The United States is experiencing a nursing shortage that is expected to grow through 2030. Hospitals are struggling to recruit and retain registered nurses due to the overwhelming national turnover rate for nurses ranging from 8.8% to 37%, depending on the location and nursing specialty. As the need for health care grows and care is needed for a rapidly growing older population, experts expect that the problem will only intensify.

Hospitals across the country cited staff burnout, trauma, and inequitable workforce distribution as factors fueling the nursing shortages. The COVID-19 pandemic of course has put enormous strains on our health care systems and providers. These factors have likely caused many to choose early retirement or resign from the profession altogether.

Reducing the number of patients each nurse cares for would reduce burnout and improve retention. This could be done by enforcing standards for adequate staffing levels through nurse-to-patient ratios. Currently there are no federal mandates or guidelines governing the number of patients assigned to a registered nurse in the United States. The lack of regulations or professional guidelines means that nurses are consistently required to care for more patients than they can safely and sustainably provide for, thus exposing them to a high-stress work environment. Adopting a mandatory nurse-to-patient ratio would require hospitals to adequately staff every unit and will consequently reduce the nurse turnover rate. Future emergencies and unforeseeable events, like the COVID-19 pandemic, will present challenges and create exceptions and flexibility in enforcing normal staffing ratios. Not maintaining professional guidelines will negatively contribute to the nursing work environment and patient safety.

Congress should pass the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2021 and its companion bill in the House. The legislation would amend the Public Health Service Act to establish a specific requirement for minimum nurse-to-patient staffing ratios in hospitals. Having a recommended nurse-to-patient ratio is crucial in helping hospitals attract and retain nursing staff while improving working conditions for registered nurses. This requirement can help address the nursing shortage by improving the retention of senior staffers who will be relieved by the demands created by inadequate staffing and the ongoing pandemic. Another provision of the bill would promote the nurse workforce by creating programs for students and early career nurses and providing them with practical clinical experiences to help them adapt to a hospital setting.

Nurse staffing impacts the nursing profession and the overall health care system. Like all working Americans, nurses have the right to a work environment that is safe for themselves and their patients.

In his State of the Union speech, President Joe Biden called for capping the monthly out-of-pocket spending by patients on insulin to $35 per month. “For Joshua, and for the 200,000 other young people with Type 1 diabetes, let’s cap the cost of insulin at $35 a month so everyone can afford it.” Indeed, the Build Back Better bill calls for setting insulin monthly payments at the lesser of $35 or 25% of the net price including all rebates and discounts, even if the plan’s deductible has not been reached. The “Affordable Insulin Now Act,” introduced by Senator Reverend Raphael Warnock, D-Ga., in the Senate and the companion bill, sponsored by Representative Angie Craig in the House, take a similar approach.

But why stop there? At this time of accelerating inflation and rampant economic uncertainty, it would be both good policy and good politics for Congress and the Administration to consider extending the principle of capped first-dollar co-pays to a broader class of medicines in Part D to treat chronic conditions such as diabetes, asthma, and congestive heart failure, as well as medicines aimed at preventing stroke. These are medicines where regular use translates directly into better health outcomes and lower hospital costs.

In practice, we’re talking about implementing capped, first-dollar co-pays for chronic diseases for Medicare Part D recipients. Why is this good politics? Americans, and in particular seniors, are begging for some relief from rising costs. Not everyone has a chronic condition, but most people know someone (like their parents) who do, and it can be a shock to see how much drugs cost them. Instituting certainty in patient out-of-pocket costs would definitely reduce the level of apprehension.

PPI has long focused on the need to cap co-pays. In October 2019 we put out our trailblazing policy brief, “The Prescription Escalator: The Real Reason Why Americans Pay More for Drugs Each Year, Why They Are So Upset, and What Can Be Done About It.” As part of that brief, we reported that Americans found themselves paying for more and more essential medicines as they aged, many for chronic conditions. That meant they get hit by soaring spending, even if the price of individual medicines didn’t change much.

Originally, the idea behind deductibles and co-insurance — co-pays that are a percentage of the list price — was to give patients some skin in the game. If they absorbed a share of the cost, the theory went, they would be more likely to seek out the lowest cost medicines.
But forcing patients to bear a flexible share of costs hasn’t worked out as expected, especially for Medicare Part D recipients. Because of perverse incentives in Part D, drug insurance plans, pharmacies, PBMs, and manufacturers gravitated towards setting high list prices, offset by huge rebates and discounts. One result was low net prices for payers, which is good.

The downside is that co-insurance is usually based on the inflated list price, so consumers don’t see the “true” net prices. Similarly, before consumers meet their deductible, they are paying list price. In either case, consumers can be hit by out-of-control costs that have nothing to do with true net prices.
A policy of capping co-pays starting at the first dollar for medicines to treat chronic disease is a straightforward way of offering certainty to the patients who need it the most—those who need their medicines just to survive. And they don’t balance the budget on the backs of those in ill-health. Moreover, when patients fill and take these chronic meds regularly, it avoids spikes in hospital and other health costs.

