission. Officials in Illinois, Washington, Tennessee and Mississippi have indicated they might not be far behind.

“I would be surprised if there was a state that didn’t submit some kind of waiver,” Matt Salo, executive director of the National Association of Medicaid Directors, told me. “Everyone is going to be looking at this.”

It’s not the first time the federal government has given states Medicaid waivers to help them mitigate disasters. Back in 2009, then-HHS Secretary Kathleen Sebelius invited states to apply for 1135 waivers after President Barack Obama declared the H1N1 influenza a national emergency.

The Department of Health and Human Services has also lifted some Medicare rules in a way that's not been done before — more evidence the Trump is starting to take the pandemic more seriously.

Officials announced that Medicare will begin broadly reimbursing medical providers for telemedicine services, encouraging more doctors to limit person-to-person interactions and save elderly people from having to make a physical visit to an office where they might be exposed to the virus. (The Health 202 did a two-part series last year on Medicare and telehealth here and here.)

Gretchen Jacobson, vice president of Medicare for the Commonwealth Fund:

And clinicians who use popular apps such as Skype or FaceTime to meet with patients don’t have to worry about being penalized for violating medical privacy laws, according to an unprecedented action by the HHS Office of Civil Rights, whose job it is to enforce the federal HIPAA law.

“We’re making clear that we will not be imposing penalties against health-care providers that use widely available communication apps to engage in telehealth during this emergency,” OCR Director Roger Severino told me.

Trump called the steps “a historic breakthrough” during a White House press briefing — and described them using his own, Trumpian verbiage. 

“By doing this, the patient is not seeing the doctor, per se, but they’re seeing the doctor, so there’s no getting close,” the president said.

Trump is using dramatic language to describe the virus, a marked shift from his rhetoric in recent weeks:

The American Medical Association, which had urged Trump to issue an emergency declaration, praised the move. “The steps CMS has taken demonstrate the agency was listening,” said AMA President Patrice Harris.

There's another higher-profile way the administration says it wants to fight the virus: By sending direct cash payments to Americans to help them cope with pay cuts and other resulting economic hardships, as part of a massive stimulus package being negotiated by the White House and Capitol Hill.

Treasury Secretary Steven Mnuchin said the overall price tag of the package could be about $1 trillion, making it one of the largest federal emergency fiscal packages ever assembled, my Washington Post colleagues Erica Werner, Jeff Stein and Mike DeBonis report. 

“News of the stimulus planning sent the Dow Jones industrial average up more than 1,000 points on Tuesday, recovering some of its losses from Monday,” they write. “However, reservations expressed by Democrats on Tuesday over various aspects of the package suggested that it could take some time to arrive at a bipartisan agreement that could pass both chambers of Congress.”

Amid all these moving pieces, Trump is now claiming he knew the virus would turn into a pandemic before anyone else did — after spending weeks publicly downplaying the risk.

“I felt it was a pandemic long before it was called a pandemic,” he told reporters.

Post fact-checker Glenn Kessler:

AHH, OOF and OUCH

AHH: Former vice president Joe Biden swept the Arizona, Florida and Illinois primaries, once again dramatically outperforming Sen. Bernie Sanders (I-Vt.) as efforts to combat the spread of the coronavirus complicated voting. 

“A key question for Tuesday was to what extent voters would stay home to avoid exposure to the virus. So far this year, turnout has increased by about 30 percent over 2016 levels,” our Post colleagues Michael Scherer, Annie Linskey and Sean Sullivan write. “Initial estimates by Edison on Tuesday night showed turnout in Florida up about 8 percent from four years ago, bolstered by a substantial early vote. In Illinois, turnout appeared lower than in 2016.”

— Biden addressed the nation in a live-stream speech from his home in Wilmington, Del., offering a message meant to unify the party and to address the ongoing crisis. “Tackling this pandemic is a national emergency that is akin to fighting a war,” he said. “This is the moment for each of us to see and believe the best in every one of us.”

— In an online address during the day, Sanders spoke of ways to tackle the coronavirus crisis but did not mention the Tuesday contests. “Among the ideas Sanders pitched: empowering Medicare to cover all medical bills during the crisis; using emergency authorities to scale up the production of medical supplies; and providing economic relief, including a $2,000 monthly cash payment to every household for the duration of the crisis and a waiver for student loan payments,” Sean writes. 

The Post's Matt Viser:

— There was chaos at polling places in the trio of states casting votes, as people faced closed polling locations, a lack of cleaning supplies and struggling officials. Ohio, the fourth state scheduled to vote, postponed voting in a last-minute move, citing the “health emergency.” 

The obstacles were unprecedented, as officials sought to make sure people could safely cast their ballots even as health officials warned people about the dire need to stay isolated. 

“The challenges Tuesday intensified questions about how subsequent primaries — and the general election — can go on if the pandemic does not subside,” our colleagues Elise Viebeck, Amy Gardner, Isaac Stanley-Becker and Mark Guarino report. “Many have called for states to conduct all voting by mail, but there are questions of whether Congress has the votes to pass such a mandate, as well as about states’ abilities to implement such a massive new initiative in a matter of months. Only three states — Colorado, Washington and Oregon — currently run elections with mail-in ballots only.”

— Some state officials are hoping to avoid this kind of confusion and are delaying their contests ahead of time. Five states have already done so — Georgia, Kentucky, Louisiana, Maryland and Ohio — and others are expected to follow.

OOF: Now the ones taking care of the sick are getting sick. Doctors, nurses and EMTs across the country have fallen ill or are being quarantined after being exposed to the coronavirus.

