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More dimensions for privacy in the post-Roe world

The fall of Roe is a big boon for cyberstalkers.

All too frequently, people monitor our intimate lives in betrayal of our trust—and it’s often those we know and love. They don’t even need to be near us to capture our data and to record our activities. Surveillance accomplished by individual privacy invaders will be a gold mine for prosecutors targeting both medical workers and pregnant people seeking abortions.

Intimate partners and exes download cyberstalking apps to personal devices that give them real-time access to everything that we do and say with our phones. To do this, they only need our phones (and passwords) for a few minutes. Once installed, cyberstalking apps silently record and upload phones’ activities to their servers. They enable privacy invaders to see our photos, videos, texts, calls, voice mails, searches, social media activities, locations—nothing is out of reach. From anywhere, individuals can activate a phone’s mic to listen to conversations within 15 feet of the phone.

Now and in the future, that may include conversations that pregnant people have with their health care providers—nurses, doctors, and insurance company employees helping them determine their life’s course and the future of their pregnancies. Victims of such privacy violations are never free from unwanted monitoring. Abusers count on them to bring their cellphones everywhere, and they do, as anyone would.

For abusers, finding cyberstalking apps is as easy as searching “cellphone spy.” Results return hundreds of pages. In my Google search results, a related popular search is “spy on spouse cell phone.” More than 200 apps and services charge subscribers a monthly fee in exchange for providing secret access to people’s phones. When I first began studying stalkerware in 2013, businesses marketed themselves as the spy in a cheating spouse’s pocket. Their ads are more subtle now, though affiliated blogs and videos are less so, with titles like “Don’t Be a Sucker Track Your Girlfriend’s iPhone Now: Catch Her Today.”

Though we don’t have precise numbers of stalkerware victims, domestic violence hotlines in the United States help more than 70,000 people every day, and according to the National Network to End Domestic Violence as many as 70 percent of those callers raise concerns about stalkerware. A 2014 study found that 54 percent of domestic abusers tracked victims’ cellphones with stalkerware. Security firm Kaspersky detected more than 518,223 stalkerware infections during the first eight months of 2019, a 373 percent increase from that period in 2018. Millions of people, right now, are being watched, controlled, and manipulated by partners or exes. The United States has the dubious distinction of being one of the leading nations in the number of stalkerware users around the world. That destructive accomplishment has a disproportionate impact on women, LGBTQ individuals, and people from marginalized communities.

Abusers will use intimate data obtained from stalkerware to terrorize, manipulate, control, and—yes—incriminate victims. Now that a woman’s exercise of her reproductive liberty is soon to be, or already is, a crime in many states, abusers have even more power to extort and terrorize victims. They may threaten to disclose information about abortions unless women and girls give into their demands, including having unwanted sex or providing intimate images, both forms of sextortion. (Sextortion routinely involves threats to disclose intimate information like nude images unless victims send more images or perform sex acts in front of webcams.) If victims refuse to give into their demands (and even if they do), privacy invaders may post information about abortions online and report it to law enforcement. Two birds, one stone: the ability to humiliate, terrorize, and financially damage victims and to provide evidence to law enforcement. Exes can extinguish victims’ intimate privacy by enabling their imprisonment.

The law’s response to intimate privacy violations is inadequate, lacking a clear conception of what intimate privacy is, why its violation is wrongful, and how it inflicts serious harm upon individuals, groups, and society. Legal tools—criminal law, tort law, and consumer protection law—tackle some privacy problems, but few (if any) capture the full stakes for intimate privacy. In criminal law, privacy violations are mostly misdemeanors, which law enforcers routinely fail to pursue when reported. Criminal law is woefully underenforced when the illegality involves gendered harms, like privacy violations and sexual assault where victims are more often female and LGBTQ individuals. (Yet when the very same people are the alleged perpetrators, law enforcement eagerly investigates.) Because policymakers fail to recognize the autonomy, dignity, intimacy, and equality implications of intimate privacy violations, we have too few protections.

Call me crazy, but I don’t see any chance that legislation to deal with these issues will pass in the next Texas legislative session. Maybe in the next Congress, if Dems can hold the House and pick up a couple of Senate seats to overcome the Manchin/Synema blockage – in other words, possible but a longshot. We know the House can do it, at least. Otherwise, good luck to you.

Another place where existing law falls short: HIPAA doesn’t cover medical apps.

The Health Insurance Portability and Accountability Act, the federal patient privacy law known as HIPAA, does not apply to most apps that track menstrual cycles, just as it doesn’t apply to many health care apps and at-home test kits.

In 2015, ProPublica reported how HIPAA, passed in 1996, has not kept up with changes in technology and does not cover at-home paternity tests, fitness trackers or health apps.

The story featured a woman who purchased an at-home paternity test at a local pharmacy and went online to get the results. A part of the lab’s website address caught her attention as a cybersecurity consultant. When she tweaked the URL slightly, a long list of test results of some 6,000 other people appeared.

She complained on Twitter and the site was taken down. But when she alerted the Office for Civil Rights within the U.S. Department of Health and Human Services, which oversees HIPAA compliance, officials told her they couldn’t do anything about it. That’s because HIPAA only covers patient information kept by health providers, insurers and data clearinghouses, as well as their business partners.

Deven McGraw is the former deputy director for health information privacy at the HHS Office for Civil Rights. She said the decision overturning Roe, called Dobbs v. Jackson Women’s Health Organization, should spark a broader conversation about the limits of HIPAA.

“All of a sudden, people are waking up to the idea that there’s a lot of sensitive data being collected outside of HIPAA and asking, ‘What are we going to do?’” said McGraw, who is now the lead for data stewardship and data sharing at Invitae, a medical genetics company. “It’s been that way for a while, but now it’s in sharper relief.”

McGraw noted how that’s not just the case for period-tracking apps but also some apps that store COVID-19 vaccine records. Because Congress wrote HIPAA, lawmakers would have to update it to cover those cases. “Our health data protections are badly out of date,” she said. “But the agencies can’t fix this. This is on Congress.”

Consumer Reports’ digital lab evaluated eight period-tracking apps this spring and found that four allowed third-party tracking by companies other than the maker of the app. Four apps stored data remotely, not just on the user’s device. That makes the information potentially subject to a data breach or a subpoena from law enforcement agencies, though one of the companies surveyed by Consumer Reports has said it would shut down rather than turn over users’ data.

In a press release last week, HHS sought to allay worries with some advice that sounds reassuring.

“According to recent reports, many patients are concerned that period trackers and other health information apps on smartphones may threaten their right to privacy by disclosing geolocation data which may be misused by those seeking to deny care,” HHS said in the release.

The document quoted HHS Secretary Xavier Becerra about the protections provided by HIPAA: “HHS stands with patients and providers in protecting HIPAA privacy rights and reproductive health care information,” Becerra said. He urged anyone who thinks their privacy rights have been violated to file a complaint with the Office for Civil Rights.

See above in re: the chances of federal legislation passing. Also note that until the law is updated, if a Republican wins the Presidency, they’ll appoint the HHS secretary and will set the direction for that agency regarding patient privacy. How much faith do you want to put in that?

Paxton sues over emergency guidance to doctors

This is what “leaving it to the states” looks like.

Best mugshot ever

Texas is suing the Biden administration over guidance released Monday telling the nation’s doctors they’re protected by federal law to terminate a pregnancy as part of emergency treatment — and threatening to defund hospitals that don’t perform these procedures.

The Biden administration’s guidance states that federal law requires doctors to perform abortions for pregnant people in emergency rooms when it is “the stabilizing treatment necessary” to resolve a medical emergency, including treatments for ectopic pregnancy, hypertension and preeclampsia.

On Wednesday, the Biden administration also warned retail pharmacies that they must fill prescriptions for pills that can induce abortion or risk violating federal civil rights law.

These two recent actions pit the federal executive branch against state governments after the U.S. Supreme Court undid a nearly half-century-old precedent that had affirmed access to abortion as a constitutional right.

Texas Attorney General Ken Paxton’s office filed the suit challenging the guidance in federal court on Thursday, saying the Biden administration’s guidance violates the state’s “sovereign interest in the power to create and enforce a legal code.”

[…]

The Biden administration reassured the nation’s doctors that they don’t need to wait until a patient’s health deteriorates before acting and that they can act in cases where nontreatment would result in serious impairment, guidance that comes as medical professionals in Texas and other states where abortion is banned are trying to figure out what kind of women’s health care is allowed under new restrictions. The guidance isn’t seeking to update existing law but is said to clarify a hospital’s duties under the Emergency Medical Treatment and Active Labor Act.

I thought it was federal law that was sovereign, but what do I know? I know that if Paxton gets his way women are going to die because doctors won’t be able to treat them properly and in a timely fashion. That’s what’s really at stake here. And I expect Paxton to get his way, at least at first. The Chron points out the obvious:

The case underscores the dominant position that conservative Republicans hold in the federal judicial system: Paxton filed the case in Lubbock, in the U.S. Northern District of Texas, where there are 12 judges, 10 of whom were appointed by Republican presidents and six of whom were named by former President Donald J. Trump.

