In the wake of an unprecedented year for healthcare, the stage has been set for a new administration to enter with a new slate of health policy goals.
With big swaths of the world still overrun by COVID-19, an improved system for vaccine rollout and public health measures to curb the pandemic will likely be Biden’s first priority upon taking office. But other health policy issues may still be on the table this year – whether or not there’s any realistic chance for anything major to be passed.
“Democratic control of the Senate opens up different if more modest opportunities for legislation to expand access and make healthcare more affordable, while narrow margins provide the political benefit of lowered expectations for big health legislation to go with it,” Drew Altman, president and CEO of the Kaiser Family Foundation, wrote in a recent post on the organization’s website. “And there is a long list of actions the President-elect can take with executive and administrative authority that cumulatively could really make a difference.”
Those actions might include restoring federal spending on navigators for the Affordable Care Act and revising Centers for Medicare and Medicaid Services guidance on making sure eligible people can enroll in Medicaid. But a more robust response to the ongoing pandemic will clearly be the Biden administration’s overarching mission.
“The key priorities upon Biden taking office will be public health measures to deal with the COVID-19 pandemic, messaging about the need for social distancing and taking it from being a political argument to being a public health message,” predicted Coalition for Healthcare Communication executive director Jon Bigelow. He added that Biden’s second priority will likely be a major economic stimulus package.
The COVID-19 response could include a renewed declaration of national emergency, as well a push to restore U.S. membership in the World Health Organization (WHO) following the Trump administration’s withdrawal in July 2020. It will almost certainly feature plans to jumpstart the vaccination process and clear up the fog of communications around availability.
Chris Sloan, an associate principal on the policy team at healthcare consultancy Avalere, said he divides potential health policy changes into two categories: regulatory and legislative.
“On the regulatory side, you’ll see the administration rolling back what the Trump administration did,” he explained. “That could be strengthening protections around benefits and pulling back flexibility that the Trump administration provided to states to apply for block grants. That’s going to be [the Biden administration’s] first task from a regulatory side, just pulling back the things the Trump administration did.”
The Affordable Care Act will come into focus this spring as well, Sloan added. It’s likely Congress will attempt to enhance the ACA to make health coverage more affordable, perhaps by increasing the income ceiling for people receiving subsidies.
“In terms of legislation, we’re not going to see big swings – there’s not going to be Medicare for All. The Democrats don’t have the votes for anything like that,” Sloan said. “But I do see a discussion about legislative coverage changes, particularly focused on the ACA.”
Other potential tweaks to the ACA could include the reversal of a 2017 change that reduced open enrollment time to only 45 days. Democrats may also try to restore federal marketplace user fees, which help fund operating expenses, after the Trump administration cut them in 2018.
“Democrats are going to be working on ACA enhancements – that is, increasing the subsidies and the generosity of coverage, and making it more affordable,” Sloan said. He added that this will likely amount to “taking the dials that were in the ACA and turning them up.”
Bigelow agreed that ACA reform is likely during 2021. “The discussion about the ACA has gone in the last two to three years from, ‘We’ve got to eliminate Obamacare,’ to being where the public strongly supports the ACA. The pandemic has shown how important it’s been, as tens of millions of people lost employment-based insurance as a result of the recession,” he explained. “Now the discussion is, ‘How do you maintain the ACA?’”
Terry Haines, founder of healthcare policy consultancy Pangea Policy, is a bit more skeptical about changes this year. He believes that the most likely outcome is small, administrative changes in regulatory bottom lines.
“There’s not going to be a lot of instant change,” he said. “People talk about ‘new administration, instant change’ – it won’t happen.” That’s mostly due to the deficit developed in the wake of COVID-19, Haines added.
Sloan agreed. “If you look at the kinds of things that might need to be done on big ticket issues – the ACA, prescription drug reform – a lot of those things have budgetary impact,” he said. “In a world where we’ve already created a deficit larger than what it was a year ago, what you’re going to get is a situation where people will say, ‘What do we want to spend our political capital on?’ They’re going to continue to spend it on COVID.”
Haines, however, stressed that drug pricing will return as a main point of discussion.
“I don’t think it is on the backburner at all,” Haines said. “There’s a huge amount of interest among the public in getting something done, COVID or no COVID. There’s a huge amount of pressure from actual citizens who think their drug prices are too high, and members of Congress want to respond to it.”
Finally, the Biden administration may attempt to close the Medicaid gap. A public health plan is far less likely to move through reconciliation to come into effect, but it’s possible that smaller changes may help expand Medicaid. One possible balm: providing ACA tax credits to people left without health coverage due to a lack of Medicaid expansion in 12 states.
So while widespread health policy reform remains unlikely, Sloan believes potential ACA reform could leverage attention in the coming year.
“ACA enhancements, tweaks and rollbacks represent the most likely chance in three or four years of getting a big legislative healthcare proposal through,” he said. “It’s not insignificant that there’s a chance for legislative change on coverage. So it is an interesting environment because there is a chance something changes legislatively, and it’s been a while since we’ve been paying attention to a legislative process in healthcare.”