Gabriel Perna | October 7, 2020
During the 2020 campaign, former Vice President Joseph R. Biden Jr. has outlined major health policy legislative goals for his potential presidency, which includes expanding the Affordable Care Act, lowering the age of Medicare eligibility, and passing prescription drug pricing reform. Those larger policy goals, of course, will have to include addressing COVID-19 during Biden’s first year in office.
“Any element of health care reform is going to have to fit into the larger context and the larger context is that COVID is undoubtedly the dominant issue going forward. And on January 20, it’s going to be how do I get vaccines out as rapidly as possible?” said Ezekiel Emanuel, MD, Vice Provost for Global Initiatives, Co-Director, Healthcare Transformation Institute, University of Pennsylvania.
Creating a centralized, federal response to COVID, distributing a vaccine, and managing supply chain issues, Emanuel said, would be the major focus of a Biden administration in year one. But the Biden administration would also be dealing with other pressing issues outside of health care.
“Besides COVID, we’ve got climate change, we’ve got challenges with the economy and jobs that needs to be attended to, and we have a very volatile situation with China. All of that means major focus on health care reform, at least in the first year, is probably going to be regulatory, rather than legislative, just given a bandwidth issue,” said Emanuel, who is on Biden’s COVID-19 task force.
Emanuel was joined by former Senator Tom Daschle, Founder & CEO of The Daschle Group, in the Health Evolution Executive Briefing webcast, Biden’s Health Care Policy – How Big Is the Aperture for Change? Kavita Patel, MD, Nonresident Fellow, The Brookings Institution and a Venture Partner at New Enterprise Associates, lead the discussion.
“Vice President Biden has a clear point of view on health care and his approach is very different from President Trump’s,” Patel said. “But that point of view also has to be executed.”
The three experts discussed the impact of the Supreme Court’s decision on the ACA, whether a public option is viable, the future of value-based care and more.
ACA and the Supreme Court
On the campaign trail, Biden has made it clear he would like to improve upon the ACA in a number of ways, rather than go for Medicare for All. Experts agree that the future of the ACA comes down to two things: Congressional makeup and the Supreme Court. A week after the election, the Supreme Court is ruling on the fate of the ACA in a case called, “Texas vs. Azar.” The result of that ruling won’t be known until mid-2021 but it’s certainly a factor going forward.
If the Court rules the ACA unconstitutional, it will mean Biden and Congress would have to start over with a wholesale replacement. If it works out a compromise or gets saved in some capacity, as both Emanuel and Daschle predicted, any additions to the ACA can be made in concert with Congress. In both cases, whatever happens to the ACA—whether its replaced or expanded on—will completely depend on what Congress looks like in 2021.
“Will it be Democratic? That’s one question. The other is what will the Senate do to change its rules? Will it follow recent precedent and completely eliminate the filibuster? For over 200 years, the Senate has depended on bipartisanship to work well, but it’s become deeply polarized and deeply dysfunctional today. There were 37 filibusters in the first 50 years after cloture was created. There were 239 in the last two years alone,” said Sen. Daschle.
With that in mind, the easiest way for Biden and Democrats to pass ACA legislation would be to eliminate the filibuster on all legislation if they controlled the Senate. If that happens and they control the House and White House, Daschle predicted they would try to rebuild the ACA and improve upon it.
“They’d repeal the waivers, the short-term junk plans that the Trump administration has offered. They’d press for Medicaid expansion for the remaining 14 states. I think they’d lift the cap of the tax credit eligibility. They would do a lot of aggressive marketing and outreach to expand enrollment,” Daschle said.
Public option and more plans for the uninsured
Emanuel, who was an architect of the ACA, agrees with Daschle’s predictions that Biden’s administration would try to get rid of the Trump administration’s short-term health plans, derided by critics as junk plans. He said they don’t offer patients real protection. He also sees an expansion of the ACA tax subsidies to reach more people, as well as lowering the age of Medicare eligibility and a potential public option to be a four-legged stool to expand health coverage to patients.
“If I had to push them for a fifth stool, I would say we’d need some auto enrollment program into Medicaid. Because there is no way getting to 100% coverage or even 97% coverage without some auto enrollment program,” Emanuel said.