If Paxton were to lose, the case would go to the Fifth Circuit Court in New Orleans, widely recognized as one of the most conservative federal appellate courts in the country, and the final step would be the Supreme Court, which ruled last month to overturn Roe v Wade in the first place.

I guarantee you, whatever the district court judge does, the Fifth Circuit will give Ken Paxton what he wants because that’s what they do. And then SCOTUS gets to make another abortion ruling. Great system we have here, isn’t it?

I had drafted a post about the imminent threat to EMTALA that the Biden administration’s guidance had queued up, and then made the mistake of not publishing it in time to keep up with the news cycle. My bad. The original post is beneath the fold. I stand by what I said in this post. Now let’s bring the fight that this requires. Daily Kos and Mother Jones have more.

(more…)

Biden signs executive order to protect trans kids

Good.

President Joe Biden signed an executive order Wednesday to enhance protections for transgender children and take steps to ban conversion therapy as efforts continue in Texas and other states to restrict gender-affirming medical care.

The executive order calls on the U.S. Department of Education and the Department of Health and Human Services to increase access to gender-affirming care and develop ways to counter state efforts aimed at limiting such treatments for transgender minors.

Biden signed the order Wednesday afternoon, joined by six LGBTQ teens who were reportedly from Texas and Florida.

“My message to all the young people: Just be you,” Biden said to a crowd of members of Congress, administration officials and LGBTQ advocates. “You are loved. You are heard. You are understood. You do belong.”

The federal health department will release sample policies for states to expand health care options for LGBTQ patients. The federal education department will release a sample school policy to achieve full inclusion of LGBTQ students.

[…]

Biden’s order also asks the health department to lead an initiative aimed at reducing youth exposure to conversion therapy and expand awareness and support for survivors of the practice. Biden is also asking the Federal Trade Commission to see if conversion therapy “constitutes an unfair or deceptive act or practice, and whether to issue consumer warnings or notices,” per the White House. He is also directing department heads to promote an end to conversion therapy worldwide.

Texas is one of 22 states that has not banned conversion therapy, a debunked practice that seeks to change a person’s sexual orientation or gender identity. The health department will explore guidance clarifying that federally funded programs cannot conduct conversion therapy.

Biden’s order calls on the health department to expand youth access to mental health services and issue new guidance for providing mental health care for LGBTQ youth. The order also charges the health department with strengthening LGBTQ nondiscrimination practices in the foster care system. Biden is also calling on the department to increase access to voluntary family counseling.

“We’re in a battle for the very soul of this nation,” Biden said. “It’s a battle I know we will win.”

I feel like there had been some earlier promise from President Biden to take this action, but if so I don’t see that I blogged about it. I assume there will be a lawsuit filed by our shitbird Attorney General to stop all this, which will exist alongside the earlier lawsuit that had been filed to stop the feds from turning off some funding sources in response to our anti-trans bullying ways. In the meantime, we’ll wait and see what the new policies this order directs look like. Whatever the ultimate outcome, this was the right thing to do.

Texas sues to keep federal funds that would be denied for bullying trans kids

The utter gall, it’s breathtaking.

Texas is worried it could lose over a billion dollars in federal funding over Gov. Greg Abbott’s directive requiring medical professionals to report transgender children receiving gender-affirming health care as potential child abuse.

Texas Attorney General Ken Paxton amended an existing lawsuit suing the Biden administration Wednesday, attempting to void guidance issued by the U.S. Health and Human Services on March 2 that said restricting someone’s ability to receive medical care solely on the basis of their sex assigned at birth or gender identity is likely a violation of the Affordable Care Act for federally funded entities. That federal guidance came in response to Abbott’s directive issued late last month to treat certain medical treatments for trans children as possible crimes to be investigated by the Department of Family and Protective Services.

The federal guidance stated that health care providers do not need to disclose private patient information regarding gender-affirming care and that it is illegal to deny health care based on gender identity.

Paxton, in the lawsuit, said that guidance is based on “erroneous interpretation of sex discrimination.” The lawsuit says Texas does not aim to deny health care based on gender identity. Instead, the state argues its investigations disregard gender entirely, barring all children from “unnecessary medical interventions.”

In 2020, $1.36 billion in federal funds went to Texas’ Department of State Health Services, Paxton said in the lawsuit. More than $26 billion went to the State’s Health and Human Services Commission.

I noted the federal guidance in this post. The main thing you need to know at this point is this:

It’s not a guarantee that Paxton will get what he wants from his hand-picked judge. But there’s a reason he picked him, you know? Daily Kos has more.

Paxton appeals gender affirming care order

Of course he did.

Attorney General Ken Paxton filed for an appeal Thursday after a state judge blocked Texas’ child protection agency from investigating the parents of a transgender teenager who received gender-affirming medical care.

District Judge Amy Clark Meachum had granted a temporary restraining order on Wednesday. It did not stop the agency from opening investigations into other families in similar situations.

Meachum was scheduled to consider issuing a statewide injunction blocking such investigations into all parents of trans children on March 11, but that hearing has been put on hold until an appeals court rules on Paxton’s request.

And U.S. Health and Human Services Secretary Xavier Becerra said his agency is looking into tools that would shield transgender Texans from the state’s attempts to hinder access to gender-affirming care.

“The Texas government’s attacks against transgender youth and those who love and care for them are discriminatory and unconscionable,” he said. “These actions are clearly dangerous to the health of transgender youth in Texas.”

[…]

Becerra released guidance Wednesday that says refusing health care because of gender identity is illegal and that health care providers are not required to disclose information regarding gender-affirming care.

President Joe Biden also released a statement Wednesday condemning Texas’ actions.

“This is government overreach at its worst,” Biden said in a statement. “Like so many anti-transgender attacks proliferating in states across the country, the Governor’s actions callously threaten to harm children and their families just to score political points. These actions are terrifying many families in Texas and beyond. And they must stop.”

See here for the background. This is primarily about preventing Judge Meachum from being able to issue a statewide injunction, since the hearing for that action is on hold pending the appeal. The Third Court is more likely than not to deny Paxton’s appeal, but then he’ll go to the Supreme Court, and who knows how long that could take. And delay is good enough for Paxton and Abbott and their wicked aims.

Texas Children’s Hospital has “paused” hormone-related prescription therapies for gender-affirming care in response to the controversial directive from state leaders to investigate medical treatments for transgender youth as child abuse, according to a statement from the hospital.

“The mission of Texas Children’s Hospital is to create a healthier future for all children, including transgender children, within the bounds of the law,” the statement reads. “After assessing the Attorney General’s and Governor’s actions, Texas Children’s Hospital paused hormone-related prescription therapies for gender-affirming services. This step was taken to safeguard our healthcare professionals and impacted families from potential criminal legal ramifications.”

[…]

Lou Weaver, a transgender man and community advocate for transgender children and adults, said very few facilities offer gender-affirming care for children, and Texas Children’s is among the biggest programs in Texas that offered it.

“This is a truly frightening time for trans youth and their parents and guardians,” he said. “The doors to life-saving health care are literally being shut in their faces.”

UT Southwestern’s children’s hospital in Dallas shut down services for new patients at the end of the last legislative session due to political pressure, Weaver said.

I can’t blame Texas Children’s for not wanting to risk the legal exposure, but this is truly harmful and there’s not a clear endpoint. That harm is also financial for the families involved. I don’t know what the feds can do, but they need to figure it out quickly.

And in what may be the most infuriating but least surprising part of this, the opinion Paxton issued was based on misreading studies and making false claims.

One researcher said Paxton distorted her work for political purposes and that she’s “mortified” her research was included in the opinion.

Alexandra Minna Stern, a professor of history at the University of Michigan, studies the history of forced sterilization in the United States. Paxton’s office drew a parallel between forced sterilization and gender affirmation surgeries for minors. “I’m adamantly opposed to this interpretation and it does not align with my research and the conclusions of my research,” she said.

“If they knew anything about my scholarship more generally, they would know that I am someone whose research demonstrates the harm of the very types of policies they’re trying to enact on marginalized people.”

[…]

In his opinion, Paxton cited the work of Dr. Cecilia Dhejne, a Stockholm-based researcher, to support the idea that gender-affirming health care could be harmful to transgender children.

Dhejne led a 2011 study that found that transgender people who have undergone gender-affirmation surgery have worse mental health outcomes than the general population. Dhejne did not respond to a request for comment. However, in the text of the 2011 study, Dhejne and her team caution specifically against using the study to conclude that gender-affirming surgery is problematic, noting that the study did not compare the mental health outcomes of people before and after gender-affirming surgery.

The study’s “results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment,” the study says.

Dhejne and her colleagues wrote instead that the study shows a need for better support for transgender people after they undergo surgery.

Paxton also asserts that there has been a recent “spike” in minors receiving gender-affirming “procedures.” He cited the Society for Evidence Based Gender Medicine, an anti-trans advocacy group.

