Commentary, COVID-19

Experts: Health pandemic exposes failure to expand Medicaid, reliance on employer-provided insurance

In case you missed it, there was a fine story on NBC News last week that highlighted North Carolina’s failure to expand Medicaid, and the huge and unnecessary problems it was causing for uninsured people even before the coronavirus pandemic.

Among other things, “Coronavirus challenges states that rejected Medicaid expansion, leaves uninsured with few options” tells the sobering story of a family physician who practices in Senate President Pro Tem Phil Berger’s district confronting the crisis.

William Luking, a doctor in rural North Carolina who runs a clinic with his brother about 25 miles north of Greensboro, said he treated one of his regular patients last week who had a dry, hacking cough and trouble breathing. The longtime patient turned scarlet when Luking said he should go to the hospital.

Amid wheezing and a severe fever, Luking’s patient said he couldn’t afford that kind of care. He didn’t have insurance.

“How many folks with this virus are going to be making the same decision?” Luking asked, noting that Medicaid expansion would have provided his patient hospital access. “That same scenario will play itself out here real quickly with folks soldiering on doing their minimum wage work while carrying the virus without seeking care. It has all the makings of a disaster.”

Luking and doctors like him have gone to great lengths to treat their patients and made personal sacrifices because, as he said, “We’re not going to fold up shop now.”

But there’s a risk that they may have to. Luking said because he will mostly have to move to doctor’s visits over the phone, he will see fewer reimbursements and payments and a greater number of uninsured patients. He’s prepared to zero-out his own salary but fears he may soon have to lay off members of his staff to keep his facility afloat.

Meanwhile, in today’s Washington Post, Prof. Jonathan Gruber of MIT lays out three steps the U.S. must take to care for the huge surge in uninsured sick people that’s coming — both as a result of the failure to expand Medicaid in states like North Carolina and the huge number of people who are becoming uninsured through job losses. Here’s the conclusion:

First, we should suspend insurance network restrictions for covid-19 patients. Patients should be able to go to the provider that is best for them, and for the community, regardless of network restrictions. Read more

Commentary, COVID-19, NC Budget and Tax Center

Three reasons why federal aid to state, local governments is not enough

Last week, Congress passed the Coronavirus Aid, Relief, and Economic Security Act, or the CARES Act, which was immediately signed by the President.

While the bill has many good provisions, it misses the mark in many ways, like prioritizing tax breaks for big companies over federal aid to state and local governments.

Of the approximately $4 billion North Carolina is expected to receive, the Center on Budget & Policy Priorities estimates that $3.5 billion will go to the state and only about $481 million to local governments. This is largely a result of the allocation formula, which only provides allocation to local governments if the population is above 500,000 residents.

State and local governments are on the front lines of trying to keep communities healthy and to protect people from losing income and access to basic needs. Prior to the passage of the CARES Act, the NC League of Municipalities wrote letters to state leaders calling for additional resources to make up for declining revenue and meet the growing need for public safety personnel and broadband access. In a letter to Congress, the National League of Cities outlined four recommended improvements the CARES Act: enact a stabilization fund for cities and states, make local governments eligible for tax credit to offset costs of paid leave, stabilize the municipal bond market, and repeal state and local and property tax deduction caps.

Although the state and local aid in the CARES Act is a meaningful and important first step, it is likely to be insufficient to support North Carolina’s increased expenditures from combating COVID-19, as well as the potential loss in revenue from an economic downturn. Read more


North Carolina experiencing “first wave” of COVID-19 cases, more likely to come

The peak of flu season occurred in early February. After reports of flu-like illness fell, by early March, they began increasing again, because of COVID-19. (Graph: NC DHHS)

North Carolina is in the “acceleration phase” of the COVID-19 pandemic, state epidemiologist Dr. Zach Moore said today, with the number of cases expected to rise over the next two weeks.

“There’s every indication that it’s really ramping up now,” Moore told the media during a call-in press conference. “We have not peaked.”

As of March 30, more than 1,300 people have been diagnosed with COVID-19; six people have died. Ninety-one have been hospitalized, according to the NC Department of Health and Human Services. However, Moore reiterated that the number of reported cases is an undercount. For example, it doesn’t include people who have not gone to the doctor and who have mild or no symptoms.

Gov. Roy Cooper has issued a statewide stay-at-home order, effective at 5 p.m. today, through April 30. Only businesses deemed essential, such as groceries, can remain open. Restaurants are limited to take-out or delivery services. Gatherings of more than 10 people are prohibited. People should also stay at least 6 feet apart from one another.

The state’s flu surveillance regions are also reporting data about confirmed and suspected COVID-19 cases, which helps epidemiologists better understand the outbreak. (Map: NC DHHS)

To better estimate the number of cases, the state has directed doctors and medical facilities to conduct “syndromic surveillance,” which means they are reporting incidents of fever and cough, even lacking a formal diagnosis of COVID-19. “This allows us to get to people who present for medical care but who can’t be tested,” Moore said.

