The Health 202: Democrats are torn over how and when to try expanding health coverage

Democrats are expected to advance legislation this spring and summer lowering pharmaceutical prices.

But when it comes to their other top health-related goal — expanding coverage — plans are up in the air. Way up in the air.

Twenty-nine million Americans still lack coverage, even after the 2010 health-care overhaul creating the Affordable Care Act.  But Democrats are hardly united on how and when to pass legislation getting more of them covered.

Next week, Biden is expected to announce the second part of his major legislative proposal to overhaul the country’s infrastructure. The next piece is expected to address the needs of families including child care, elderly care and health care.

But the White House hasn’t made any final decisions on which of many difference insurance expansion options to pursue, as my colleague Jeff Stein reports.

House Speaker Nancy Pelosi (D-Calif.) is urging the administration to propose a permanent expansion of ACA subsidies, which were extended temporarily in the coronavirus relief package. But Sen. Bernie Sanders (I-Vt.) told Jeff he wants Biden to push for lowering the Medicare eligibility age to 55 or 60.

“Either approach would offer more health insurance to lower-income Americans,” Jeff writes. “But the choice facing Biden will allow him to decide whether he wants to continue to focus on the ACA, which operates largely through private insurers, or use political capital on a government-run program.”

Biden is reaching out to Republicans; yesterday he invited top senators from both parties to the White House to discuss his infrastructure package. 

“President Biden vowed Monday that the size and scope of his $2.25 trillion jobs plan — as well as how to pay for it — is up for negotiation, setting the stage for what is likely to be months of congressional wrangling on one of the White House’s chief legislative priorities,” Seung Min Kim and Jeff report.

Whether a bipartisan deal ultimately materializes is far from clear, however, they write. It’s hard to imagine any Republicans supporting boosting the corporate tax rate, as Biden’s plan does. 

That would allow them to push through Biden’s priorities with just 50 Senate votes, without having to garner any GOP support. One of those priorities is almost certainly parts of H.R. 3, the bill allowing the government to directly negotiate lower Medicare prices with pharmaceutical companies.

Up until last week, there were questions over whether Democrats would have just one chance to pass a budget reconciliation bill, since only one budget resolution was allowed in any fiscal year. The idea was to dump as much of Biden’s proposals as possible into the single package and try to force it through Congress.

But then the Senate parliamentarian issued a surprise ruling that may allow Congress to amend current budget reconciliation rules and advance multiple reconciliation bills in 2021. 

It’s not a foregone conclusion that Democrats can and will all agree to do that. There’s still come confusion over what the new ruling actually means and how it can be acted on.

But it potentially gives Democrats two chances this year to pass reconciliation bills. Congress-watchers say the current plan is to use one reconciliation package to pass infrastructure by Sept. 30, and then spend the fall trying to pass Biden’s other priorities — including health care — in a second package.

For instance, moderate Sen. Joe Manchin III (D-W.Va.) might not agree to change the budget resolution rules. And either way, Democrats, holding only very slim majorities in the House and Senate, can only pass health insurance expansions supported by the most moderate among them.

“I think the problem is they don’t have a plan yet for how this is all going to evolve,” said Chris Meekins, a former Health and Human Services official who is now a health policy research analyst at Raymond James.

Tune in to Washington Post Live at 11 a.m. today, where I’ll be talking coronavirus vaccines and variants with Julie Morita, executive vice president of the Robert Wood Johnson Foundation, and Céline Gounder, clinical assistant professor of medicine and infectious diseases at New York University. Watch here.

The White House announced that Biden has selected Milgram, a former New Jersey attorney general, to lead the DEA, The Post’s Dan Diamond and Devlin Barrett report. A longtime advocate for reform of the criminal justice system, Milgram once declared that there is “no system more old-school and broken and problematic than the criminal justice system.”

During his presidential campaign, Biden vowed to direct the DEA to protect communities from the drivers of the opioid epidemic. DEA officials have warned that the smuggling of fentanyl, methamphetamines and other drugs into the country is helping to fuel overdoses and deaths.

Mayor Bill de Blasio (D) announced on Monday that students in all grades who signed up for in-person classes in recent weeks will be able to return starting April 26. The city had previously only committed to allowing elementary students to switch to in-person learning. 

“The announcement marks one of the most significant changes prompted by last month’s guidance from the Centers for Disease Control and Prevention that schools could reduce social distancing between students in classrooms to three feet from six. For now, only elementary schools will switch to three feet,” the New York Times’s Eliza Shapiro reports.

City schools have had low transmission and tens of thousands of teachers have received vaccine doses. Still, the families of 650,000 of the city’s roughly 1 million students have decided to continue with remote learning through the end of this school year.