The link in Paxton’s citation leads to a graph showing an increase in youth referrals to the United Kingdom’s Gender Identity Development Service. That national clinic provides a range of care, including counseling; the number of clinic referrals is not necessarily the number of medical interventions like the legal opinion implies.

Similarly, Paxton’s opinion cited the World Professional Association for Transgender Health and said that transgender people should typically be adults before receiving the listed types of gender-affirming care.

In a statement to the Star-Telegram, WPATH said that Paxton applied the citation too broadly. While WPATH does state in its standards of care that genital surgery should typically wait until a transgender person reaches the age of majority, Paxton’s opinion applied that standard to less-invasive interventions, too, including puberty blockers.

“It’s disheartening to see the Texas Attorney General’s opinion referencing WPATH to bolster an overall argument completely at odds with WPATH guidance,” the organization said in a written statement. “The citation is accurate but does not apply here because the AG’s opinion is arguing against reversible blockers while the cited WPATH content relates to gender affirming surgery.”

There’s a lot more and you should read the rest, but you get the idea. Lying has never bothered Ken Paxton. It’s serving him pretty well right now. The Statesman has more.

A broader look at the Houston project to track COVID in wastewater

The DMN tells me things I did not know about my current favorite public works project.

The [Houston] health department is conducting the wastewater surveillance for COVID-19 in partnership with researchers at Rice University and Baylor College of Medicine. Wastewater testing cannot identify individual people who have COVID-19, but it can identify neighborhoods with particular virus variants or relatively high virus loads.

Dallas County is not participating in similar wastewater surveillance to track the virus, said Dr. Philip Huang, director of Dallas County Health and Human Services. He said he doesn’t know of any other organizations or municipalities in North Texas that are operating similar programs.

While Dallas County previously considered using wastewater surveillance, the price of creating such a system was too high. “It’s actually quite expensive to set that up,” Huang said.

“After the 10-week survey, [the water district] discontinued its participation in the study due to inconsistent data that required continuous interpretation by local and state public health officials,” said Kathleen Vaught, public relations specialist at the water district.

Public health experts have long used wastewater samples to track the growth and spread of bacteria and viruses, like the poliovirus.

The Centers for Disease Control and Prevention began discussing the use of the tool to study COVID-19 in February 2020.

By September of that same year, the CDC and the U.S. Department of Health and Human Services launched the National Wastewater Surveillance System, also known as NWSS, to help state, tribal and local health departments track and respond to COVID-19.

[…]

Houston is the only Texas city to participate in the NWSS, although that could change as the program grows in the next month, said NWSS team lead and CDC microbiologist Dr. Amy Kirby. Data taken from Houston wastewater samples is submitted to a national database tracking similar data from nearly 400 utilities across the country.

The University of California, Merced’s Naughton Lab created and maintains a dashboard, called COVIDPoops19, to track global wastewater testing for the virus.

I just want to say that learning of the existence of a dashboard called COVIDPoops19 has improved my life in ways I could not have imagined. You can zoom in on Houston in this dashboard and click on the various icons to learn more; clicking on the icon for Baylor College of Medicine led me to the actual Houston dashboard for this, which I had not seen before. If you play around with the slider, which shows you what the viral levels were for past weeks, you can see that the inflection point for this year was the week of June 21 – levels had been dropping through June 7, then you saw a few upticks on June 14, and on the 21st it was all increases, and it got worse for the next few weeks. We’re on more of an upward trend right now (December 6 is the most recent date), but there are increases and decreases in the various locations. I’m going to be bookmarking this page. Anyway, if you want to know more about this project, there you go.

From the “ounce of prevention” department

What is that worth, again? It’s right on the tip of my tongue.

Accessing a critical COVID-19 therapy could soon be tougher in Texas as the federal government moves to ration the treatment amid the spread of new variants.

The Biden administration is taking over distribution of monoclonal antibodies, returning to the system that had been in place until vaccines became readily available and infections began to plummet this year. It also purchased 1.4 million additional doses.

Under the old system, the federal government had been doling out doses to states based on need, and states were then responsible for distributing them.

The administration had until recently been allowing hospitals and other health care centers to order directly from manufacturers, and the U.S. Health and Human Services Department would initiate a review of any individual site that ordered more than 50 doses to make sure none were hoarding.

But with the highly contagious delta variant continuing to spread nationally, demand for the treatment has soared, with concerns that it could soon outstrip supply. By last week, the vast majority of doses — 70 percent — were going to just seven Southern states where COVID cases are still high and vaccination rates are low, including Texas.

“The recent increase in the prevalence of the delta variant coupled with low vaccination rates in certain areas of the country resulted in a substantial (20-fold) increase in the ordering and utilization of (monoclonal antibodies) since mid-July,” the federal health services agency said in a statement. “Just seven states accounted for about 70 percent of our monoclonal antibody ordering. Given this reality, we must work to ensure our supply of these lifesaving therapies remains available for all states and territories, not just some.”

Under the new model — and a 50 percent bump in allocations that President Joe Biden ordered this month — Texas and Florida are still getting far more doses than other states. Texas received 23,640 doses this week, behind only Florida, which received 30,950. Georgia received the third most, 9,920.

There’s an extremely whiny quote in the story from Chip Roy, and y’all, if people like that put one tenth the effort they exert being crybabies into getting people vaccinated, we wouldn’t have these problems, because we’d have crushed COVID by now. My sense of empathy has been a major casualty of this pandemic, and I’d really like to get it back.

More federal support for emergency contraception

Good.

The federal government announced Friday it is providing additional funding to Austin nonprofit Every Body Texas to address a potential increase in clients’ need for emergency contraception and family planning services now that Texas prohibits abortions as early as six weeks into pregnancy.

Health and Human Services Secretary Xavier Becerra said in a release Friday that the Office for Population Affairs will award funding to the group, which is the statewide administrator of the federal Title X funding program, which provides family planning and reproductive health services to low-income patients.

Friday’s move comes as the Biden administration is challenging Texas’ near-total ban on abortion in court.

The federal government is also launching a new funding program that allows any entity across the country, regardless of if it receives Title X funding, to apply and receive additional money to provide reproductive and family planning services to patients impacted by Senate Bill 8.

There is $10 million available for these two programs, though it is unclear how much Every Body Texas is receiving directly. According to the federal government’s website, the grant application for the new program, called Funding to Address Dire Need for Family Planning Services, says they expect to award 10 grants between $150,000 and $1.5 million by the end of this year. The announcement said Every Body Texas must use the money provided by March 31.

[…]

Becerra also issued a memorandum detailing two federal statutes he says his department would enforce to provide protection for patients who may need an abortion and health care providers who assist pregnant patients in certain situations.

“​​Today we are making clear that doctors and hospitals have an obligation under federal law to make medical decisions regarding when it’s appropriate to treat their patients,” Becerra said in a release. “And we are telling doctors and others involved in the provision of abortion care, that we have your back.”

It was not immediately clear late Friday how Becerra’s memorandum would impact people’s ability to access an abortion in Texas or providers’ willingness to perform the procedure.

The two federal laws Becerra referred to include the Emergency Medical Treatment and Labor Act and the Church Amendments. The federal government issued a memorandum reminding health care providers that patients who appear in the emergency room must receive appropriate medical screening, stabilizing treatment and a transfer, in or out of state, regardless of state laws, including pregnant patients or patients experiencing a pregnancy loss.

Becerra said the federal government would impose civil monetary penalties against hospitals or physicians if they violate that law.

Second, the federal Office of Civil Rights released guidance about the Church Amendments, which prevent discrimination against health care personnell who object to performing an abortion because of their relgious beliefs. Those amendments also protect health care providers from discrimination if they do assist or perform a lawful abortion, such as an abortion where federal funds are used to end pregnancies that result from rape or incest or to save the life of the pregnant person.

See here for the full statement from HHS. This is the sort of thing that would have been good to do at any time, but these are not normal times, and it’s everyone’s job to fight back against SB8. I hope the commitment continues once we have a (hopefully positive) resolution to the litigation. The Chron has more.

The nursing home vaccination mandate

This just seems obvious to me.

President Joe Biden announced on Wednesday that he is directing all nursing homes to require their staff be vaccinated against Covid-19 in order to continue receiving Medicare and Medicaid funding.

Biden said he is directing the Department of Health and Human Services to draw up new regulations making employee vaccination a condition for nursing homes to participate in Medicare and Medicaid. The decision on nursing home staff represents a significant escalation in Biden’s campaign to get Americans vaccinated and the tools he is willing to use, marking the first time he has threatened to withhold federal funds in order to get people vaccinated.

“Now, if you visit, live or work at a nursing home, you should not be at a high risk of contracting Covid from unvaccinated employees. While I’m mindful that my authority at the federal government is limited, I’m going to continue to look for ways to keep people safe and increase vaccination rates,” the President said during a speech at the White House.

[…]

The move comes as the more transmissible Delta variant now accounts for 99% of Covid-19 cases in the United States and as data shows a link between low vaccination rates in certain nursing homes and rising coronavirus cases among residents.