How much will the co-pay caps cost, and who pays? Given the massive redesign of the Part D program that is also part of Build Back Better, it’s tough to say for sure. The government would have to ante up some additional subsidies, but the cost of capping co-pays would be reduced because the redesign would eliminate the coverage gap which is now part of Part D and which produced some huge patient payments. In addition, the redesign would limit out-of-pocket payments to $2,000 annually across all drugs, and a number of drugs would be chosen for price negotiation by the government. For medicines selected for price negotiation, the subsequent lower cost to Part D would greatly help to offset reduced patient cost sharing. And for competing medicines not selected for negotiation, insurance companies and PBMs will have bargaining leverage to command higher rebates, similarly reducing net prices and also helping to offset costs of better patient access.

This is the right time now to extend Biden’s insulin proposal to other medicines for chronic conditions. Capping co-pays for medicines that older Americans have to take is the quickest and most direct way to introduce more certainty into an uncertain economy.

Twelve years ago, Congress approved, and President Obama signed the Affordable Care Act (ACA) into law. And what started as a small program that provided health coverage to people on cash assistance was cemented as the most impactful health insurance program: Medicaid.

Medicaid was first approved in 1965 as a part of Lyndon B. Johnson’s great society. While Medicare provided health coverage to seniors, Medicaid was envisioned as a more limited program for low-income pregnant women and people with disabilities. But over the forthcoming decades, it’s been expanded and reformed to become the largest health insurance program in the country: covering 80 million lives, paying for nearly half of all births, and protecting 10 million people with disabilities in addition to millions more who need long-term care.

During the pandemic, Medicaid and the ACA served as a safety net as many people lost jobs. Though the pandemic led to huge economic and employment downturns, the number of uninsured people actually fell by 0.6 million, or 1.9%. This was in stark contrast to the Great Recession of 2008-2009 when 9.3 million people lost their jobs and, subsequently, their health insurance — roughly 9.5% of children were uninsured. This time, safety net programs like Medicaid and subsidies available through the ACA kept people from losing health care coverage. Medicaid and CHIP enrollment increased to 83.2 million, up nearly 18% since February of 2020 and enrollment in Marketplace plans increased from 11.4 million in 2020 to 14.5 million in 2022. This was largely in part to the expanded subsidies pushed by the Biden administration and approved through the American Rescue Plan Act (ARPA).

But all this progress is now in jeopardy. Throughout the pandemic, states have been obligated to keep people covered through Medicaid in exchange for higher payments from the federal government. But when the national declaration of a Public Health Emergency expires, states will lose the enhanced Medicaid funding and be required to conduct eligibility determination on all 83.2 million enrollees.

The risk is that the administrative process of chasing down enrollees and making them mail in the proper documentation will inadvertently kick-off millions of eligible people — putting them at risk for economic and physical harm.

The Biden administration has been working to streamline the redetermination process, saying that it can take up to 12 months to complete the renewals. States are also being asked to outline how the process will work, and how they will connect ineligible people with other forms of coverage, such as through the ACA exchanges.

Many states lost workers during the pandemic. That compounded with poor technology, outdated addresses, and the heavy lift of determining eligibility could leave many people left uninsured — intentionally or unintentionally. Red states, particularly those who resisted Medicaid expansion, could use it as an opportunity to “purge” Medicaid roles for political reasons. There are still 14 states that haven’t expanded Medicaid to cover all low-income residents and others that only expanded begrudgingly under state referendum.

The Urban Institute estimates roughly 16 million people who currently have coverage will be found ineligible. Of the adults, roughly a third should be eligible for federal tax credits for ACA private plans — if they enroll during the so called “special enrollment period.” But millions could slip through the cracks without a concerted effort to connect them to available resources, undoing the successes of the ACA right after it proved its utmost utility during the worst pandemic in modern history. States should take advantage of new flexibilities put in place by the Biden administration to simplify the redetermination process for beneficiaries and make the transition between Medicaid and private insurance as smooth as possible and Congress should make the enhanced ARPA subsidies permanent.

With the stalled Build Back Better package, President Joe Biden needs to use the State of the Union address to create momentum around a health care policy agenda. He should push for a clear policy that will make health care more affordable for millions of Americans: a public option.

A public option would address many of the goals of the Build Back Better’s health care provisions: providing coverage for those in the Medicaid gap and bringing down the cost of plans available on the exchanges. Furthermore, pushing for a public option is a clear policy that the public understands and wants – which will help bolster Democrats in the midterms.