Rochelle Walensky, director of the Centers for Disease Control and Prevention, said on Monday that Michigan needs to “shut things down” rather than rely on the federal government to send extra doses of vaccine, The Post’s Amy Goldstein reports.

The remarks come nearly two weeks after Michigan Gov. Gretchen Whitmer (D) appealed to the White House to rush more vaccine doses to parts of the country where cases are surging. While the Biden administration has urged states to pause reopening plans, the comments represent the first time top health officials have urged a state to shut down again.  

“If we try to vaccinate our way out of what is happening in Michigan, we will be disappointed that it took so long for the vaccine to work,” Walensky said during a White House briefing.

Michigan is diagnosing about 73 new cases each day per 100,000 residents, compared to a rate of 21 cases in the United States overall, according The Post’s coronavirus tracker. 

Japan has had relatively few coronavirus deaths, despite an elderly population, few lockdown measures and limited testing resources. Around 7 out of every 100,000 people in Japan have died of covid-19, compared to 171 in 100,000 people in the United States.

“From the beginning we did not aim at containment,” said Hitoshi Oshitani, a virology professor at Tohoku University Graduate School of Medicine in Japan and key architect of Japan’s coronavirus response. “Our legal system does not allow us to implement an aggressive system like a lockdown.”

Instead, Japan was quick to recognize airborne transmission of the virus, even when the World Health Organization and some U.S, were downplaying this possibility. By April, public health authorities were recommending open windows on public transport. The country targeted superspreader events, advising the public to avoid the three Cs — closed spaces, crowded places and close-contact settings.

Oshitani also points to the country’s strong public-health system and a high level of  trust in government. When contact tracers in Japan reached out to infected individuals, they got responses from almost everyone, he said. In the U.S., in contrast, response rates in some regions hovered below 50 percent.

“I don’t think the U.S. or European countries can do what we are doing in Japan,” Oshitani said. “There’s no one-size-fits-all approach to covid-19. The legal systems are different, the resources are different, the epidemiological systems are different.”

But the pandemic is also far from over. Japan is now seeing a spike in cases, potentially driven by the spread of more transmissible coronavirus variants, which could jeopardize the Summer Olympics set to be held in Tokyo starting in July.

• Washing surfaces with soap and water will remove most virus particles, Lindsey Bever reports. Disinfecting sprays and wipes (Clorox, Lysol, etc.) are needed only when someone who has coronavirus has recently been in the home.
• There are almost no examples of transmission at beaches and other open spaces where breezes disperse airborne particles, distancing is easier, and humidity and sunlight render the coronavirus less viable, Karin Brulliard and Lenny Bernstein write.
• More women than men are receiving coronavirus vaccines, according to a Kaiser Health News analysis. In all of the 38 states that list gender breakdowns, women are getting more shots than men, with statistics showing the vaccine breakdown close to 60 percent and 40 percent, KHN’s Laura Ungar writes.
• Regeneron says its coronavirus antibody cocktail is effective in preventing symptomatic virus among people exposed to the it, CNN’s Jamie Gumbrecht reports.
• Former Food and Drug Administration commissioner Scott Gottlieb makes the case for vaccine passports in a Wall Street Journal op-ed. “Some have panned this as a way of denying Americans access to restaurants or other businesses. It’s more likely to allow Americans to visit places they otherwise can’t, such as nursing homes or hospitals that aren’t allowing family members,” he writes.

The Department of Health and Human Services approved a waiver for the state to extend Medicaid coverage for a full year after a woman gives birth, up from the current standard of 60 days.

Illinois is the first state to receive a waiver for federal funding to extend postpartum coverage. It may be easier for other states to follow suit. The recent $1.9 trillion stimulus bill included a provision that will make it easier for states to extend coverage without requiring a federal waiver. Some states, including West Virginia, have already taken steps toward extending coverage through their state plans.

Insurers are limited in the amount of premium income that they can keep for administration, marketing and profits by the Medical Loss Ratio rebates provision of the Affordable Care Act. If claims for insurance policies are lower than the percent required by the provision, then insurance companies are required to provide rebates to customers.

The rebates are calculated based on a three-year average, so this year’s rebate will incorporate financial data from 2018, 2019 and 2020. A Kaiser Family Foundation analysis of preliminary data found that it will represent the second-largest amount since the rebates started in 2012.

The large rebates this year are driven in part by the fact that people visited doctors and hospitals less during the pandemic, driving down health spending and allowing insurers to recoup larger profits. Individual market insurers were also highly profitable in 2018 and 2019, according to the KFF analysis.