The Delta variant has spurred a jump in daily new cases from a low of 319 on June 27 to nearly 2,700 on August 8, according to Centers for Medicare & Medicaid Services. Many are in facilities in areas with the lowest staff vaccination rates.

In the seven states in which less than half of nursing home staff is vaccinated, weekly cases were 7.9 times higher in the week ending August 1 than they were in the week ending June 27. Meanwhile, in states that have vaccinated a larger share of staff than average (more than 60%), cases reported in the week ending August 1 were only three times higher than cases reported in the last week of June.

The new regulations could go into effect as early as next month, but Johnson said the CMS will work with nursing homes, employees and their unions to ramp up staff vaccinations before the regulations go into effect.

About 1.3 million people are employed by the more than 15,000 nursing homes that participate in Medicare and Medicaid. Some 62% of those workers are vaccinated nationwide, according to CMS data, but the figure ranges from 44% to 88% depending on the state.

“We have seen tremendous progress with low Covid rates within the nursing home population and I think we’re seeing signs that it is starting to tip the other direction. We don’t want to go backwards,” said Jonathan Blum, CMS’ principal deputy administrator.

Blum said CMS officials are “confident we have the legal authority” to implement the new regulation, noting that the law allows CMS to take action as it relates to the health and safety of nursing home residents.

As the story notes, this came a day after Biden directed the Education Department to get involved in the mask mandate fight. You would think, given how devastating the first wave of COVID was to the residents of nursing homes, that their staffers would be highly vaccinated as well, but you would be wrong.

Nationwide, most of the elderly and vulnerable in long-term care facilities have taken the coronavirus vaccine, but many of the staff caring for them have refused it. The federal program responsible for bringing vaccines to the vast majority of nursing homes and similar settings inoculated roughly half of long-term-care workers in the nation, and in some states a much slimmer percentage, as of March 15, according to new data from the Centers for Disease Control and Prevention provided to the Center for Public Integrity.

In seven states and the District of Columbia, the program vaccinated less than a third of staff members.

Now the federal program is winding down in the coming days, leaving states and facilities to figure out how to vaccinate the remainder of workers in settings where COVID-19 has already taken a heavy toll.

Though they represent a tiny fraction of the American population, long-term-care residents made up 34% of the nation’s COVID-19 deaths as of March 4, according to the Covid Tracking Project. Low vaccination rates among staff at these facilities mean that workers continue to have greater risk of contracting COVID-19 themselves or passing the virus to their patients, including residents who can’t be inoculated for medical reasons. Low staff uptake can also complicate nursing homes’ attempt to reopen their doors to visitors like Caldwell, who are striving for some sense of normalcy.

“Going into it, we knew it was going to be a problem,” said Ruth Link-Gelles, who led the team at CDC working on the federal initiative that’s now closing up shop, the Federal Pharmacy Partnership for Long-Term Care Program.

She cited past years’ low vaccination rates among long-term-care workers for diseases such as the flu. “We were disappointed, but I don’t think anyone was shocked to see the low uptake. … There is a stubbornly large portion of the population that really doesn’t want to get vaccinated, and we have a lot of work to do generally and in this community in particular.”

Federal agencies and states have poured resources into a #GetVaccinated educational campaign, hosting listening sessions, live chats and virtual town halls for long-term-care staff to get their questions answered.

In spite of all these efforts, many workers are reluctant to take the shots because they don’t trust information about the vaccines’ safety or they don’t wish to be among the first to take them, experts said.

“There are many reasons to blame nursing homes and the federal government,” said David Grabowski, a professor of health care policy at Harvard Medical School who studies long-term care. “We knew this coming in — that this was a group that was not very trusting of leadership and frankly not very trusting of the vaccine so it was going to take some work in terms of building that trust.”

That story was from late March, so things may be better by now. According to the map embedded in this story, as of that time about 54% of the long-term care workers in Texas who have been vaccinated got their shots through this federal program. But as usual, the overall story in Texas is not great.

The number of nursing homes across the state with at least one active COVID-19 case has shot up nearly 800% in the past month — while nearly half of nursing home employees in Texas remain unvaccinated.

Nursing home residents were among the hardest hit by COVID-19 last year as the virus tore through facilities at an alarming rate. More than 400 Texas nursing home residents died during a single week in August 2020; since the pandemic began, 9,095 have died after contracting COVID-19, according to the Texas Health and Human Services Commission. As of Aug. 11, that’s 17% of the state’s COVID-19 deaths.

To slow the virus’s spread, Gov. Greg Abbott shut down nursing home visitation in March 2020, then eased those restrictions five months later for facilities that didn’t have active cases in the previous two weeks. HHSC’s current visitation guidelines for nursing homes require visitors to wear a mask at all times and limits visitation to no more than two “essential caregivers” per resident.

But after seeing infections remain relatively low in recent months, the state’s more than 1,200 nursing homes are seeing a new wave of infections as COVID-19 cases explode around the state, driven by the highly contagious delta variant:

  • The number of Texas nursing homes with active COVID-19 cases has risen by 773% in the past month, from 56 in mid-July to 489 on Aug. 11. That’s still well below the peak in January, when more than 900 facilities had at least one active case.
  • Deaths are increasing as well. From July 21 to Aug. 11, 84 nursing home residents died from COVID-19, compared to seven deaths during the four-week period before.
  • Roughly 76% of nursing home residents in Texas have been fully vaccinated, putting the state 46th nationally. The national average is 82%.

But the current surge in nursing home cases hasn’t triggered renewed restrictions by the state.

“We continually assess what actions are necessary to keep people safe in the facilities we regulate,” HHSC spokesperson Helena Wright-Jones said in a written statement.

Meanwhile, just over half — 56% — of nursing home staff have been fully vaccinated, below the national average of 59%, which puts Texas 33rd nationally for nursing home staff vaccination rates.

In other words, the usual indifference from state government and general mediocrity, which puts a whole lot of people at risk. What do the nursing homes have to say for themselves?

Kevin Warren, the president and CEO of the Texas Health Care Association, whose members include both for-profit and nonprofit long-term health care facilities, said nursing homes are hesitant to require staff to be vaccinated because they are fearful of losing employees who might look for other jobs that don’t require vaccinations.

“Right now, we have a severely stretched workforce,” Warren said. “And when we see this surge occurring again, the stress and the emotional toll it places on staff and others that are in the building, the concern is: ‘If I put this vaccine mandate on, am I potentially going to lose staff?’”

The percentage of nursing home staffers who are unvaccinated is similar to the general population, Warren added, “so let’s not set them out to the side.”

Except they’re in close contact with the most vulnerable people in the state, and not enough of them are vaccinated, either. The DMN has a whole story on that, and while I can believe it to some extent, there’s a quote from a nursing home operator whose staff is 70% vaxxed, and I cannot see how this is any less urgent than getting hospital staff vaccinated. We’ve tried the carrot, now there needs to be a stick. There’s plenty of polling data to suggest that a non-trivial number of people who are vaccine hesitant will give in and get the shot if their workplace mandates it. Let’s put that to the test.

Here comes President Biden

Visiting next week for disaster-related matters, itinerary TBD.

President Joe Biden

President Joe Biden said Friday that he’ll sign a major disaster declaration for Texas after millions in the state suffered power outages and water disruptions during prolonged freezing temperatures. He’s also expected to visit Texas soon.

Biden already signed an emergency declaration for Texas on Feb. 14, which authorized the Federal Emergency Management Agency to provide the state with critical equipment, like generators, and other resources like water and diesel to alleviate the effects of the disaster. A major disaster declaration is distinct from an emergency declaration. It essentially provides a wider range of assistance through “federal assistance programs for individuals and public infrastructure.”

“I’m going to sign that declaration once it’s in front of me,” he said Friday.

An emergency declaration functions as a supplement to state and local emergency services, while a major disaster declaration is issued if the president determines a disaster “has caused damage of such severity that it is beyond the combined capabilities of state and local governments to respond,” according to FEMA’s website.

The declaration allows for various assistance programs at the discretion of the governor’s specific request, and it can include programs for crisis counseling, disaster case management, disaster unemployment assistance and legal services, among others. Biden told reporters on Friday that he has already directed various federal agencies, like the Department of Defense and the Department of Health and Human Services, to continue assisting Texans through the crisis.

The major disaster declaration has been singed. Nice to have a President who doesn’t require some bizarre loyalty tests before performing the normal duties of serving the public, isn’t it? I seem to recall President Obama was like that, too – it’s hard to remember things from so many millions of years ago, but that’s the way I remember it. I will be very interested to see who besides Greg Abbott, who I presume will have to be there, will greet him. Might be a bit awkward, what with the whole sedition-and-insurrection thing. Dan Patrick might chip a tooth, he’d be gritting his teeth so hard. If we don’t get at least one meme-worthy photo out of this, I will be mildly disappointed. Anyway, maybe there will be a public appearance or two, so keep your calendar open.