“The risk to our health-care workers is one of the great vulnerabilities of our health-care system in an epidemic like this,” said Liam Yore, a board member of the American College of Emergency Physicians. “Most ERs and health-care systems are running at capacity in normal times.”

Still, it’s not clear how widespread the impact is. “Gauging how badly providers have been hit is difficult because no nationwide data have been released by the U.S. Centers for Disease Control and Prevention, medical associations or health-care worker unions,” Lenny Bernstein, Shawn Boburg, Maria Sacchetti and Emma Brown report. “A federal official who was not authorized to speak with the media said the government has received reports of more than 60 infections among health-care workers. More than a dozen are related to travel.” 

Two emergency physicians are hospitalized in critical condition — in Kirkland, Wash., and in Paterson, N.J. It’s not clear if the physicians were infected at their hospitals or in their communities.

— Are hospitals near you ready for the coronavirus? ProPublica’s Annie Waldman, Al Shaw, Ash Ngu and Sean Campbell have a new tool to determine the preparedness of nearby facilities. 

Assessing the D.C. area, the model notes that as of 2018, the district “had 5,060 total hospital beds, of which about 68% were occupied, potentially leaving only 1,600 beds open for additional patients. … In the moderate scenario, in which 40% of the adult population contracts the disease over 12 months, Washington, DC would be among the regions that would need to expand capacity.”

In that moderate scenario, there would be 6,000 beds required in a year, which is 3.8 times the number of available beds in that time. 

The New York Times similarly mapped the capacity expansion necessary in hundreds of cities to deal with the crush of cases, via reporter Sarah Kliff: 

Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services in the Obama administration: 

OUCH: Americans are growing desperate for more coronavirus testing, and major labs are ramping up their efforts. Still, the United States is behind other countries, and the rationing of scarce supplies remains an obstacle. 

“The push to accelerate coronavirus testing nationwide made significant advances this week, from the Pacific Northwest to the Northeast,” our Post colleagues Carolyn Y. Johnson, Laurie McGinley, Juliet Eilperin and Emma Brown report. “On Tuesday, Adm. Brett Giroir said that nearly 59,000 tests had been done, with commercial labs administering 8,200 on Monday alone.” 

In some cities, there are drive-through testing operations, and more will soon pop up, the administration said. 

Who is getting access to tests? “With access to traditional testing still limited, the Trump administration has said priority will be given to health-care workers and people older than 65, who are at higher risk for complications,” our colleagues write. 

— States and local governments continue to release new guidance:

• North Carolina’s Outer Banks will start restricting tourists and visitors to reduce travel and limit possible exposure for permanent residents.
• New York Mayor Bill de Blasio said he was considering a “shelter in place” order to keep millions of people home, per the New York Times. “It is definitely a possibility at this point,” the mayor said at a news conference. But Gov. Andrew Cuomo downplayed the suggestion and said there's “not going to be any quarantine, where we contain people within an area, or we block people from an area.”
• In California, public schools are likely to be closed for the rest of the school year, Gov. Newsom said, per the Los Angeles Times. 
• There's a patchwork of responses from governors, mayors and county leaders nationwide. While some places have instituted shelter-in-place orders and school closures, authorities in other locations have been more lenient, as our Post colleagues Griff Witte, Katie Zezima, Ariana Eunjung Cha and Tim Craig report.

— Some other headlines and developments to catch up on this morning: 

By the numbers: 

• The death toll in the United States has surpassed 100 people. “Nearly all — about 85 percent — were older than 60, and about 45 percent were older than 80. It’s unclear how some of them contracted the disease, but more than a third were living in residential care facilities when they became ill,” The Post’s Reis Thebault, Abigail Hauslohner and Jacqueline Dupree report.
• As of yesterday, there have been cases confirmed in all 50 states and the District of Columbia. West Virginia was the last state to confirm a case.

Stories from the Washington area: 

• As the number of cases in the area increases, hospitals are rushing to expand testing and free up beds, our colleagues Jenna Portnoy, Rachel Chason and Kyle Swenson report.
• A local psychotherapist who tested positive for the novel coronavirus and went from perfect health to grappling with the virus in a week is “emblematic of what government officials fear awaits tens of thousands of Americans now ordered to remain at home,” The Post’s Paul Schwartzman writes.

On social distancing and the impact on the individual: 

• Social distancing is difficult because it’s contrary to human nature, The Post’s Karin Brulliard writes.
• An analysis of millions of tweets related to the coronavirus found that “the whole world is sad,” said Manlio De Domenico, a scientist at Italy’s Bruno Kessler Foundation’s Center for Information and Communication Technology.
• Experts acknowledge the public health crisis also takes a severe mental toll, The Post’s Joel Achenbach reports. “Right now people are feeling grief over the loss of routines, certainty, and a perception of themselves as being generally healthy and protected,” says psychiatrist Joshua Morganstein.

The response from agencies: 

• The Internal Revenue Service and the Social Security Administration have been closing field offices across the country to contain the spread, our colleagues Lisa Rein and Kimberly Kindy write.
• The Pentagon will make up to 5 million respirator masks, 2,000 deployable ventilators and at least 14 testing labs available, The Post's Dan Lamothe reports.

Those hardest hit: 

• An estimated 1 in 6 children live in homes without enough food, and many families rely on schools to feed them. What happens when these safety nets close amid the outbreak? From The Post’s Moriah Balingit.
• Supermarkets have started restricting the number of shoppers in stores or offering elderly-only hours, per our colleague Abha Bhattarai.
• In a statement, FDA Commissioner Stephen M. Hahn said while the agency is “confident that stores will remain open and supply will continue to meet demand nationwide, we ask all Americans to only purchase enough food and essentials for the week ahead.”