As part of the Outlook 2021 feature package set to be published in the December print edition of MM+M, executive editor Larry Dobrow sat down with veteran D.C. hand Terry Haines, who leads the healthcare consultancy Pangaea Policy. In this Q&A, Haines outlines the policy considerations likely to dominate the D.C. conversation during 2021.

This interview has been lightly edited for length and clarity.

MM+M: At this time last year, what were some of the things that were most on your radar from a healthcare-policy perspective? Obviously there were one or two small things you might not have anticipated…

Haines: Yeah, COVID became the subtext to pretty much everything. It sucked a lot of oxygen out of the room. But since 2020 was an election year, not a lot would’ve gone on anyway.

I have been and will continue to be a bit of a broken record on prescription drugs and pricing. I thought there was more of a possibility of something happening there than most people did.

Did that play out at all over the course of the year? 

Folks talk themselves into partisanship on every issue, when in fact drug pricing reform is very bipartisan. One of the things I was really interested in during the elections was that you saw politicians from both parties in a lot of different states talk about it. In Virginia, for example, there wasn’t a top-of-the-ticket race that was close, but you had Mark Warner talking in his ads about the things he was doing around prescription drugs and pricing. That’s how much it resonated: Even in a year there wasn’t a whole lot happening, Warner felt compelled to talk about it.

How does what we saw during the election cycle – I’m going to assume we come out of it with a Biden presidency and a Republican-held Senate – color what comes next?

Well, it’s always interesting when there’s a new administration and a new political configuration. There’s a really interesting opportunity around COVID, because Washington will continue to do whatever’s necessary in order to move the economy forward. There’s not a question in my mind about whether or not there’s going to be another stimulus bill; the only question is when it comes and what it is. My view overall is that it’s going to be a $1.5-$2 trillion bill, but it won’t arrive until after the Biden inauguration.

What stands in the way?

You have to remember that we don’t really have two negotiating groups. We have five: progressive Democrats, centrist Democrats, centrist Republicans, conservative Republicans and the White House. So as it stands now, you’re not going to get anything done.

Here’s another thing. Nancy Pelosi is looking to bail out Democrat-run cities and states. I’m not faulting her for that, but the idea that in this stimulus you were going to do things not related to COVID – that’s why Republicans wouldn’t move. Substantively, they thought it was outside the bounds of a COVID bill. Politically, it was like, “What, you’re going to bail out Chicago?”

So what’s Biden’s potential first move?

You need to remember. It’s not just a decision, it’s the first decision that Biden makes as President. If he knows what he’s going to do, on COVID or whatever, two months before becoming President, I’d strongly urge him to take a seat. In two months, a lot can happen.

He has the opportunity to make the kinds of decisions with COVID that will either bring people together or drive people apart. Either he’s going to do something that’s sensitive to the virus, with the economic part and everything else, or he’s not. If he decides to do something that comes down hard on one side or the other, he’s going to lose a lot of people who’d otherwise be willing to support him.

The Advisory Committee he announced – do I feel good that these people who are advising Biden have learned something from what we saw earlier this year? One hopes a little bit more subtlety is in order, because I don’t think you want to engage in another national lockdown. Biden’s been all over the board. Sometimes it’s “I want to follow the science,” sometimes it’s “I want a lockdown.”

How does that play out over the first months of the Biden administration?

I have a visceral problem with people who say they’re going to defer to a bunch of unelected specialists. That’s not what elected officials are meant to do. They’re advised on things by their people – the key phrase is “advised by,” not “deferring to.” The jury’s out on what the Biden people might do here.

There are huge, HUGE consequences to whatever Biden decides. What he does on COVID will color the rest of his presidency. When the initial decisions of a presidency are partisan, things don’t go well for a while – just look at Obama ceding the writing of the stimulus package to Harry Reid and Nancy Pelosi. Others have had better luck when the mix was more bipartisan.

Where do you see common ground on the policy front?

Pricing of prescription drugs is quite bipartisan. Both Democrat centrists and Democrat progressives have been agitating about this for a while, and they can engage centrist Republicans. Fixing the Affordable Care Act – that’s another one that interests me. During the 2016 campaign, Mrs. Clinton stopped talking about defending the ACA and started talking about the ways it could be improved. You change the stuff that’s bad and doesn’t work.

For four years, there was no opportunity for that – but there is one now with Biden and centrist Democrats. “Look, we can certainly improve this thing and do things differently.” It can’t go away in the current political configuration, so let’s try to make it better. If Biden is serious about listening, there are some Republicans who have said they’d be open to improvements and changes.

Should I interpret that as you saying the Supreme Court won’t throw the ACA out?

I never buy the idea that the Justices telegraph themselves as much as the press thinks they do. That said, I’d put $20 on the severability arguments and that ACA survives with the individual mandate gone. Really, Republicans have wrung out pretty much everything they needed to wring out. If the mandate is gone, that’s a big part of their objection.

Here’s something I’ve always been fond of telling people. Take all the Affordable Care Act arguments and cut-and-paste the phrase “cable TV” where “healthcare” is. That’s the objection people have, that they have to do it. Or think about telephones before mobile phones came along. At their peak, 94% of Americans had regular telephones – which means 6% didn’t.

That’s the essence of the Republican argument: If you don’t want to have healthcare in this country, fine, you don’t have to have it. At root this country was founded on the right to be stupid, which means making bad choices.

Give me one under-the-radar prediction on the policy front.

I only remember about three things from law school, and one of them is to say “it depends” as much as possible (laughs). But it all goes back to COVID for me. If we end up with a vaccine soon, the pandemic phase of this thing won’t last much longer. But if COVID continues even close to where it is now, it turns into a wet blanket over a lot of the things we’re talking about here. People won’t feel like they can move forward.

If the pandemic continues for another year, it scrambles any hope of doing anything on prescription drugs and pricing. On the other hand, you can do some ACA tweaks and Republicans would certainly join with Democrats to make sure preexisting conditions continue. “Preexisting conditions” – that’s the new bogeyman, right? It’s replaced Social Security as the third rail.