“Nobody is getting enough”

Pretty much says it all.

As Texans scramble for appointments for the COVID-19 vaccine, federal data helps explain why: Relative to its population, the Lone Star State ranks near the bottom in the country in number of doses received.

Texas has received the second-highest number of doses in the country. Per capita, however, Texas comes in closer to the bottom at 49th out of all 50 states, Washington, D.C., and Puerto Rico, according to an analysis of Centers for Disease Control and Prevention data. Federal officials say there is a good reason for that: Vaccine distribution is based on the adult population of each state. And roughly a quarter of Texans are under the age of 18. Still, even when adjusted for adults only, Texas ranks 48th.

As Texas politicians from Congress down to local county judges push for more doses, the supply remains scarce, even for people older than age 65 and those with serious medical conditions.

“Nobody is getting enough. That is plain and simple,” said Brazoria County Judge Matt Sebesta, estimating that more than half of the roughly 130 providers that signed up to distribute vaccines in the county have yet to receive any doses. “We are kind of where we were last April with personal protective equipment and testing equipment: not enough to go around.”

State health officials insisted they are ordering as many doses as they can from the federal government and distributing them as quickly as they can.

“The supply of vaccines is limited by both the manufacturers’ ability to produce it and the amount allotted to Texas by the federal government,” said Lara Anton, a spokeswoman for the Texas Department of State Health Services. “The federal government determines how much vaccine will be sent to providers in the state on a weekly basis.”

U.S. Department of Health and Human Services spokesman Bill Hall said the vaccines are distributed based on an algorithm that takes into account the adult population in each state and U.S. territory. “We are committed to fair and equitable allocation of vaccines and therapeutics,” Hall said.

Texas has received more than 3.5 million doses of the vaccine, though the rollout so far has been anything but smooth. County registration lines have crashed under demand.

We know the story by now. There’s more vaccine coming, and that supply will increase further over time, but the administration of those doses has been chaotic. Greg Abbott has done the hard work of taking credit for everyone else’s hard work, but he never did anything to push the Trump administration to have a plan – let alone make sure the state of Texas had one, given Trump’s plan was to make the states do it – and it’s hard to imagine him making a diplomatic call to the Biden administration to ask for more help. He has reassured us that everything is going great, though, so at least we have that.

Culberson’s stock purchase

Interesting.

Rep. John Culberson

In a heated confirmation hearing for then-Georgia U.S. Rep. Tom Price for Secretary of Health and Human Services, Democrats raised pointed questions about the congressman’s trading in stocks of companies regulated by the House committees he serves on.

One in particular, Innate Immunotherapeutics, a small Australian biotech firm, generated particular attention because it had sold nearly $1 million in discounted shares to two House members: Price and New York Republican Chris Collins, who turned out to be the firm’s biggest investor.

Amid the controversy in January, Price said everything he did was “ethical, aboveboard, legal and transparent,” though he agreed to divest himself of that and other stocks that could raise ethics questions.

Collins also denied any wrongdoing, though he is now reportedly being investigated by the Office of Congressional Ethics for his role in touting the stock to investors from the halls of Congress.

But the public heat did not dissuade two Texas congressmen from quietly buying into the Australian company Jan. 26, two days after the Price hearing before the Senate Finance Committee, records show. John Culberson of Houston and Mike Conaway of Midland, are among at least seven Republican House members who have invested in the company. The two Texans bought in at what was then close to a 52-week peak in the stock price on the Australian Securities Exchange. The transactions were first reported by Politico.

[…]

Culberson’s stock buy, which he valued at between $1,000 and $15,000, was particularly unusual, because by the congressman’s own account, he is not an active stock trader.

Beside his stake in Innate Immunotherapeutics, his most recent financial reports to Congress list holdings in Apple stock and some past investments in “military collectibles.”

In a statement, Culberson offered this motive for the stock purchase in the fairly obscure foreign company that works to develop treatments for multiple sclerosis: “One of my father’s best friends died of MS, and we have a family friend with multiple sclerosis, so I’m always on the lookout for breakthroughs on treating MS. This one looks promising. I rarely buy or sell stock.”

He declined interview requests this week and staffers offered no details about the exact amount and timing of his stock purchase, which coincided with that of Conaway. Nor have they explained why Culberson waited until April 6 to report the stock buy, well beyond the 30-day window required to inform the House clerk’s office.

Through a spokeswoman, however, Culberson dismissed Democrats’ accusations that he might have used non-public information.

“Representative Culberson originally learned of the company through press reports,” his spokeswoman, Emily Taylor, said Thursday. “He continued his own research on their promising MS treatment, which is an issue important to him, and that led to the purchase.”

I don’t know how big a deal this is. The circumstances are fishy and Culberson’s explanation is weak, but unless Tom Price gets into a heap of trouble for his actions, I don’t see much happening to Culberson. That said, having stuff like this turn into blaring headlines seems to me to portend a rough campaign season. If nothing else, having all these candidates and a national focus on CD07 guarantees that every little thing will be news, and that’s not something Culberson has had to deal with lately. Better get used to it.

If we really cared about improving mental health in Texas

We would have expanded Medicaid at our first opportunity.

It's constitutional - deal with it

It’s constitutional – deal with it

Federal health officials say people with mental illness and addictions are being left behind in Texas because the state hasn’t expanded Medicaid to more low-income adults.

The health care program for the poor is controversial for many Republicans. The U.S. Supreme Court ruled that expansion was a voluntary part of the Affordable Care Act, and 19 states have declined to expand it.

A new federal report estimates that expanding Medicaid in Texas could help 406,000 mentally ill and uninsured Texans get treatment, according to Richard Frank, an Assistant Secretary for Planning and Evaluation at the U.S. Department of Health and Human Services.

“If states are serious about addressing mental illnesses, opioids, and other substance use disorders, expanding Medicaid offers a unique opportunity to do so,” Frank said in a national conference call with reporters. “It will bring people into effective treatment and is fully paid for under the Affordable Care Act.”

The new federal report discusses how untreated mental illness affects homelessness, job productivity, and jails and prisons. The report says states that did expand Medicaid were able to save money on programs for mental health or the uninsured, or divert the money to other programs.

A copy of the report is embedded at the link above. This is the same song we’ve been singing since 2011, with this being roughly the 1000th verse. The positive effect of getting access to reliable mental health care for these people cannot be overstated – among many other things, it would keep a lot of so-called frequent flyers out of jail – but the state Republican leadership does not care and will not hear it. You know how whenever there’s another gun massacre, the only thing we’re all allowed to say is that we should do more to promote mental health as a way to maybe not have so many gun massacres? The part we’re not allowed to say is that the Republicans in this state won’t do a damn thing to actually promote mental health. It’s the same old story, and the only way it ends is with electing different leaders. The Statesman has more.

One million plus Texas Obamacare enrollments

It keeps going up.

It's constitutional - deal with it

It’s constitutional – deal with it

Just over one million Texans had signed up on the federal health insurance exchange as of last Saturday, signaling a steady drumbeat of interest and giving local advocates a chance for some celebration.

“I will take it,” Ken Janda, president and CEO of Community Health Choice, a Houston-based non-profit health plan offering insurance plans through the Affordable Care Act’s federal marketplace, said Tuesday when he heard the numbers.

The 1,040,246 Texas enrollees included those signing up for the first time and people renewing existing coverage, according to U.S. Department of Health and Human Services statistics released Tuesday.

Nationally, 8.2 million had signed up as of last week, topping last year’s numbers for the same time period by about 2 million, she said, the agency announced.

“We have never seen this level of activity,” HHS Secretary Sylvia Burwell said during a conference call with reporters and community groups across the country. Calling the demand “unprecedented,” she added: “This is what we wanted to see.”

For comparison, the numbers were 734K in 2014, and 850K for 2015. They won’t change the mind of anyone whose mind needs to be changed, but this law has made a big difference in a lot of people’s lives. People can believe whatever BS they want to believe, but a million people who can see a doctor and who can not have to worry about being bankrupted by an illness know better. Kevin Drum, who looks at the national numbers, has more.

Lots of newly insured folks in Texas

Thanks, Obamacare!

More than half of 1.2 million Texans who enrolled in private health insurance plans through the federally operated marketplace this year were new customers, according to a government report released Tuesday.

The analysis from the U.S. Department of Health and Human Services said 57 percent of Texans who enrolled in 2015 – about 681,500 people – were first-time consumers, who did not buy health insurance through the HealthCare.gov platform last year.

[…]

The vast majority of shoppers qualified for tax credits to help pay their insurance premiums. In Texas alone, more than a million people – 86 percent of those who enrolled – were granted tax credits. The average tax credit seen in Texas was $239 per month, Dr. Meena Seshamani, director of the federal Health and Human Services’ Office of Health Reform, said during a conference call with reporters Tuesday.

Before tax credits were applied, the average monthly premium in Texas would have been $328, the report showed. Once the tax credits took effect, the average monthly premium for marketplace plans across the state was $89.

