If there’s anything that healthcare marketers can count on during the upcoming year, it’s uncertainty.

While healthcare has been front and center in Washington for a full decade now, it stands to be overshadowed by the 2020 presidential election and inevitable fallout from the impeachment hearings. Politicians know that healthcare ranks as the most important issue for American voters, yet somehow still manage to de-emphasize it amid the partisan noise.

As the calendar flips, health policy experts point to four major issues to watch — a few of them are similar to the ones that dominated the discourse in recent years. But there’s a caveat that needs to be attached to all such 2020 discussions: We’re about to experience a presidential campaign that promises to be unlike anything anyone’s ever seen.

“It’s clearly going to suck the oxygen out of anything,” says Peter Pitts, president and cofounder of the Center for Medicine in the Public Interest. “Even if there was no impeachment, you have the House controlled by one party and the Senate controlled by the other. The likelihood of passing meaningful legislation, even in the absence of impeachment trials, is practically nil during the political season.”

Presidential election years are always a strange beast. Translated: Lots of candidates and surrogates will be talking about healthcare, but the chances of meaningful change are slim.

Whether they support Medicare For All or expansion of the Affordable Care Act, the Democratic presidential hopefuls have all made healthcare proposals a centerpiece of their campaigns. Almost all of those proposals include measures that would cut drug prices, whether through allowing Medicare negotiation, legalizing the importation of drugs or some combination of the two.

President Donald Trump, for his part, has once again made drug prices a central campaign issue. He and his administration are pushing for across-the-board decreases and advocating for more stringent new measures, like tying prices to an international average. It’s worth noting that Congressional Democrats and presidential candidates are more than willing to listen to such proposals.

senator grassley
Senator Chuck Grassley (R-IA) is aggressively pushing ahead with laws and regulations around the disclosure of list prices in DTC consumer ads.

“Neither President Trump and the Republicans nor the Democrats want to go into this election without having something to talk about,” says Jon Bigelow, executive director of the Coalition for Healthcare Coalition. “They’re actually closer in their positions on drug pricing than they are on most of the issues in front of them. That increases the chances that something will be done on drug pricing.”

There’s little such common ground on health insurance. Democrats vying for the White House are proposing an overhaul that makes public insurance available to more Americans in some form. Some candidates go further than others, proposing the elimination of private health insurance completely. Those proposals, of course, are projected to cost many trillions of dollars.

However, Republicans have backed off insurance reform and will likely treat it with kid gloves through the end of 2020, predicts Anna Sinaiko, an assistant professor of health economics and policy at Harvard’s T.H. Chan School of Public Health.

“It doesn’t seem like there’s a lot of interest in moving forward with health reform from the Republicans, in part because the promise from the Republican side was to repeal and replace the Affordable Care Act and there has been no good proposal put forward about what that replacement would be,” she explains. “A lot of people in the states who have benefited from the Affordable Care Act have done so through the expansion of Medicaid. Many state governors are not interested in taking away Medicaid benefits from their constituents.”

There is still an effort moving through the courts that puts the ACA in jeopardy. A group of states challenged the ACA in court, with a Texas judge deeming the law unconstitutional. Another group of states appealed that ruling. You can probably guess where each group lands on the political spectrum.

It doesn’t seem like there’s a lot of interest in moving forward with health reform from the Republicans.
Anna Sinaiko, Harvard’s T.H. Chan School of Public Health

Whatever the appellate court decides, this case will likely head to the Supreme Court. That leaves the future of the ACA relatively uncertain heading into 2020.

As for the Food and Drug Administration, it spent much of 2019 without a permanent leader following the March resignation of Dr. Scott Gottlieb. With Dr. Stephen Hahn nominated in early November to formally replace him, many assume the agency will pick up its pace again in 2020.

That thinking could prove overly optimistic. Hahn, who has never served in government, may take some time getting up to speed. Pitts says Hahn will face “a very steep learning curve” — that is, assuming he is confirmed by the Senate.

“When Dr. Gottlieb was up for confirmation, it was all about opioids,” Pitts explains. “Senators asked about the commitments the FDA was going to make vis-à-vis opioids and that resulted in serious resources devoted to and policies developed by the FDA. This time around opioids are going to be there, as well as e-cigarettes.”

Pitts also notes that Hahn may face questions about pricing and innovation, as lawmakers consider measures to rein in high drug prices while not simultaneously de-incentivizing pharma companies to pursue new avenues of treatment. Bigelow, on the other hand, worries that a lengthy confirmation process may send the FDA into “a period of drift.”

House Speaker Nancy Pelosi, D-CA
While Speaker of the House Nancy Pelosi and the Democrats continue to pass legislation, Senate Republicans won’t be approving any bills in the near future.