Over the past year, Democrats pushed for many health care priorities, fearful of when their next chance at the majority would be. But to keep costs down, many of the proposed health care provisions were set to expire after a few years. This was the wrong approach. Democrats have a narrow majority and it’s in peril. Temporary health care programs do not encourage good policy making or an efficient use of public dollars — and are at risk of termination under a Republican-controlled Congress.

Creating a national public insurance option can increase coverage and bring down costs – accomplishing many of the objectives of the BBB. In the 14 Republican-controlled states that have refused to expand Medicaid under the Affordable Care Act, a public option could be fully subsidized for those who would otherwise be eligible for Medicaid. This would help the 2.2 million Americans who currently fall into the so-called Medicaid-gap obtain coverage.

But rather than solely focusing on a narrow program that would only benefit people in states Democrats will be hard-pressed to win in 2022, the public option would also be available on the exchanges nation-wide. Pulling on lessons from Washington state’s experience, the government could use Medicare contracts as leverage to incentivize hospitals and physicians’ groups to contract with the public option plan. Reimbursement rates could be set higher than Medicare rates and lower than average commercial rates to result in a plan that would be more affordable than many exchange plan offerings.

Currently, with the enhanced premium subsidies, plans have had minimal incentives to lower costs in the exchange marketplace. The Affordable Care Act (ACA) provided subsidized health insurance coverage for people with incomes up to 400% of the federal poverty line (FPL) (roughly $54,000 for an individual or $73,000 for a family of three). But because many families still found coverage cost prohibitive, Congress used the American Rescue Plan Act (ARPA) to temporarily expand the subsidies for families above 400% FPL and increase the amount of the subsidy for all income levels. These changes pushed exchange enrollment to its highest levels ever, hitting 14.2 million for 2022 coverage. Making coverage more affordable helped more people obtain coverage. But rather continually increasing subsidies and putting no downward pressure on costs, Biden should push to add a competing product with the leverage of the government to drive down costs across the board.

The Urban Institute modeled the cost of a public option that reimbursed physicians 115% of Medicare rates and hospitals 160% of Medicare rates and found it would drive down premiums in the non-group market by 12% and reduce federal deficits by $6 billion annually.

Health care is complicated and expensive, and programs typically need to be tweaked and reformed after passage. Passing programs for a limited period does not provide the opportunity for iteration, as their very survival will be in question. President Biden should push for a public option in his State of the Union address to help people get affordable coverage and help Democrats win in 2022.

A new study found low-income people were more likely than other groups to use telehealth services during the pandemic, proving that telehealth does increase access to needed care for underserved people.

Telehealth use skyrocketed during the pandemic when restrictions around telehealth use were eased. In particular, Medicare expanded the number of services allowed to be delivered via telehealth and allowed greater flexibility with the acceptable technology platforms providers could use, even expanding audio-only services. However, though audio-only services are an important part of telehealth, video-enabled telehealth allows for a better patient interaction and may be better in many clinical situations.

The study found that people earning less than $25,000 were more likely to use audio-only services and less likely to have video appointments than other groups. Without addressing barriers like unequal broadband distribution and limited access to video-capable devices, telehealth won’t live up to its potential.

Using data from the Census Bureau’s Household Pulse Survey from April to October 2021, researchers at HHS’ office of Assistant Secretary for Planning and Evaluation (ASPE) found that a quarter of respondents reported using telehealth in the previous four weeks. While there was some variation across demographic groups, the most significant disparities were between those who used audio versus video telehealth services.

Video telehealth rates were higher among young adults ages 18 to 24 (72.5% reported using video telehealth), those earning at least $100,000 (68.8%), those with private insurance (65.9%), and white individuals (61.9%). Conversely, video telehealth use was lowest among those without a high school diploma (38.1%), adults ages 65 and older (43.5%), and Latino (50.7%), Asian (51.3%), and Black individuals (53.6%).

For people without access to broadband internet, phone visits can make it easier to access to care. But video appointments allow for more physical examination, better communication, and a more substantial patient-provider relationship. Further, a video connection allows a provider to have a glimpse into the patient’s home where some social indicators may increase understanding of a patient’s health condition.

But video appointments require video-capable devices, broadband access, software literacy, and often English proficiency. These all prevent barriers for older patients, lower-income patients, non-English speaking patients, and those who don’t have privacy in their homes.

The report underscores the urgency of bringing high-speed broadband to everyone, so that telehealth doesn’t become another example of health disparities where only the relatively affluent can take full advantage of the easy access and lower costs digital health enables. While Medicare has decided to permanently cover audio-only mental health visits if the patient doesn’t have access to video capable devices, a video connection allows for more expansive clinical evaluation for other types of care. Payers should not limit access to audio-only services at this time, but rather should push for broadband expansion so that more people can access video-enabled care.