There was indeed a data dump this week, because sites like Daily Kos, which points to Medium, and Wonkblog, which points to the Kaiser Family Foundation, are highlighting the state of play and what the effect would be if the Supreme Court buys the ridiculous argument in King v. Burwell (which the plaintiffs’ own lawyer agreed was BS) and throws out the subsidies for healthcare.gov recipients. The effect in Texas would be substantial, perhaps finally big enough to get people like Erin Meredith to pay attention. Regardless of that, follow those links and look at those charts and remind yourself that this law has helped a lot of people, and anyone who says otherwise is at best misinformed or (in the case of elected officials and hacks from outfits like the TPPF) lying. Ask the people who have insurance now when they didn’t before and who stand to lose it if the Supreme Court decides to take it away from them.

Approaching a million Obamacare signups in Texas

We are well ahead of last year’s pace.

It's constitutional - deal with it

It’s constitutional – deal with it

More than 256,000 Houston-area residents have selected plans or been re-enrolled in coverage through the health insurance marketplace mandated by the Affordable Care Act, and federal and local health officials and experts believe a last-minute surge could significantly increase the numbers before the 2015 open-enrollment period ends later this month.

There have been about 75,000 more local sign-ups than in 2014, during the inaugural year of the marketplace. About 1 million Houston-area residents remain uninsured.

During a conference call with reporters on Wednesday, Marjorie Petty, the U.S. Department of Health and Human Services regional director overseeing Texas, released updated sign-up data showing nearly 969,500 residents statewide selected coverage or were automatically re-enrolled between Nov. 15 and Jan. 30.

The latest update was the first to include local figures. The Houston area recorded 256,982 plan selections and re-enrollments for the period, up from the estimated 180,000 residents who enrolled in coverage last year.

“These numbers would not be as strong as they are without local leadership,” Petty said. “We are making progress across the country and in Texas.”

[…]

Despite Petty’s optimism, millions of Texans and thousands of Houstonians will remain uninsured because state leaders have not come up with a way to expand Medicaid to cover them. Since California expanded the program to cover more of its residents, Texas has overtaken it as having both the highest rate and highest number of uninsured residents.

Elena Marks, president and CEO of Houston’s Episcopal Health Foundation, said Wednesday’s updated numbers are encouraging – until one considers that about 6 million Texans are uninsured.

“If you look at the glass as half full, more adults are becoming insured at a faster rate and in a shorter period of time,” she said. “We ought to be proud we’ve made this much progress.”

See here for the last update. Local leadership is definitely to be applauded for this, since Lord knows the state leadership is doing exactly nothing to help. The goal for Texas this year is 1.25 million signups, which would be an increase of over 60% from 2014. The latest national figure has enrollments at ten million. And there’s still more than a week to go till the deadline. KUHF has more.

What’s the health insurance enrollment status in Texas?

The short answer is that we don’t know. The longer answer, as this Express-News story indicates, is that we’ll never really know.

It's constitutional - deal with it

It’s constitutional – deal with it

Self-sufficiency. Distrust. Desire for flexibility.

Those are some reasons many consumers bypassed health insurance plans sold on government-run exchanges and instead chose to buy coverage directly from insurance agents or brokers before open enrollment ended March 31.

No one is sure exactly how many people did this. There is no singular source that aggregates nationwide health insurance enrollment numbers outside the exchanges. But these consumers will push the total number of enrollments for 2014 health coverage beyond the 7.1 million Americans who went through the federal- and state-operated exchanges.

In Texas, “it could be a big number,” said Stacey Pogue, senior policy analyst at the Center for Public Policy Priorities in Austin. “It could be more people than enrolled in the marketplace in Texas. But we don’t know. It certainly will be a significant number of people.”

The state Department of Insurance doesn’t collect enrollment figures.

Those who did not go through the exchange weren’t able to apply for tax credits or subsidies to reduce their premiums. That’s because tax credits can only be obtained through government-run markets.

There are a number of reasons why some consumers went a different route, independent agents and brokers say. Some made too much money to qualify for tax credits. Some didn’t believe in accepting subsidies. Others feared giving personal information, such as Social Security numbers, to the U.S. Health and Human Services Department.

“Frankly, I have talked to a number of consumers who are concerned about what they feel is an invasion of privacy,” said Carla Adams, president-elect of the San Antonio Association of Health Underwriters and an independent agent. “All of the information that they have to provide once you go on to the exchange … that makes some consumers nervous.”

[…]

Some consumers bypassed the exchange because they wanted the flexibility to choose doctors or hospitals they preferred instead of being limited to a smaller network, several agents said.

For instance, some shoppers who selected certain types of plans on the exchange after verifying their doctor was part of the network learned two weeks later that the doctor was no longer accepting patients with that form of coverage. Loretta Camp, co-owner of Davidson Camp Insurance Services in San Antonio and an independent agent, said her agency intervened in such cases so patients could stay with their doctors.

Local agents also helped consumers going through the federal exchange who wanted professional help to select the most cost-effective plans.

There is no extra cost for consumers who use agents’ or brokers’ services, several experts in the insurance field said. Insurance carriers pay agents’ commissions.

“The reality is, what I’m experiencing with consumers, they’re confused when they try to get on the exchange themselves,” Adams said. “They have no idea what the true differences are between these plans or how to compare, and they’re overwhelmed. Someone like an agent who understands the inner workings of these plans can help them navigate through the differences.”

The state of Texas, of course, tried to make it as hard as possible for non-profits and charitable organizations to provide navigator services, but that’s neither here nor there at this point. We don’t know how many Texans got coverage through the federal healthcare.gov exchange yet. The most recent numbers were 295,025 enrollments as of March 1 – see here for the breakdown – but I haven’t seen anything more up to date than that. The main thing to keep in mind is that whatever the final figure for Texans enrolling via healthcare.gov is, the real number – the number of people who got coverage is higher, perhaps much higher. It would be nice to know how much higher, but that number isn’t available. We’ll have to rely on polling data for that. Here’s hoping we get that soon for Texas.

ACA enrollments in Texas

As was the case with the rest of the country, there was a big surge in December.

It's constitutional - deal with it

It’s constitutional – deal with it

Texas enrollments in the online insurance marketplace created under the Affordable Care Act rose nearly eightfold in December, according to 2013 figures that the U.S. Department of Health and Human Services released Monday.

Texas ranks third in the number of 2013 enrollments following the troubled launch of healthcare.gov on Oct. 1. As of Dec. 28, nearly 120,000 Texans had purchased coverage in the federal marketplace, up from 14,000 one month before.

The number represents a tiny fraction of the uninsured in Texas, which has a higher percentage of people without health coverage than any other state. In 2012, more than 6 million Texans, about 24 percent of the population, lacked health insurance, according to U.S. census data.

Florida led the nation in the number of 2013 enrollments, with 158,000. In a media call from Tampa, U.S. Health and Human Services Secretary Kathleen Sebelius praised Florida’s high enrollment numbers. Like Texas, Florida has a largely unfavorable political climate toward the Affordable Care Act, and a high rate of the uninsured, at 21 percent. HHS officials offered no explanation for why more people enrolled in some states compared with others.

“The numbers show that there is a very strong national demand for affordable health care made possible by the Affordable Care Act,” Sebelius said in the call announcing the enrollment data, adding that nationwide enrollment had reached nearly 2.2 million.

The Better Texas Blog breaks the numbers down further.

  • 457,382 individual Texans applied for coverage with completed applications, revealing a high level of interest in Marketplace coverage;
  • 390,658 Texans were determined eligible to enroll in a Marketplace plan, and 180,349 Texans were found eligible for financial assistance in the Marketplace. Many of the 210,000 Texans who are eligible to buy in the Marketplace, but ineligible for subsidies likely fall into the “coverage gap” created when Texas leaders refused federal funds to expand health care coverage through Medicaid to Texas adults below the poverty line;
  • 47,177 Texans were assessed eligible Medicaid/CHIP by the Marketplace (a number that would be much higher with Medicaid expansion);
  • 55 percent of Texans who chose a health plan are women; and
  • 26 percent are between the ages of 18 and 34. Young adults are enrolling in the Marketplace, and previous experience from Massachusetts indicates that enrollment by this age group will increase as we near the March 31 enrollment deadline.

These numbers prove that the law and its website are working–more Texans are able to apply for and select health plans that fit their budgets. (Read about our intern’s experience enrolling in a Marketplace plan). People can enroll in the Marketplace through March 31, 2014.

There’s still a lot more growth to come, in other words. Progress Texas adds on.

Ed Espinoza, Executive Director of Progress Texas, released the following statement:

Twelve weeks of ACA has done more to help Texans without health care than Rick Perry has done in twelve years as Governor.

…Texas Still Has a Significant Coverage Gap

In addition to the top-line numbers, a little digging shows how Rick Perry and Greg Abbott’s refusal to expand Medicaid has created a significant coverage gap in Texas:

  • 210,309 Texans who applied for coverage could have received financial assistance for the Marketplace plans.

