Biden Takes On Sagging Safety Net With Plan to Fix Long-Term Care

President Biden’s $400 billion proposal to improve long-term care for older adults and those with disabilities was received as either a long overdue expansion of the social safety net or an example of misguided government overreach.

Republicans ridiculed including elder care in a program dedicated to infrastructure. Others derided it as a gift to the Service Employees International Union, which wants to organize care workers. It was also faulted for omitting child care.

For Ai-jen Poo, co-director of Caring Across Generations, a coalition of advocacy groups working to strengthen the long-term care system, it was an answer to years of hard work.

“Even though I have been fighting for this for years,” she said, “if you would have told me 10 years ago that the president of the United States would make a speech committing $400 billion to increase access to these services and strengthen this work force, I wouldn’t have believed it would happen.”

knocking millions of women out of the labor force — or deplete their resources until they qualify for Medicaid.

Whatever the limits of the Biden proposal, advocates for its main constituencies — those needing care, and those providing it — are solidly behind it. This would be, after all, the biggest expansion of long-term care support since the 1960s.

“The two big issues, waiting lists and work force, are interrelated,” said Nicole Jorwic, senior director of public policy at the Arc, which promotes the interests of people with disabilities. “We are confident we can turn this in a way that we get over the conflicts that have stopped progress in past.”

And yet the tussle over resources could reopen past conflicts. For instance, when President Barack Obama proposed extending the Fair Labor Standards Act of 1938 to home care workers, which would cover them with minimum-wage and overtime rules, advocates for beneficiaries and their families objected because they feared that states with budget pressures would cut off services at 40 hours a week.

“We have a long road ahead of passing this into law and to implementation,” Haeyoung Yoon, senior policy director of the National Domestic Workers Alliance, said of the Biden proposal. Along the way, she said, supporters must stick together.

half of adults would need “a high level of personal assistance” at some point, typically for two years, at an average cost of $140,000. Today, some six million people need these sorts of services, a number the group expects to swell to 16 million in less than 50 years.

In 2019, the National Academy of Social Insurance published a report suggesting statewide insurance programs, paid for by a dedicated tax, to cover a bundle of services, from early child care to family leave and long-term care and support for older adults and the disabled.

This could be structured in a variety of ways. One option for seniors, a catastrophic insurance plan that would cover expenses up to $110 a day (in 2014 dollars) after a waiting period determined by the beneficiary’s income, could be funded by raising the Medicare tax one percentage point.

Mr. Biden’s plan doesn’t include much detail. Mr. Gleckman of the Urban Institute notes that it has grown vaguer since Mr. Biden proposed it on the campaign trail — perhaps because he realized the tensions it would raise. In any event, a deeper overhaul of the system may eventually be needed.

“This is a significant, historic investment,” Mr. Espinoza said. “But when you take into account the magnitude of the crisis in front of us, it’s clear that this is only a first step.”

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Doctors Accuse UnitedHealthcare of Stifling Competition

UnitedHealth directly competes with U.S. Anesthesia, according to the Texas lawsuit, through an ownership interest in Sound Physicians, a large medical practice that provides emergency and anesthesiology services. Sound Physicians is looking to expand in markets like Fort Worth and Houston, and U.S. Anesthesia claims in the lawsuit that its doctors were contacted by Sound Physicians “to induce them to leave” and challenge the noncompete provisions in their contracts to work with the United group.

The major insurer throws its weight around in other ways, the lawsuit claims. While the company’s Optum unit, which operates the surgery centers and clinics, is technically separate from the health insurer, the doctors accuse United of forcing its OptumCare facilities to sever their relationships with the anesthesiology group and pushing in-network surgeons to move their operations to hospitals or facilities that do not have contracts with U.S. Anesthesia.

“United and its affiliates have extended their tentacles into virtually every aspect of health care, allowing United to squeeze, choke and crush any market participant that stands in the way of United’s increased profits,” the doctors claim in their lawsuit.

It is standard practice, United said, for an insurer to encourage the use of hospitals and doctors within its network.

In contrast to many smaller physician groups that are struggling because of the pandemic, United has maintained a strong financial position, shoring up profits while elective surgeries and other procedures were shut down, resulting in fewer medical claims. So it has continued to expand, hiring more doctors and buying up additional practices. The company says it plans to add more than 10,000 employed or affiliated doctors this year.

