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If you needed one more
data point about the draw-
backs of America’s frag-
mented and dysfunctional
healthcare delivery struc-
ture, here it is.
That’s not all. The com-
mitments made by the
states, the federal govern-
ment and insurers have
been carefully worded to
apply only to coronavirus
testing.
For the most part,
they’re silent on what hap-
pens to a patient if a test
comes up positive. None has
made a commitment to
cover treatmentwithout
cost-sharing.
That could discourage
people from even asking for
a test — individuals whose
tests reveal an infection
might realize that they’re
facing a potentially costly
stay in a hospital and might
choose not to know.
Let’s take a look at
what’s been promised and
where it falls short.
To begin with, the federal
task force headed by Vice
President Mike Pence an-
nounced Wednesday that
the test was deemed an
“essential health benefit.”
That’s a category created by
the Affordable Care Act,
designating services that
must be offered by insur-
ance plans. The 10 EHB
categories include hospital-
ization, mental health care,
prescriptions and certain
preventive procedures.
Placing coronavirus tests
on the list means that their
costs will be covered for
Medicaid patients. But it
doesn’t mandate a waiver of
cost-sharing for Medicare,
private or ACA plans. “In-
surers can (and do!) impose
cost-sharing for EHBs, and
could do so for a COVID-19
test,” Bagley observed,
calling Pence’s designation
of the test as an EHB “a
completely meaningless
statement.”
As David Anderson, the
health insurance expert at
Duke University, puts it:
“The question is not if a
COVID-19 screen is a cov-
ered benefit under current
EHB regulation. The ques-
tion is who pays and if there
are barriers to access and
care.”
The federal government
could require a waiver of
cost-sharing for the tests,
under a provision of the
ACA applying to preventive
procedures certified by the
U.S. Preventive Services
Task Force. But the task
force doesn’t customarily
issue emergency recom-
mendations, and under the
ACA whatever recom-
mendations it does issue
can’t take effect in less than
one year. So there’s no joy
coming from that quarter.
Congress could legislate a
change and Trump could
sign it, but that hasn’t hap-
pened yet.
The states of
Washington, New York and
California all have issued
directives that insurers
subject to their regulations
waive cost-sharing for tests.
Washington, which has
become a hot spot for
COVID-19 infection, also hasordered that insurers waive
previous authorization
procedures for tests and
treatment, though it doesn’t
guarantee a waiver of cost-
sharing for the latter.
Washington also has
ordered insurers to allow
patients to obtain one-time
refills of covered prescrip-
tions sooner than the cus-
tomary refill waiting periods
so that patients can keep a
backup supply on hand.
In California, Gov. Gavin
Newsom and state Insur-
ance Commissioner Ri-
cardo Lara said Thursday
that they were ordering all
public and commercial
insurance plans to cover the
entire cost of testing for the
coronavirus and medically
necessary screening.
As my colleagues Phil
Willon and Noam Levey
reported, the orders mean
that Californians will not
have any out-of-pocket
expenses for the tests, evenif they’re screened at hospi-
tal emergency rooms and
urgent care clinics. State
officials say the orders
would cover some 22 million
Californians — but that
leaves more than 17 million
outside their reach, whether
because they’re covered by
federal programs or self-
insured employers or they
simply don’t have health
coverage.
Plans sold through Cov-
ered California, the state’s
exchange for individual
ACA plans, are subject to
the directive, state officials
say. Like New York’s ACA
exchange, Covered Cali-
fornia is actively managed,
meaning it has the authority
to set benefit terms for its
plans.
As for the commercial
insurance industry, its
principal trade group,
America’s Health Insurance
Plans, was rather vague
about what its membercarriers would guarantee.
“We will cover needed diag-
nostic testing when ordered
by a physician,” AHIP said
in a statement attributed to
its board of governors. “We
will take action to ease
network, referral, and prior
authorization requirements
and/or waive patient cost
sharing.”
That sounds aspira-
tional, not concrete.
Cigna and Aetna
(through its parent CVS
Health) both issued state-
ments assuring their enroll-
ees that they would be able
to receive COVID-19 testing
without cost-sharing. One
can expect other major
insurers to follow suit.
ERISA’s preemption of
state regulation of employer
plans may be the biggest
gap in requiring coverage of
testing without cost-shar-
ing.
“Self-insured plans don’t
have to listen to state regu-lators,” Duke’s Anderson
notes. Whatever they’ve
promised the public, he
adds, the insurers “can’t
make employers that actu-
ally pay the claims do any-
thing that the employers
don’t want to do.”
Anderson says it’s a good
bet that employers with
self-funded plans will go
along with their insurance
firms’ policies as a matter of
“good corporate citizenship
or fear of negative PR.”
But that’s a thin reed for
the healthcare system of the
entire nation to rely on. At
this moment, the co-
ronavirus battle in the U.S.
is relying on hope and unen-
forceable promises to battle
a burgeoning enemy.Keep up to date with
Michael Hiltzik. Follow
@hiltzikm on Twitter, see
his Facebook page or email
michael.hiltzik
@latimes.com.No guarantees on coronavirus testing
[Hiltzik,from C1]
ASSURANCESmade by the Trump administration’s coronavirus task force are “more limited in scope than they appear,” an expert says.Chip SomodevillaGetty Images