Many, if not most, of those 210,000+ Texans who couldn’t get financial assistance would have been covered if Texas had expanded Medicaid. We know that one million low-income Texans are left out of health coverage because elected leaders in Texas chose politics over what was right for our people.

Just imagine how many more people could be getting coverage if Rick Perry wasn’t doing everything in his power to stand in the way. Several Texas Congressional Democrats have now sent a letter to AG Eric Holder asking him to step in and do something about Texas’ ridiculous navigator rules, but I don’t really expect anything to come of that. For more on the national numbers, see Jonathan Cohn, TPM, Sarah Kliff, and Ezra Klein.

Texas Left Me Out

This.

It's constitutional - deal with it

It’s constitutional – deal with it

Obamacare advocates are actively recruiting those left out of the Medicaid expansion in Republican-controlled states to lobby state officials to change their minds and participate in that key provision of the health care reform law.

So far, the effort is most organized in Texas, which is also the state with the most people in that Medicaid expansion gap: 1 million. But it’s likely to pick up elsewhere as the Obama administration and outside advocates apply pressure to the 25 states that have resisted expansion for the first year.

Texas Left Me Out, the combined effort of several community groups, is a website designed to collect those people’s stories and organize them into a cohesive political action constituency. It asks those in the Medicaid gap to sign a petition to stay informed about advocacy events and share their story on the site.

Are they going to turn Texas blue on the backs of people who have traditionally been ignored by Republicans? Are they going to convince an anti-Obamacare stalwart like Rick Perry to buy into the law? That’s a tough sell. But they’re going to try.

“When you personalize a policy, when you make it real, it’s always much more powerful. It’s always going to resonate,” Tiffany Hogue, state health care campaign coordinator at the Texas Organizing Project, one of the groups involved with the campaign, told TPM. “People have really have awakened to the fact that people really are getting left behind.”

Texas Left Me Out had a soft launch in October in preparation for a January rollout. The Texas Organizing Project says it has already contacted 100,000 people who are in the gap and convinced 20,000 to commit to be part of the campaign. They hope that those numbers will grow substantially before the Texas legislature reconvenes in 2015, its next opportunity to expand Medicaid under Obamacare. They’ve set recruitment targets for specific legislative districts to focus their efforts.

The broader coalition is also eyeing the 2014 elections. The presumed Democratic frontrunner for governor, state Sen. Wendy Davis, has enthusiastically endorsed expansion, and a more Democratic legislature would also be more likely to sign onto a major piece of the health care reform law.

The strategy is simple: sheer political force. They’ll ask people to turn up at legislative committee hearings and stage protests at the state capitol. Conference calls and press conferences will be the norm. They aren’t waiting for 2015 either. A group is going to a state insurance department meeting Dec. 20 to rally for expansion.

The website is here. I’m not at all surprised to see that Progress Texas is one of the forces behind it. The goals are ambitious, but we’re not going to get anywhere by thinking small.

And despite the ferocious efforts by Texas Republicans to deny health care coverage to its residents, demand for health insurance is strong.

Texas has the second-highest number of people who have purchased health plans through the embattled online insurance marketplace created by the Affordable Care Act, according to enrollment figures for October and November released Wednesday by the U.S. Department of Health and Human Services.

But as a percentage of the uninsured in the second-largest state — which has the nation’s worst rate of health coverage — the number is tiny: 14,000 Texans had purchased coverage through healthcare.gov by the end of November.

The number of people who purchased coverage in the federal marketplace, which has been riddled with technical problems, was four times higher in November than in October: 137,204 people, including 14,000 Texans, had purchased coverage there as of the end of November, whereas only 27,000 people, including 3,000 Texans, had purchased coverage there at the end of October.

“Evidence of the technical improvements to HealthCare.gov can be seen in the enrollment numbers,” U.S. Health and Human Services Secretary Kathleen Sebelius, said in a press statement.

Florida had the highest enrollment numbers, with 17,900 people purchasing coverage in the federal marketplace, followed by Texas, and Pennsylvania, with 11,800 people purchasing coverage. 2.2 million people, including 245,000 Texans, have now completed applications through the federal marketplace.

Texas has the nation’s highest rate of people without health insurance at 24.6 percent, according to U.S. Census data. About 48 million Americans — including more than 6 million Texans — were uninsured in 2011 and 2012.

Those numbers are two weeks old now, but there’s no indication that the pace has slowed since then. Remember when you hear a Texas Republican whine about Obamacare that they have been in complete control of Texas’ government for over a decade now. If they cared at all about those six million uninsured people, they’ve had ample opportunity to do something about it. But they don’t, so they haven’t. Nothing will change until our state government changes. That’s why efforts like Texas Left Me Out matter.

Premiums for insurance exchange plans released

Guess what? They’re pretty darned affordable.

It's constitutional - deal with it

It’s constitutional – deal with it

“In just 99 days, millions of Americans will finally have the security and peace of mind that have eluded them for years,” U.S. Health and Human Services Secretary Kathleen Sebelius said on a press call, “as coverage starts to kick in on insurance purchased through the new health insurance marketplace.”

To help people comply with the individual health insurance mandate that takes effect on Jan. 1, the federal government will launch an Orbitz-style online marketplace on Oct. 1 for consumers to apply for tax credits and compare and purchase health plans.

According to the federal report released Tuesday night, Texas will have comparatively low premium rates for health plans offered in the federal marketplace compared with other states. The average monthly rate for a standard plan in the 48 states analyzed in the report was $328, while Texas’ was $305. Fourteen states and the District of Columbia will have lower rates on average than Texas for a standard health plan offered in the marketplace.

“Texas has historically had a reasonably competitive insurance market compared to some states,” said Gary Cohen, director of the Center for Consumer Information and Insurance Oversight at the federal Centers for Medicare and Medicaid Services. He explained that in some states one insurance carrier may dominate 75 to 80 percent of the market. “Texas has not had that situation,” he said.

Texans will have on average 54 health plan options available in the federal marketplace. The number of available plans will vary depending on the region. For example, people in Austin will have 76 health plans to choose from on average, while people in the Rio Grande Valley will only have 30 options on average.

Four types of plans will be offered in the marketplace: Bronze, Silver, Gold and Platinum. In general, Bronze plans will have lower monthly premiums but higher out-of-pocket costs, while Platinum plans will have the highest monthly premiums but lower out-of-pocket costs. Premium rates and out-of-pocket costs will vary depending on age, the number of people in the household and the region in which the person lives, among other factors. Ultimately, the prices are based on the estimated cost of health care services over the course of a year.

People who have annual incomes between 100 and 400 percent of the federal poverty line will qualify for sliding-scale tax credits to help them purchase a health plan in the federal marketplace. For an individual, that’s an annual income of $11,490 to $45,960; for a family of four, it’s $23,550 to $94,200.

Click over to see some detailed information about what will be available in Texas, or click here to see the full report. Some highlights from the latter:

Individuals will have an average of 53 qualified health plan choices in states where HHS will fully or partially run the Marketplace

  • Individuals and families will be able to choose from a variety of bronze, silver, gold, and platinum plans in the Health Insurance Marketplace, as well as catastrophic plans for young adults and those without affordable options. Health insurance issuers can offer multiple qualified health plans, including multiple qualified health plan choices within a single metal level. In the 36 states in this analysis, the number of qualified health plan choices available in a rating area ranges from a low of 6 to a high of 169 plans. On average, individuals and families will have 53 qualified health plans to choose from in their rating area. Young adults will have an average of 57 qualified health plans to choose from, including catastrophic plans. The average number of choices will likely increase after including final data from state-based Marketplaces, which tend to have greater issuer participation.
  • On average, there are 8 different health insurance issuers participating in each of the 36 Marketplaces included in this analysis. This ranges from a low of 1 issuer to a high of 13 issuers within a state. About 95 percent of the non-elderly population in these 36 states lives in rating areas with 2 or more issuers. Roughly one in four issuers is offering health plans in the individual market for the first time in 2014.

Premiums before tax credits will be more than 16 percent lower than projected

  • The weighted average second lowest cost silver plan for 48 states (including DC) is 16 percent below projections based on the ASPE-derived Congressional Budget Office premiums.11 In 15 states, the second lowest cost silver plan will be less than $300 per month – a savings of $1,100 a year per enrollee compared to expectations. Overall, 95% of the uninsured potentially eligible for the Marketplaces live in states with average premiums below ASPE-derived CBO projected premiums (see Figure 1).
  • Young adults will pay lower premiums and also have the option of a catastrophic plan that covers prevention, some primary care, and high costs in cases of major accident or illness. The weighted average lowest monthly premiums for a 27-year-old in 36 states14 will be (before tax credits): $129 for a catastrophic plan, $163 for a bronze plan, and $203 for a silver plan. More than half of the uninsured potentially eligible for the Marketplaces live in a state where a 27-year-old can purchase a bronze plan for less than $165 per month before tax credits. There are an estimated 6.4 million uninsured Americans between the ages of 25 and 30 who may be eligible for coverage through Medicaid or the Marketplaces in 2014.