“Lab-confirmed counts are never the whole picture. We need to rely on other evidence-based tools. This is a rapidly evolving situation, and we need to use data from different strategies to understand the spread.”

State, commercial and hospital labs have conducted 18,945 tests, as of March 30. The state lab is caught up with its tests, Moore said, but some commercial and outside labs are experiencing backlogs.

The effects of the statewide stay-at-home order won’t be realized for about two weeks, equivalent to the extent of the 14-day incubation period for the new virus. The average incubation period — the time of exposure until the appearance of symptoms — for COVID-19 is five to seven days.

There are seven influenza surveillance regions in North Carolina; health officials from these areas are also reporting data related to COVID-19 symptoms. After influenza-like illnesses peaked in early February — the result of the incidences of the common flu — the numbers began to fall. But since early March, all seven regions have reported an increase in influenza-like illnesses. Emergency room visits for fever and cough have also increased over the same period.

“That tells us that what we’re seeing now is likely being driven by COVID-19,” Moore said.

No antibody tests are yet available to detect those who have been infected but who had no symptoms. This information would help researchers and epidemiologists better understand the full reach of the virus — and to control future outbreaks, which are likely.

“We are very much in the first wave — worldwide, the nation and the state,” Moore said. “Nobody has immunity to this and everyone is susceptible. It’s possible that we’ll have additional waves.”

COVID-19, News

UNC School of Government on statewide and local “Stay-at-Home” orders

Gov. Roy Cooper’s statewide “stay-at-home” order goes into effect at 5 p.m. Monday and will last 30 days.

But how is the order different from similar orders already put in place by local government around the state?

The UNC School of Government has put together a breakdown of the important questions surrounding the order that is worth your time today.

The piece compares local “stay-at-home” orders with Executive Order 121 and explains the differences between what local governments have ordered and are authorized to order as contrasted with the state.

It also gets into the difference between “stay-at-home” and “shelter-in-place” orders, why they are sometimes used interchangeably and why that can be confusing.


From the explainer:

Which is more restrictive – A local “stay-at-home” declaration or EO121?

It depends.  If a county or city has already imposed (or is still considering imposing) a local “stay-at-home” declaration, its businesses, residents, and others who might be traveling within its jurisdiction are legally subject to both the local declaration and EO121.  Piecing together local restrictions with those of EO121 to determine which is more restrictive may be complicated and confusing.  For example, if a local “stay-at-home” declaration defines an essential business or essential worker more broadly than EO121, the more restrictive definitions in EO121 control.  Conversely, if the local “stay-at-home” declaration defines essential businesses more narrowly, the local declaration will control.  Even if a county or city has not imposed a full set of “stay-at-home” restrictions, other restrictions such as limited entry or curfews (see discussion above), neither of which are imposed under EO121, would still be in effect at the local level.

Is documentation of essential business or essential employee status required?

EO121 does not require documentation for proof of essential business or essential employee status.  However, if a local “stay-at-home” declaration does require documentation for compliance with its local restrictions, those documentation requirements would remain in effect for purposes of enforcing local restrictions.  EO121 directs businesses to contact the NC Department of Revenue (NCDOR) to apply for essential business status; NCDOR does not have the jurisdiction to take applications from businesses seeking essential business status as defined (or not defined) in a local declaration, nor can NCDOR interpret the meaning of these or similar terms in local declarations.  Thus, counties and cities with local “stay-at-home” declarations must continue to provide guidance on terms like essential business and essential employee for purposes of enforcing restrictions imposed under their own local declarations.

In other words, the Governor interprets and provides guidance on compliance with his Executive Orders; counties and cities interpret and provide guidance on compliance with their local declarations.

Should counties and cities keep local restrictions in place?

Whether a county or city should keep in place a local “stay-at-home” declaration (or for that matter, any other local restrictions or prohibitions) is a decision best left to that jurisdiction’s officials based on their judgment of what continues to be reasonably necessary to protect the health and safety of their communities.  Ultimately, such decisions would be acted upon by the county or city official authorized by ordinance to declare a state of emergency and impose restrictions or prohibitions under that declaration.  This author offers no opinion, nor should this blog be construed as doing so, on what those local decisions should be.  The Governor himself recognized in Section 4 of EO121 that “the impact of COVID-19 has been and will likely continue to be different in different parts of North Carolina,” and specifically preserved the authority of county and city officials to impose more restrictive measures than those of EO121 if they determine such measures are reasonably necessary to mitigate against the spread of COVID-19 and to the extent authorized under North Carolina law.

Nonetheless, should county or city officials determine the restrictions imposed under EO121 are sufficient to address the COVID-19 threat within their individual jurisdictions, they have the authority to rescind or modify their local restrictions in the same manner those local restrictions were imposed.  Doing so would in no way effect whether EO121 applies within their jurisdictions.  The Order is effective statewide regardless of any action taken – or not taken – by county and city officials.

