What changes can we expect to see to healthcare policies during the Biden administration?
In less than two months, Joe Biden will be inaugurated as the 46th president of the United States, and Kamala Harris will become vice president. The 2020 presidential election was contentious, with the ongoing coronavirus pandemic making healthcare and the economy key issues. As we look toward the next four years under a Biden administration, we will likely see a variety of changes to health policy issues.
Medecision hosted a webinar in mid-November to discuss post-election implications for the healthcare industry. We brought together three thoughtful and visionary healthcare policy experts to share their astute observations about how a Biden administration could impact the industry—especially during a global pandemic. Julie Barnes, J.D., founder and principal of Maverick Health Policy, moderated the discussion between Krista Drobac, founder of Sirona Strategies and executive director of Alliance for Connected Care, and Colin Roskey, senior vice president of Lincoln Policy Group. In a poll, we asked webinar participants to vote on the most pressing issues that they wanted Barnes, Drobac and Roskey to discuss. Participants selected challenges related to COVID-19, health insurance coverage, healthcare costs and virtual care, as well as a few short-term healthcare policy issues.
Five Key Healthcare Policy Issues
- The COVID-19 pandemic. Confirmed cases are surging across the nation, and with increased holiday travel, we anticipate an even greater uptick. The pandemic continues to pose serious challenges to lab testing and supply chains and exposes the weaknesses of our public health infrastructure.According to Roskey, we should expect a more coordinated national pandemic strategy from the Biden administration—one that relies on executive orders, rather than congressional authority and legislation. While we expect a federal economic relief package, we shouldn’t expect that to include additional monies for state and local governments. Nor should we expect liability reform, Roskey noted, because the Republican and Democratic parties are too divided on the issue.
However, we can expect both political parties to be looking for wins and for issues that they can work on together, Drobac added. “For strategic advocacy purposes, I have found over the past nine months that most healthcare issues can be couched in COVID-19,” she said. “There’s something in every healthcare issue that relates back to COVID-19, whether it’s more depression and substance abuse during this period or an increased focus on social determinants of health, food and housing because of the corresponding economic crisis.”
- Health insurance. At this point, it seems probable that the United States Supreme Court will uphold the Affordable Care Act (ACA). But we will surely see changes to health insurance coverage, with coverage expansion seemingly possible in Medicaid, Medicare and the insurance exchanges, Barnes said.With Medicaid, Roskey suggested that the Biden administration will work diligently with local jurisdictions to remove some of the new burdens that were added or voluntarily adopted by Republican-led states, with respect to the new work requirements. There may also be other incentives that the Biden administration tries to provide states to expand Medicaid, Roskey said. For example, Oklahoma and Missouri are both red states that expanded Medicaid—and that puts pressure on the remaining red state governors who are facing reelection. We should fully expect the Biden administration to make it hard to resist by finding creative ways to supplement state funding, or penalizing states that do not expand, Drobac added.For Medicare, it would not be surprising to see the Center for Medicare and Medicaid Innovation (CMMI) as a landing place for a Medicare buy-in opportunity, or a Medicare eligibility age-reduction demonstration that could potentially be used to allow people younger than 65 into the program. “Whether that’s into a Medicare Advantage plan or into a fee-for-service plan, I see the CMMI construct as possibly the fastest way to test that out,” Roskey said. “With the CMMI, there’s the most amount of flexibility to waive statutory and regulatory constraints.”In addition, even if ACA is kept in place, we’ll definitely see coverage expanding, with more options in the health exchanges marketplace being more aggressively promoted—more open enrollment periods, more opportunities for people to buy, and more subsidized coverage on healthcare.gov. Among Medicaid, a potential new Medicare option with CMMI, and the exchange marketplace, we could have a few new coverage options that the Biden administration can claim will diminish the uninsured rate in the country. “I think we could see all that happening within the first six to seven months of Biden’s term,” Roskey said.