Premiums after tax credits

  • Tax credits will make premiums even more affordable for individuals and families. For example, in Texas, an average 27-year-old with income of $25,000 could pay $145 per month for the second lowest cost silver plan, $133 for the lowest cost silver plan, and $83 for the lowest cost bronze plan after tax credits. For a family of four in Texas with income of $50,000, they could pay $282 per month for the second lowest cost silver plan, $239 for the lowest silver plan, and $57 per month for the lowest bronze plan after tax credits.
  • After taking tax credits into account, fifty-six percent of uninsured Americans (nearly 6 in 10) may qualify for health coverage in the Marketplace for less than $100 per person per month, including Medicaid and CHIP in states expanding Medicaid.

It should be noted that it’s not all butterflies and lollipops, as Wonkblog explains.

Health experts say it is a good sign for consumers that premiums have come in lower than expected. Under the law, the plans must offer a basic set of benefits, including mental health and maternity care, which previously were not included in many private plans. Insurers are also forbidden from rejecting or charging people more because of preexisting conditions.

Many experts worried that those factors would drive up the cost of insurance. They partially credit competition on the marketplaces, where people will be able to directly compare plans from different insurance companies, for restraining premiums.

But they warn that premiums don’t tell the whole story.

The low rates are possible in part because insurance companies created special plans that include fewer in-network doctors and hospitals than many current plans.

This may not be a problem for healthy people who currently lack insurance. But those with illnesses may discover that their specialists are not covered by an exchange insurance plan. Low-income people accustomed to a certain community clinic may find that going there is no longer an option. And everyone may encounter long waits to see a doctor.

In addition, many of the lowest-cost plans may carry high deductibles, despite a cap imposed by the law that limits out-of-pocket costs to $6,350 per person per year.

“Despite the fact that the premiums are lower than expected, enrollees on exchanges are likely to face very high out-of-pocket costs before they hit their cap, and they are at risk of being in very narrow network plans that may or may not include all the providers they need access to,” said Caroline Pearson, vice president of health reform at the consulting firm Avalere Health, which did its own report on rates this month.

It’s still going to be a lot better than having no insurance, and for people who are currently paying exorbitant prices for individual plans, or who can’t get insurance at all because of pre-existing conditions, it will be awesome. That will include millions of Texans, some of whom are friends of mine, and all of whom Ted Cruz cares nothing about. Kevin Drum and the Kaiser Family Foundation have more.

Counties may try to expand Medicaid on their own

The Washington Post reports on the efforts of county and hospital district officials in some of Texas’ largest counties to bypass Rick Perry’s refusal to expand Medicaid for Texas and seek approval to do it themselves for their own jurisdictions.

It's constitutional - deal with it

George Hernandez Jr., CEO of University Health System in San Antonio, came up with the idea of the alternative, county-run Medicaid expansion, and said he has been discussing it with other officials in his county, Bexar. “They are all willing,” he said. He added that he has also been talking up the proposal with officials in other big counties, such as those including Houston and Dallas, and is optimistic they’ll support the idea.

Robert Earley, CEO of JPS Health Network, the public hospital system serving Tarrant County, which includes the Fort Worth area, said he could see the idea catching on.

[…]

Under the federal health law, the Medicaid expansion would begin in 2014, and would cover people with incomes of up to 133 percent of the poverty level. The federal government would pay the entire bill for the first three years and 90 percent thereafter. If there were a county-backed expansion in Texas, the local hospital districts would tax residents to come up with the 10 percent state share. Texans living in counties that participated in the expansion would be eligible for Medicaid under the less restrictive rules, while those living in the rest of the state would not.

An official from the U.S. Department of Health and Human Services declined to comment on the idea, but said, “We look forward to continuing our dialogue with states . . . as we work to meet the law’s goals.”

Alan Weil, executive director of the National Academy for State Health Policy, said that the idea, despite its challenges, “is certainly not far-fetched.”

Weil noted that there is precedent for a federal waiver of this type: After California declined to take advantage of a provision in the health-care law that allows states to accelerate their Medicaid expansion, the leaders of several counties got permission from the Obama administration to do so on their own.

The Texas proposal, of course, represents more than a temporary bridge to statewide expansion; it could be a permanent arrangement.

“And federal authorities might feel differently about that,” Weil said. “But as a general proposition, could you have different counties with different eligibility standards? I think the answer would be yes.”

We first heard about this a few weeks ago, after the Perry announcement and the sheepish admission by outgoing HHSC Chair Tom Suehs that Medicaid expansion would not cost nearly as much as his agency had first claimed. It’s an interesting approach, one that I could see being allowed to happen, and I admire creativity and perseverance of the officials who are pursuing it, but let’s be clear that it’s at best a kludge designed to work around a bad decision. For one thing, it cannot possibly be more efficient to have up to 254 potentially different standards for eligibility in Texas than just one statewide standard. For another, while I expect that many counties would do this if they are permitted to do so, some others will choose instead to be free-riding parasites on their neighbors; this is another reason why a statewide solution is better. Given the choice between no Medicaid expansion and a patchwork of Medicaid expansion done by the counties, I’ll gladly take the latter – it’s way better than the status quo, and could easily wind up covering a significant portion of the large uninsured population in Texas, many of which are now served by these overburdened hospital districts. But again, it’s a patch that’s being applied to a strictly self-inflicted wound.

And this approach now has a champion in Congress.

Congressman Henry Cuellar is asking the U.S. Department of Health and Human Services if Texas counties can bypass their state government in order to expand Medicaid coverage.

The Laredo Democrat says he supports giving counties the choice. He said he set up a teleconference call with HHS after reading an article in the Washington Post that said some of Texas’ largest counties want to make an end run around Gov. Rick Perry’s opposition to the expanded Medicaid program included in President Obama’s health-care law.

“I will be talking to HHS next week. I want to know if it is up to the Texas Legislature to decide if counties can do their own thing or whether it is something we can make happen at the federal level. I want to do all I can to give counties the choice,” Cuellar said, in an interview with the Guardian in Rio Grande City on Tuesday.

[…]

Cuellar recalled his time in the state legislature when he wanted to give Texas counties the opportunity to expand the Children’s Health Insurance Program. “We do not do as good a job with the CHIP program as other states do and I wanted to negotiate with HHS to give our counties the chance to expand it. I was opposed by the other states. They understood that if Texas sent CHIP money back, they could get some of it,” Cuellar said.

The Washington Post story focused on the larger Texas counties that have large public hospitals and hospital districts. Many border counties do not. Asked if border counties could bypass the state government in order to secure expanded Medicaid coverage under the ACA, Cuellar said he is going to ask HSS if such a maneuver is possible. “I want to see if the border counties can group together. I want to see if we can give them an option,” Cuellar said.

Again, given the constraints of Rick Perry’s obstinacy and antipathy towards non-rich people, that’s a great idea. Any opportunity to bypass the Lege should be grasped with both hands. Make that option available to any group of counties that don’t have a hospital district but want to do right by their taxpayers, too. If there’s any justice, Texas would achieve near-complete coverage by this method. It will probably take something like that to change the status quo. It’s still a stupid way to do business, but you gotta do what you gotta do.

There’s one remaining question that I have about all this, and that’s what Harris County intends to do. Bexar County has been the driving force behind this movement. Harris has the same need and a much bigger population, so its participation would be a big deal. I placed a call and was informed that Harris County Hospital District CEO David Lopez is “not granting interviews” on this topic at this time. Disappointing, but I suppose the politics of this are rather tricky for them, and they want to get as many ducks in a row as possible before deciding on a course of action. If you’re an officeholder in Harris County and you like the idea of providing coverage to the million or so uninsured residents of this county, I suggest you bring this up to Mr. Lopez at your next opportunity. You never know who else might be talking to him if you aren’t.

We’re #50!

The state of Texas is dead last in delivering health care.

The 2011 State Snapshots report is based on 155 quality measures gathered by the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. The measures include disease prevention efforts, deaths from various conditions as well as infant mortality and suicides, cancer treatment, and how well health care providers manage chronic conditions such as diabetes and patients with incurable conditions.

Texas is weakest on measures of home health care but showed strengths in nursing home care, said the report, released this week.

Overall, Texas scored 31.61 out of 100 points. The No. 1 state, Minnesota, scored 67.31, with Wisconsin close behind at 67.20.

“For some states, like Texas, we hope it will motivate policy makers and providers to improve the quality of care,” said report researcher Dr. Ernest Moy, a medical officer at the agency’s Center for Quality Improvement and Patient Safety.

Yeah, I couldn’t read that quote with a straight face, either. The report is here. The TM Daily Post summarizes as follows:

State health officials say Texas’ poor rating is a result of inadequate funding and a large uninsured population. About 25 percent of the state’s residents lack health insurance, more than any other state.

This is, of course, a feature and not a bug in our state. Keep that in mind when the geniuses in charge make their decision about expanding Medicaid, which would go a long way towards dealing with those issues. Juanita has more.