The relationship between insurers and providers has become more complicated as more insurance carriers own doctors’ groups or clinics. “They want to be the referee and play on the other team,” said Michael Turpin, a former United executive who is now an executive vice president at USI, an insurance brokerage.

Employers that rely on UnitedHealthcare to cover their workers have a difficult time judging who benefits when insurers fail to reach an agreement to keep a provider in network. “This is just as much about profit as it is about principle,” Mr. Turpin said.

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Doctors Sue UnitedHealthcare

UnitedHealth directly competes with U.S. Anesthesia, according to the Texas lawsuit, through an ownership interest in Sound Physicians, a large medical practice that provides emergency and anesthesiology services. Sound Physicians is looking to expand in markets like Fort Worth and Houston, and U.S. Anesthesia claims in the lawsuit that its doctors were contacted by Sound Physicians “to induce them to leave” and challenge the noncompete provisions in their contracts to work with the United group.

The major insurer throws its weight around in other ways, the lawsuit claims. While the company’s Optum unit, which operates the surgery centers and clinics, is technically separate from the health insurer, the doctors accuse United of forcing its OptumCare facilities to sever their relationships with the anesthesiology group and pushing in-network surgeons to move their operations to hospitals or facilities that do not have contracts with U.S. Anesthesia.

“United and its affiliates have extended their tentacles into virtually every aspect of health care, allowing United to squeeze, choke and crush any market participant that stands in the way of United’s increased profits,” the doctors claim in their lawsuit.

It is standard practice, United said, for an insurer to encourage the use of hospitals and doctors within its network.

In contrast to many smaller physician groups that are struggling because of the pandemic, United has maintained a strong financial position, shoring up profits while elective surgeries and other procedures were shut down, resulting in fewer medical claims. So it has continued to expand, hiring more doctors and buying up additional practices. The company says it plans to add more than 10,000 employed or affiliated doctors this year.

The relationship between insurers and providers has become more complicated as more insurance carriers own doctors’ groups or clinics. “They want to be the referee and play on the other team,” said Michael Turpin, a former United executive who is now an executive vice president at USI, an insurance brokerage.

Employers that rely on UnitedHealthcare to cover their workers have a difficult time judging who benefits when insurers fail to reach an agreement to keep a provider in network. “This is just as much about profit as it is about principle,” Mr. Turpin said.

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The Triple Tax Break You May Be Missing: A Health Savings Account

The federal government’s pandemic relief program expanded what H.S.A.s can pay for, including nonprescription medicine like pain relief and allergy pills, and menstrual products like tampons and pads. (The I.R.S. has a full list of eligible items.)

Some employers match contributions to H.S.A.s as they do retirement savings. But self-employed people and contractors can open them, too.

People often confuse H.S.A.s with other types of health accounts, such as flexible health spending accounts. But unlike F.S.A.s, health savings accounts are portable: If you change jobs or leave the work force, you keep the account. Contribution limits are higher for H.S.A.s, and there is no deadline to spend the cash. Unspent money can be invested for health needs in retirement.

A study published last summer in JAMA Network Open, a journal from the American Medical Association, found that many people with high-deductible insurance didn’t have a health savings account. And more than half who had one had not contributed to it in the previous year. People with health plans bought through a government exchange were more likely to not have an H.S.A., even though the average deductible in the federal marketplace is high enough.

How Has the Pandemic Changed Your Taxes?

Nope. The so-called economic impact payments are not treated as income. In fact, they’re technically an advance on a tax credit, known as the Recovery Rebate Credit. The payments could indirectly affect what you pay in state income taxes in a handful of states, where federal tax is deductible against state taxable income, as our colleague Ann Carrns wrote. Read more.

Mostly.  Unemployment insurance is generally subject to federal as well as state income tax, though there are exceptions (Nine states don’t impose their own income taxes, and another six exempt unemployment payments from taxation, according to the Tax Foundation). But you won’t owe so-called payroll taxes, which pay for Social Security and Medicare. The new relief bill will make the first $10,200 of benefits tax-free if your income is less than $150,000. This applies to 2020 only. (If you’ve already filed your taxes, watch for I.R.S. guidance.) Unlike paychecks from an employer, taxes for unemployment aren’t automatically withheld. Recipients must opt in — and even when they do, federal taxes are withheld only at a flat rate of 10 percent of benefits. While the new tax break will provide a cushion, some people could still owe the I.R.S. or certain states money. Read more.