The idea of adding a public option may be a little more difficult than the other proposed changes mentioned by Daschle and Emanuel. Patel said that the public option was part of the original ACA plans before getting removed for numerous political and financial reasons. The challenges that derailed it the first time may come to a forefront again.
Sen. Tom Daschle, Founder & CEO of The Daschle Group
“If you look at the public option, that’s not just a Washington centric challenge, you’ve got two states that couldn’t get it passed this year in spite of favorable legislative conditions. You have to start with the realization that this is going to be really hard. It will be an uphill battle,” said Daschle.
Daschle said there has to be consensus with Republicans to accomplish anything related to a public option. In this regard, one potential he offers is a Medicare Part C or D public option. Emanuel agrees with this idea and said Medicare Advantage’s popularity with seniors make it a potential “sweet spot” for bipartisanship. They also suggest Part C could be used as an incentive to expand Medicaid, particularly in states with high levels of health disparities.
Regardless of what happens, there needs to be bipartisanship, Daschle said. “Compromise is the oxygen of democracy. You’ve got to have compromise in public policy,” he noted.
Patel stated that some areas of health reform—prescription drug pricing, surprise medical billing—have actually had “a bizarre amount of consensus,” considering the times we live in. One area that has been emphasized by both sides of the political spectrum is value-based reimbursement. While the Biden administration would undoubtedly continue down the path of pushing the system toward value-based reimbursement, Daschle made the point that several obstacles still remain.
“We have an addiction to fee-for-service. It’s a little bit like [enacting reform around] surprise billing and drug pricing. Everyone says they’re for it but you have to give up a little of what you got, and no one wants to do that,” Daschle said. He also noted that defining value is a challenge because it’s not just about quality over cost. It’s also considering how to factor in social determinants and integrate primary care. “We haven’t really figured out how you put all of those defining factors together to improve clarity around value-based care that is required to move the public policy needle,” Daschle added.
Emanuel said that value-based care needs consistent messaging to move forward successfully. He proposed that a potential Biden administration could put all government-controlled health plans, not just Medicare, into the same value-based model and then incentivize states to leverage those through their Medicaid programs. He also suggested creating a framework to empower private insurers to run the model and having CMMI operate much bigger mandatory experiments around bundled procedures and primary care.
Emanuel also acknowledged that value-based care will never be used for the whole system, and as such, he advocated for a rebalancing of the fee schedule. “One thing that COVID made painfully clear is how much money is tied up, both in revenue and margins, on elective procedures. That just seems cockamamie, wrong, and not want we actually want. We need the fee schedule to go away from the ruck. We need to re-evaluate the fee schedule to emphasize the things we care about, like primary care management of patients with chronic illness,” Emanuel said.
Telemedicine and tech issues
The last part of the Executive Briefing focused on technology changes required to empower value-based care and move the health system forward. Emanuel said that the shift to value would catalyze the need to keep momentum going with telemedicine.
Both say there were a number of obstacles that needed to be addressed if telemedicine were to continue to have a major impact, as it has during COVID. This includes reforming the aforementioned fee schedule, as providers are already calling patients to come back in person. “Payment is higher for in person care. That goes away with alternative payment models and capitation,” said Emanuel.
Daschle also said policymakers need to permanently waive restrictions around telemedicine reimbursement and cross-state practicing and to continue work on interoperability of health technology systems. “I think it’s just embarrassing that this country has not resolved its interoperability challenges after all these years,” Daschle said. “If we’re going to address these issues, we need to address interoperability.”
What’s needed next: bipartisan support
Daschle, Emanuel and Patel agreed that policy makers and the health care industry have an opportunity to build on what exists today by enable the industry’s ongoing shift to value-based care with appropriate policy change, considering how a public option could work and leveraging technologies.
But not of that can be achieved without cross-aisle cooperation and without first addressing the COVID-19 pandemic.
“A dirty little secret in a town like Washington that we all know very well is that in order to get anything done, you work across the aisle,” Patel said. “With COVID we’ve seen that you can’t improve, you can’t re-open the economy, you can’t have confidence in America’s education system, you can’t have even the achievement of the American Dream without having that security in health care.”
Watch an on-demand recording of this Executive Briefing:
Cover image credit: Carol Highsmith/canva.com