Should county and city officials wish to reconsider their local restrictions in light of EO121, they could choose to modify their local declarations in such a way as to keep in place (or add) restrictions not already imposed under EO121 such as limited entry or curfews (see discussion above).  Again, modifying or rescinding local restrictions in no way effects the application of EO121 within that county or city.

How would a county or city modify or rescind its local emergency restrictions?

Local restrictions and prohibitions are modified and rescinded in the same manner they are imposed.  The county or city official authorized by ordinance to declare a state of emergency may take action to modify or rescind any restrictions or prohibitions previously imposed under that declaration (see this blog for more discussion of local declaration authorities).  If the ordinance does not delegate this authority to an individual official, such as the Board Chair or Mayor, such actions must be taken by the governing board itself (G.S. 166A-19.22(a)), which it can do only in a lawfully convened public meeting.  However, if the ordinance does delegate authority to an individual official, that official may act without consent of the governing board.  That official may choose to poll the board, but no action by the board itself is legally required.  Should a county or city governing board wish to amend its local ordinance to delegate this authority to its Board Chair or Mayor (assuming authority is not already delegated), the board may do so only in a lawfully convened public meeting.  There is no authority, even during a declared state of emergency, to amend a local ordinance by any other means.

Does a county or city need to take any action for EO121 to apply and be enforceable within its jurisdiction?

No.  As discussed above, the emergency authorities of the Governor under Chapter 166A are independent of those granted to counties and cities.  EO121 applies in every county and city statewide regardless of any actions (or absence of actions) taken by local officials.  There is no need for counties and cities to amend their local emergency ordinances, declare a local state of emergency, or modify an existing local state of emergency declaration for EO121 to be in effect and enforceable within their local jurisdictions.

Read the full breakdown here.

Commentary, COVID-19

Today’s must read: Why the U.S. approach to unemployment during the crisis is off-base

Be sure to check out an excellent op-ed in this morning’s New York Times by economists Emmanuel Saez and Gabriel Zucman entitled “Enough with the baby steps on coronavirus.” In it, Saez and Zucman argue persuasively that the U.S. is missing the boat by doing much too little for workers and businesses in the current crisis. Among other things, they say, we should follow the lead of other countries by not just paying unemployment insurance benefits, but by prohibiting layoffs.

Instead of safeguarding employment, America is relying on beefed-up unemployment benefits to shield laid-off workers from economic hardship. To give just one example, in both the United States and Britain, the government is asking restaurant workers to stay home. But in Britain, workers are receiving 80 percent of their pay (up to £2,500 a month, or $3,125) and are guaranteed to get their job back once the shutdown is over. In America, the workers are laid off; they must then file for unemployment insurance and wait for the economy to start up again before they can apply for a new job, and if all goes well, sign a new contract and resume working.

Even if unemployment is generously compensated — as it is in the $2.2 trillion bill Congress passed — there is nothing efficient in letting the unemployment rate rise to double digits. Losing one’s job is anxiety inducing. Applying for unemployment benefits is burdensome. The unemployment system risks being swamped soon by tens of millions of claims. Although some businesses may rehire their workers once the shutdown is over, others will have disappeared. When social distancing ends, millions of employer-employee relationships will have been destroyed, slowing down the recovery. In Europe, people will be able to return to work, as if they had been on a long, government-paid leave.

Saez and Zucman also lament the crazy fact that millions will lose their health insurance due to layoffs:

The [relief] bill passed last week does nothing to reduce co-pays, deductibles or premiums on the insurance exchanges; nor does it reduce the price of COBRA. The next bill should introduce a Covidcare for All program. This federal program would guarantee access to Covid-19 care at no cost to all U.S. residents — no matter their employment status, age or immigration status. Fighting the pandemic starts with eradicating the spread of the virus, which means that everybody must be covered.

Covidcare for All would also cover the cost of Covid-19 treatments for people who are insured. Insurance companies would be barred in return from hiking premiums, which might otherwise spike as much as 40 percent next year.

Finally, the article calls for more support for businesses:

The United States also needs to ramp up its support to businesses. Since containing the epidemic requires government-mandated economic shutdowns, it is legitimate to expect the government, in return, to shelter businesses from the economic disruptions. To keep businesses alive through this crisis, the government should act as a payer of last resort. In other words, the government should pay not only wages of idled workers, but also essential business maintenance costs, like rents, utilities, interest on debt, health insurance premiums, and other costs that are vital for the survival of businesses in locked down sectors. This allows businesses to hibernate without bleeding cash and risking bankruptcy. Denmark was the first nation to announce such a program; it is being emulated by a growing number of countries, including Italy.

To prevent unjust windfalls, Saez and Zucman would impose an excess profits tax.

Their commonsense, bottom line take:

Some will say that the solutions we’ve outlined show excessive faith in government. They will correctly point out that some of these policies are undesirable in normal times. But these are not normal times. The big battles — be they wars or pandemics — are fought and won collectively. In this period of national crisis, hatred of the government is the surest path to self-destruction.

Click here to read the entire op-ed.