- Healthcare costs. The Biden administration is unlikely to discontinue the Trump administration’s rulemaking on price transparency, the kidney care models, telehealth waivers, information blocking and interoperability, and veterans’ mental health and suicide prevention. But healthcare spending is a big issue, and COVID-19 did nothing but emphasize that.
There’s going to be a dynamic tension among Medicare expansion, coverage and budget solvency due to the precarious nature of the Medicare trust fund, Roskey said. The Medicare Payment Advisory Commission (MedPAC) often makes recommendations to Congress about ways to reduce program spending, whether it is by the hospital, a Medicare Advantage plan, a nursing home or a home health agency. The Biden administration will look to value-based initiatives that emerge from the CMMI, despite criticism of the CMMI demonstration projects from government officials and MedPAC. We’ll likely see a reframing and reorganization with the CMMI, as well as a recommitment to producing savings to help offset new spending—and cutting back spending may look like reducing updates over time, which could have a problematic impact on providers who operate on thin margins.And, if there’s one thing that Republicans and Democrats can agree on, it’s this: Prescription drug costs are exorbitantly high, and it’s time for the government to take action to lower costs. The Trump administration proposed rules that would eliminate rebates from manufacturers to pharmacy benefit managers (PBMs), tying drug prices to the lowest drug price of an industrialized country (the “Most Favored Nations” rule). The rules were finalized on November 20, and the Biden administration will likely leave those in place.
- Virtual care in Medicare program. Virtual health and telehealth is having a heyday right now. During the first quarter of 2020, telehealth visits increased by 50% when compared with the same time period in 2019. During the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) took action to expand telehealth services for Medicare beneficiaries.“I see a lot of people say, ‘Congress gave that benefit to seniors, surely they won’t take it away,’” Drobac said. “They can and they will. If we want to make telehealth changes permanent, then we have to come up with the money to pay for it.”No one actually objects to telehealth, Drobac explained. It’s simply a budget issue. If the Congressional Budget Office (CBO) believes that telehealth is just an add-on medical service, it will estimate the cost of the service at something like $10 billion—and then Congress won’t be able to find cuts in other programs to account for that cost and pay for it.“What we have to do is convince the CBO and MedPAC that telehealth can save money,” Drobac said. “For starters, we’re showing that utilization rates stayed the same, regardless of an in-person or virtual visit. As in-person visits decreased in the spring, telehealth visits increased. But as states began reopening in the summer, we saw telehealth decrease and a subsequent increase in in-person visits. It’s not like we saw more healthcare—we saw the same amount; it was just a different mix. What it truly shows is that telehealth is a substitution for in-person care, not an add-on service.”We also have to find other ways that telehealth saves money, Drobac said. For example, consider transfers to the emergency room from skilled nursing facilities. During the spring, most visits were conducted via telehealth, saving money on people who would otherwise have been transported via ambulance to the emergency room.
The CBO has often said that medication adherence is the one thing that truly saves money—when people adhere to their medication, they have better health outcomes and it results in long-term cost savings. “We’re using that same argument with telehealth,” Drobac said. “If people don’t miss appointments because they’re easier to attend virtually, then they’ll more likely adhere to their care plan and medications and they’ll have better outcomes and lower costs.”
- Immediate healthcare policy issues. Several issues will need immediate attention from the Biden administration, such as lab testing, vaccine distribution and consumer education, addressing the mental well-being of healthcare workers and those afflicted by COVID-19, clinical staffing and the supply chain. Behavioral health is also a big topic for both parties, and the Biden administration is deeply committed to it, Drobac said.
Another important consideration, Barnes added, is the oversight of lab testing. “The vaccine trials show so much promise, and that’s fantastic,” she said. “But it could also not go well. There needs to be a serious conversation about who oversees what—is it the Food and Drug Administration (FDA) or another organization? How much will it cost, and who is going to pay for it? Genetic tests are also on the horizon, and I think we’re going to see the FDA be restructured, so health plans need to pay attention to that more than ever.”