December 11, 2020
The Honorable Joseph R. Biden
President-elect of the United States
1717 Pennsylvania Avenue, N.W.
Washington, DC 2006
Dear President-elect Biden:
On behalf of the American Hospital Association’s (AHA) nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners – including more than 270,000 affiliated physicians, 2 million nurses and other caregivers – and the 43,000 health care leaders who belong to our professional membership groups, we congratulate you on being elected the 46th President of the United States of America. We share your important goal of quickly and aggressively ending the COVID-19 pandemic, which has tested our country and our health care system like never before. This must be our nation’s highest priority. We stand ready to tackle this daunting challenge together.
Our member hospitals and health systems, along with our doctors, nurses and other team members, have been on the front lines of the pandemic, working tirelessly to provide the best care for our patients, families and communities. Given our unique role, we have repeatedly shared publicly the importance of wearing masks, washing hands and practicing social distancing. In addition, we have engaged with local and state officials to assist with testing and contact tracing. Currently, we are gearing up to support widespread deployment and administration of COVID-19 vaccines and therapies. Our hospitals and health systems are deeply committed to collaborating with you and your Administration to tackle these unprecedented challenges and to end the public health crisis.
We believe our joint focus should be on providing relief, ensuring a smooth recovery, and rebuilding a better health care system for the future. In addition, we need to address ongoing challenges that have been further exasperated during the pandemic, including issues related to health equity, workforce resilience and behavioral health.
This letter outlines a set of priority recommendations that we urge you to implement during your first 100 days in office as they require immediate attention. We will share a more extensive set of recommendations in the new year to help advance health in America.
To ensure that America’s hospitals can continue to fight the pandemic, we urge your Administration to help ensure they have the resources they need to care for their communities. Hospitals and health systems are projected to lose more than $320 billion in 2020 alone due to COVID-19. They have faced enormous costs to maintain proper personal protective equipment (PPE), ensure adequate supplies and equipment, safeguard sufficient staffing, purchase new drugs and therapies, and retrofit their physical plants to care for patients with the virus. These expenditures come as months of essential hospital revenue has eroded due to the combination of reduced demand for emergent and non-emergent care, as well as growing uncompensated care costs attributable to the newly uninsured. Specifically, we ask your Administration to:
- Ensure the extension of the public health emergency, currently set to expire on Jan. 20, 2021, to safeguard needed flexibilities, including critical 1135 waivers, through the duration of the public health crisis.
- Ensure providers can retain Provider Relief Fund dollars by allowing use of any reasonable method for calculating COVID-19-related lost revenue, movement of targeted distributions within a system, and use of funds for increased staffing costs.
- Protect vital federal funding for public programs, including stopping unlawful payment cuts that do not recognize legitimate differences among provider settings, also described as site-neutral payment policies.
- Ensure vital Medicaid financing arrangements, such as provider assessments and intergovernmental transfers, remain available to states through official rescission of the Medicaid financial accountability rule.
- Protect the 340B drug savings program to ensure vulnerable communities have access to more affordable drug therapies by reversing harmful policies and holding drug manufacturers accountable to the rules of the program, especially as it relates to contract pharmacy arrangements.
- Require that private plans serving the Medicare, Medicaid and Marketplace programs eliminate administrative and financial barriers to coverage for COVID-19 testing and treatment and ensure that providers are adequately compensated for this care.
- Rescind provider requirements to publicly disclose negotiated rates that do nothing to help patients understand their costs, could result in anticompetitive actions on the part of health plans, and, according to the Federal Trade Commission, could result in high costs for patients.
As the hospital field moves forward both with caring for COVID-19 patients and safely delivering needed health care services to others, we ask for your help in ensuring that the nation can successfully “coexist with COVID-19.” Critical to this is ensuring patients’ access to care, as the COVID-19 pandemic has only further demonstrated the importance of comprehensive health coverage. Additionally, given the economic downturn, it is more crucial than ever to ensure affordable, high-quality coverage options are available regardless of employment status or income level. Moreover, to spur recovery, we will need to quickly and effectively distribute vaccinations to the American public. We urge your Administration to:
- Engage in robust outreach and enrollment efforts to capture the millions of individuals who are eligible for, but not enrolled in, some form of subsidized coverage.
- Open a special enrollment period for the Health Insurance Marketplaces for the duration of the public health emergency.
- Eliminate rules that expanded access to health sharing ministries and short-term limited duration coverage products (so called “skinny plans”).