Probably not, unless you’re self-employed, an independent contractor or a gig worker. The tax law overhaul of late 2019 eliminated the home office deduction for employees from 2018 through 2025. “Employees who receive a paycheck or a W-2 exclusively from an employer are not eligible for the deduction, even if they are currently working from home,” the I.R.S. said. Read more.

Self-employed people can take paid caregiving leave if their child’s school is closed or their usual child care provider is unavailable because of the outbreak. This works similarly to the smaller sick leave credit — 67 percent of average daily earnings (for either 2020 or 2019), up to $200 a day. But the caregiving leave can be taken for 50 days. Read more.

Yes. This year, you can deduct up to $300 for charitable contributions, even if you use the standard deduction. Previously, only people who itemized could claim these deductions. Donations must be made in cash (for these purposes, this includes check, credit card or debit card), and can’t include securities, household items or other property. For 2021, the deduction limit will double to $600 for joint filers. Rules for itemizers became more generous as well. The limit on charitable donations has been suspended, so individuals can contribute up to 100 percent of their adjusted gross income, up from 60 percent. But these donations must be made to public charities in cash; the old rules apply to contributions made to donor-advised funds, for example. Both provisions are available through 2021. Read more.

The findings suggest that health plans, employers and financial advisers could do more to explain how H.S.A.s work, simplify their use and encourage contributions, said an author of the study, Dr. Jeffrey T. Kullgren, associate professor of internal medicine and health management and policy at the University of Michigan.

“Anything that makes it easier would be a good thing,” he said.

H.S.A. providers increasingly are cutting fees and using technology to encourage use. Fidelity Investments this month will test an app that will allow clients with employer H.S.A.s to track account balances, contributions and spending. The app will also let users scan products to check if they are H.S.A.-eligible.

Others are focusing on workers in the gig economy. Starship, a start-up, promotes its accounts through affiliations with ride-hailing and delivery companies. Its app allows workers to automatically invest contributions in low-cost index funds and exchange-traded funds. Because there is no required minimum balance, users are able to invest all of their contributions. But that would also leave no cash available to cover medical costs, unless the investments are sold. Starship sets the default minimum threshold before investing at $2,000, but users can lower it to zero, said Sean Engelking, the company’s chief executive.

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A $22,368 Bill That Dodged and Weaved to Find a Gap in America’s Health System

John Druschitz spent five days in a Texas hospital last April with fever and shortness of breath. It was still the early days of the pandemic, and doctors puzzled over a diagnosis.

They initially suspected coronavirus and hung signs outside his door warning those entering to wear protective equipment. Mr. Druschitz had already spent two weeks at home with worsening symptoms. He recalls one doctor telling him, “This is what it does to a person.”

Ensuing lab work, however, was ambiguous: Multiple molecular tests for coronavirus came back negative, but an antibody test was positive.

Doctors found that Mr. Druschitz had an irregular heartbeat and blood clots in both his lungs. They sent him home on oxygen, and ultimately did not give a coronavirus diagnosis because of the negative tests. He didn’t think much about the decision until this fall, when he received a $22,367.81 bill that the hospital has since threatened to send to collections.

too narrow, and for covering bills only where coronavirus is the primary diagnosis. A patient with a primary diagnosis of respiratory failure and a secondary diagnosis of coronavirus would not qualify, for example.

The Health Resources and Services Administration, which runs the federal fund, does not have plans to change that policy. So far, it has spent $2 billion to reimburse health care providers for the bills of uninsured coronavirus patients.

“The H.R.S.A. uninsured program is a voluntary claims program, not an insurance program,” said Martin Kramer, an agency spokesman. “The scope is narrow, and its primary function is to help combat Covid-19 by removing financial barriers.”

The hospital that treated Mr. Druschitz — the Baylor, Scott and White Medical Center in Austin, Texas — did not submit his charges for reimbursement because of the negative coronavirus tests, said Julie Smith, a spokeswoman.