“It would have potential ramifications for slower drug approvals, confusion in promotional regulation, loss of key staff — which is already happening — and difficulties in recruiting,” Bigelow explains. “The fact that the Senate is going to be tied up in budget battles and the impeachment trial and other distractions, it’s difficult to see any quick confirmation.”

The FDA will continue to grapple with its major 2019 issues in 2020. The agency has made significant progress inits regulation of e-cigarettes and vaping devices, but guidance for these products has not yet arrived and marketing applications for the devices remain under review. After proposing a ban on all flavored vapes in the fall, President Trump backtracked on the plan in November. Advisers say Trump was concerned about job losses, and polls suggested that he might have lost voters if he pressed forward on the ban.

FDA’s work around cannabidiol (CBD) should also resume anew in 2020. After holding several hearings and seeking public comment on how the agency should regulate the non-psychoactive compound in cannabis, the FDA will likely formally weigh in before 2020 concludes.

“It’s clearly on the FDA’s plate now to determine the fate of CBD through smart regulation that protects the public health and offers opportunity to those who feel it offers benefit,” Pitts says. “Now, if you ask me whether I think savvy CBD regulation is more important than moving ahead with new programs in oncology, I would say absolutely not. But politics, the media and the public are more interested in CBD than they are in new treatments for cancer.”

And still the biggest battles are almost certain to be waged over drug pricing policy. What’s overlooked is that, within the broader issue of pricing, there remain many areas of focus.

It’s clearly on the FDA’s plate now to determine the fate of CBD through smart regulation.
Peter Pitts, Center for Medicine in the Public Interest

Sinaiko, who researches consumer decision-making in healthcare, notes that healthcare costs remain a main issue of interest for voters. “When you poll Americans about healthcare and their concerns, the No. 1 concern is generally that healthcare costs can be unaffordable. It’s not only monthly premiums that people pay, but also costs that patients pay when they receive care,” Sinaiko says. “We’re seeing this among the elderly and those on Medicare, and on some middle income, commercially insured people.” 

Several polls have ranked healthcare the top issue among voters. A Kaiser Family Foundation poll found that 87% of Democrat and Democrat-leaning voters said it was very important to discuss healthcare during the presidential debates. Within that group, 28% wanted to hear about how candidates would lower costs. 

Lawmakers have obliged. Every Democratic candidate for president has unveiled a formal plan to lower drug prices. Several bills are pending in Congress, while federal agencies are working on their own approaches.

Some of the more sweeping pricing bills, like the one championed by House Speaker Nancy Pelosi, won’t come close to passing a divided Congress. But smaller, more focused bills could have a better shot.

“I don’t think any of the full plans of any of the parties, whether it be President Trump, the Democrats in the House or the Republicans in the Senate, will go through,” Bigelow predicts. “But I do think that there’s enough overlap among their positions that some measures are likely to be passed.”

Participant holding a protest sign at the rally.
It’s the one major healthcare issue Republicans and Democrats can agree on: lowering drug prices. The problem? They can’t agree on the best way to do it.

Most lawmakers can agree that drug prices are too high. Getting them to agree on a method to tame them remains the tricky part. Areas where the two parties might find common ground include the creation of an international pricing index, which the Centers for Medicare and Medicaid Services is already pursuing; a means of addressing surprise medical bills; and an increase in transparency across the drug supply chain.

“The challenge is how to reduce prices without a lot of adverse consequences,” Sinaiko says.

Keep in mind that these ideas mostly come from the minds of politicians and their staffs. The pharma industry has its own thoughts on the matter. PhRMA has proposed a range of approaches, including the implementation of value-based payments, the sharing of negotiated rebates with patients and changing how various players in the supply chain are paid.

For healthcare advertisers, some long-gestating proposals may resurface in 2020. The tax deduction for marketing spending is always an endangered species during federal budget season, Bigelow notes, but the election may intensify the focus on it. Former Vice President Joe Biden, for one, has specifically targeted the deduction in his healthcare proposal.

Laws and regulations around the disclosure of list prices in DTC consumer ads will also likely resurface, with Senators Chuck Grassley and Dick Durbin aggressively pushing forward on this front. A similar rule from the Department of Health and Human Services that was overturned by a federal judge is also working its way back through appeals.

Sinaiko says the sharing of healthcare information with consumers, like list price disclosure, doesn’t have the effect many politicians think it will. Making prices available to other healthcare stakeholders may be a more effective tactic.

“Disclosing prices is meant to help consumers make better and lower-cost choices for their care, but past experience with giving patients prices has not led to shopping behaviors like that,” she explains. “Employers and state governments could make better use of this information.”