- Encourage states to extend coverage and care to their populations through innovative state waivers (section 1115 and 1332 waivers) with appropriate safeguards against eligibility reductions and cost-sharing increases.
- Allow states to delay Medicaid eligibility recertification during the public health emergency.
- Rescind recent rules that weaken maintenance of effort protections for Medicaid enrollees.
- Implement a communication effort on vaccine safety, particularly among segments of the population who justifiably mistrust such efforts, and ensure tracking to understand better long-term outcomes and effectiveness.
America’s health care system will never be the same due to COVID-19. We need to seize this opportunity to help reimagine a new system that better protects patient access to care, advances affordability, improves quality and patient safety, and truly transforms health care financing and delivery. This includes accelerating movement toward alternative payment systems that increase provider financial stability, as well as create new care models and alternative care delivery sites. We need to explore new staffing models and the innovative use of technology, such as telehealth and remote patient monitoring, to augment care and allow it to move outside the hospital into patients’ homes. Additionally, we need to create a new era of health preparedness, which includes bolstering our public health infrastructure, diversifying the health care supply chain, and reassessing the interaction between federal, state and local governments. We look forward to sharing further thoughts with you in the new year on rebuilding and reimagining the health care system to make it stronger and more sustainable.
Address Ongoing Critical Challenges
The events of 2020 have brought forth a number of vulnerabilities in our health care system, especially those related to health equity, workforce resilience and behavioral health care. Our recommendations in these areas follow.
Equity: Unequal access to care, disproportionate disease burden and disparities in health outcomes predate the COVID-19 pandemic. However, they have contributed to one of the greatest tragedies this year: the disproportionately high mortality rate from COVID-19 among Black and Latino communities, especially among those serving as essential workers. We urge your Administration to take steps to help make meaningful progress, such as:
- Rescind the “public charge” rule that has contributed to disparities in enrollment in health care coverage among Latino and other immigrant communities.
- Repeal the June 2020 final rule that narrowed the scope of non-discrimination protections under Section 1557 of the Affordable Care Act.
- Rescind Executive Order 13950, Combating Race and Sex Stereotyping, which has a detrimental effect on diversity and inclusion training in federal agencies, grantees, contractors and beyond.
- Empower the Secretary of Health and Human Services to lead a department-wide effort addressing health inequities and engage in an inter-departmental effort to address the social and structural determinants of health.
Workforce: Recruiting, training and maintaining staff is challenging in the best of times. The surge of COVID-19 cases and the continued need to handle the pandemic has resulted in strain and exhaustion, especially among clinicians. To protect our front-line caregivers, ease workforce shortages and prevent clinician burnout, we urge you to:
- Provide support for front-line workers by ensuring child care, housing, PPE and priority access to vaccines.
- Expanding the physician supervision requirement waiver to include nurse practitioners.
- Coordinating with the Department of Defense and other relevant agencies to provide direct staffing relief in hard hit communities.
- Reinstitute critical waiver flexibilities, such as those that halted data collection and in-person routine compliance surveys.
- Make certain telehealth flexibilities permanent.
- Support a more diverse and inclusive workforce through clinician education and training efforts and new recruitment initiatives targeted at underrepresented communities.
- Reduce variability of scope of practice laws to allow caregivers to practice at the top of their license.
Behavioral Health: The burden of COVID-19 also will have far-reaching effects on behavioral health. The stress from unemployment, isolation due to quarantine, and grief over loved ones lost to the pandemic are likely to manifest in increases in already high rates of deaths of despair (i.e., suicides and substance use). While hospitals and health systems have been working hard to integrate behavioral health services into physical health care, serious gaps and barriers in insurance coverage and reimbursement have resulted in dire workforce shortages and reduced access to care. It is critical that your Administration address these urgent, nationwide needs by taking steps to:
- Enforce the Mental Health Parity and Addiction Equity Act requiring insurers who offer coverage for behavioral health conditions to use comparable standards for those services as for medical/surgical services.
- Eliminate regulatory barriers to care coordination posed by the restrictions under 42 CFR Part 2, which limit the ability of providers to share important information regarding care and treatment for substance use disorders.
- Improve the behavioral health workforce by considering additional funding and/or student loan forgiveness to support training for health professionals at all levels to reduce workforce shortages.
On behalf of our members and all of the hospitals and health systems in America, we look forward to working with your Administration to swiftly address the COVID-19 crisis and improve access to high quality care and coverage for all Americans.
Richard J. Pollack
President and Chief Executive Officer