“The nucleic amplification Covid-19 test is the standard to diagnose or rule out Covid-19,” she said in an email. “Because the diagnosis for this admission was not Covid-19, his hospital stay is not eligible.”

The positive antibody test, she said, “may indicate a previous infection.”

The hospital has submitted other claims to the uninsured fund, and has so far received a quarter-million dollars in reimbursement. It has applied a 40 percent uninsured discount to Mr. Druschitz’s $34,058 charge. It’s not clear from his billing codes whether the hospital is pursuing him for a larger amount than what the federal fund for uninsured people would have paid.

Multiple clinicians with expertise in Covid-19 reviewed Mr. Druschitz’s medical records for The New York Times. They said that his case was ambiguous: It wasn’t completely clear whether coronavirus had caused his symptoms.

“There is a good chance that he did have Covid-19, and I base that on the fact that his symptoms are consistent with that diagnosis,” said Dr. Alexander McAdam, an associate professor of pathology at Harvard. “The lab data, however, don’t definitively demonstrate that.”

Dr. McAdam was not surprised that a Covid test at the hospital could come back negative even when Mr. Druschitz was very ill.

“People can have persistent symptoms even after the virus is no longer detectable,” he said. “It could be the virus is now in the lower respiratory tract but not the upper,” meaning it might not show up on a test.

But he and Dr. Jha, who also reviewed the records, said they would have expected an earlier test, conducted 10 days before his hospital stay, to be positive. It would be unusual for a test to be negative at that point, as Mr. Druschitz’s was, when he was already symptomatic.

“It’s more likely than not that he did not have Covid, but it’s certainly not a zero chance,” Dr. Jha said. “The fact that it will end up making a big difference in the bill is really problematic.”

Mr. Druschitz’s primary care provider, Dr. Craig Kopecky, who saw him shortly before and after the hospital visit, says that the diagnosis is wrong and that his patient did have coronavirus.

Dr. Kopecky initially suspected bronchitis when Mr. Druschitz came to his office in mid-April with a cough and some shortness of breath. He began to suspect Covid in a follow-up telemedicine visit 10 days later.

“At that point he’d started to lose some of his sense of taste,” he said. “I couldn’t examine him because it was telemedicine, but I could clearly hear him struggling to breathe.”

Dr. Kopecky submitted his bills for Mr. Druschitz’s treatment to the federal fund for uninsured patients, and said he received reimbursement.

The patient advocate that Mr. Druschitz retained, Jan Stone of StoneWorks Healthcare Advocates, has asked the hospital to re-evaluate the diagnosis. She’s now running up against a deadline: Hospitals have one year to submit claims to the uninsured fund. This means the hospital would need to file for reimbursement within the next six weeks.

“The clock is definitely ticking,” she said.

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The Virus Cost Performers Their Work, Then Their Health Coverage

Musicians are struggling, too. Officials at Local 802 of the American Federation of Musicians, the New York local that is the largest in the nation, estimate that when changes to its plan take effect this month, roughly one in three musicians will have lost coverage: It will have shed more than 570 of the roughly 1,500 people who had been enrolled a year earlier.

“Nothing has kept me up at night more and weighed on me more heavily than the health care question,” said Adam Krauthamer, the president of Local 802 and a trustee co-chair of the union’s health fund.

Perhaps the most public, acrimonious battle over coverage has broken out at the Screen Actors Guild-American Federation of Television and Radio Health Plan, which insures 33,000 actors, singers, journalists and other media professionals. That plan raised the floor for eligibility to those earning $25,950 a year, from $18,040, effective Jan. 1, and also raised premiums in response to deficits projected to be $141 million last year and $83 million this year.

Officials at the plan have estimated that changes they are making will remove 10 percent of its participants from coverage. But a class-action lawsuit filed by Ed Asner, a former president of the screen actor’s union, and other mostly older actors and union members charges that at least 8,000 retirees will also lose some of their coverage. (Many companies have dropped retiree health coverage in recent decades.)

The plan’s new rules effectively strip many older members of what is often their secondary insurance. An online advocacy campaign features Mark Hamill, Whoopi Goldberg, Morgan Freeman and other stars who say they feel betrayed by the union.

“So many people, along with me, feel robbed of our health care benefits,” Dyan Cannon, 84, said in a statement provided by lawyers for the plaintiffs in the class-action.

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