By the time this issue reaches your mailbox, voters will have chosen the person who will lead the country as president through an unprecedented period marked by mass pandemic anxiety, economic instability and mounting federal debt. Polls show three issues will influence their choice most: how the COVID-19 pandemic has been handled, how the U.S. economy and jobs will be restored, and healthcare access and affordability.
Handling of COVID-19. The COVID-19 pandemic has drawn attention to the myriad federal, state and local public health programs that protect the public against communicable diseases and those most at-risk to its spread. Most voters think the pandemic has not been handled well, blaming politicians for inaction and mixed messages.
Economic recovery. The economy is a pocketbook issue for voters. It’s about paying bills and protecting their families. With over 40 million jobless, and the hospitality, airline, restaurant and retail industries reeling from lockdowns and social distancing, voters are attentive to policies they believe will be most likely to restore economic growth and secure their paychecks.
Healthcare system access and affordability. During the pandemic, the industry’s drug, device and health insurance sectors have fared well while hospitals, dentists, medical specialists and nursing homes have been hurt. But for most voters, healthcare is not about sector sustainability; it’s about the physicians and hospitals they use, the drugs they take, the insurance they have, and their out-of-pocket costs required to access all of these. Healthcare affordability and access are major concerns for voters.
These issues are closely related; the role, scope and funding for the U.S. healthcare system is the common thread. President Donald Trump revealed his health plan in August; former Vice President Joe Biden disclosed his plan in early 2020 during the Democratic primary contests.
Comparing the Trump and Biden Health Policy Plans
Core Principles
The Trump administration believes the healthcare system in the United States is fundamentally good but hampered by regulatory overreach and lack of adequate competition that lend to excessive, unnecessary spending. Trump maintains that the Affordable Care Act is a flawed framework for addressing the healthcare system’s shortcomings and that it must be repealed and replaced.
Conversely, Biden believes that healthcare is a universal right for U.S. citizens and is protected by the U.S. Constitution. Biden views the ACA as a suitable foundation on which to enhance access, quality and affordability of the U.S. health system, and he plans to build on it.
Key Policies
The Trump administration has not released a detailed plan, opting instead to advance its healthcare agenda around key themes:
- Deregulation of rules and barriers, which will reduce administrative costs, boost innovation and encourage private sector participation in the system.
- Expansion of state autonomy in managing healthcare issues like scope of practice limitations for licensed professionals, medical liability, abortion, Medicaid eligibility, insurance plan solvency and more. Providing block grants to states for their Medicaid programs is key to limiting the program’s costs.
- Increased transparency about prices, costs, outcomes, user experiences, profitability, business relationships and conflicts of interest across every sector with drug and hospital prices the primary focus.
- Expansion and acceleration of alternative payment models that replace or eliminate fee-for-service payments to providers with value-based models that require providers to assume financial risk.
- Affirmation that control of the system will be returned to physicians and patients.
Trump has executed his plan through a series of executive orders and policy changes announced by the Centers for Medicare & Medicaid Services, the U.S. Department of Health and Human Services and the U.S. Department of Veterans Affairs. In addition, the Trump administration has pursued dismantling of the ACA through court challenges and has successfully eliminated its individual mandate as part of the Tax Cut and Jobs Act passed in 2017. The president’s administration has pledged to continue these efforts in a second term. President Trump has made 2020 campaign pledges to lower drug prices, end surprise medical billing and protect consumers with preexisting conditions from denials by health insurance companies (although insurer premiums would not be capped).
Biden’s proposed policies have been made available in great detail by his campaign and center around six themes:
- Increased access to health insurance coverage through Medicaid expansion (eligibility would extend to 138% of the federal poverty level), subsidies to purchase private insurance and a new “Medicare-like public option” for eligible low-income Americans with a goal of achieving 97% coverage by 2024.
- Lowering the Medicare eligibility age to 60 from 65 to increase access to care.
- Elimination of the 400% of federal poverty level income cap for tax credit eligibility and lowering employees’ maximum contribution for coverage. No individual would be required to pay more than 8.5% of their income toward health insurance premiums.
- Elimination of “surprise billing” by providers who bill patients at out-of-network rates.
- Allowing Medicare to negotiate lower prices with drug manufacturers to lower drug costs.
- Expansion of community health centers to increase access to primary care services among underserved populations, including undocumented immigrants.
In the Biden health policy framework, equity, diversity and affordability are core tenets. The net result is a bigger role for the federal government in expanding health insurance coverage and access to health providers. He describes the plan as “ACA 2.0.”
Funding
The Trump administration anticipates government spending for healthcare will remain at current levels (2.6% annual increase), although spending for Medicare is forecast to increase 7%, threatening the solvency. Its underlying assumption is that economic recovery (3–4% annual gross domestic product growth) and its price transparency policies will drive costs lower.
Biden’s health plan would add $750 billion to current spending over
the next 10 years. It would be funded by eliminating tax cuts and closing capital gains “loopholes” implemented by the Trump administration.
What to Watch After the Election
Regardless of who is in the White House come Jan. 20, the watchlist for the industry includes three major events and initiatives that will frame the next administration’s actions through 2024:
- The Supreme Court ruling on Texas v. Azar, which would essentially invalidate the ACA.
- COVID-19 vaccine and drug development.
- Federal debt and economic recovery. The combined impact of annual operating deficits, tax cuts, pandemic relief funds and economic stagnation have added $5 trillion to the federal deficit in the last two years. The Congressional Budget Office estimates the federal deficit will be $3.7 trillion for fiscal year 2020, bringing total federal debt to 101% of the country’s GDP.
Presidential politics is a high-stakes game. A candidate’s position on healthcare issues is often the difference in winning and losing. As the pandemic illustrates, the performance of the entire health system is vital to our country’s sustainability, and the result of this election will have a profound impact on every stakeholder in the system.
Paul H. Keckley, PhD, is managing editor of The Keckley Report (pkeckley@paulkeckley.com).