With the presidential election three weeks away, healthcare policy experts are weighing how the industry would be affected if the White House were to change hands from President Donald Trump to former Vice President Joe Biden.
While a Trump win would obviously remain on a similar course for the next four years, experts say key issues a Biden administration would likely try to change range from policies on coverage to value-based care and the age for Medicare eligibility.
Here's a look at three ways healthcare could change after the presidential election:
1. Push for more coverage
No matter who wins, the next president will need to confront mounting job losses due to the COVID-19 pandemic that have had a direct impact on health coverage, experts say.
An analysis from the Commonwealth Fund estimates as many as 14 million Americans could lose their health insurance due to job losses or because they are dependents of someone who holds an employer-sponsored plan.
The lingering financial crisis will prompt a major emphasis on expanding insurance coverage to offset the millions of people who could lose their employer-sponsored insurance, some experts said. “For health industry leaders, providers and payers, coverage has to be on their mind more acutely because of the pandemic,” Ben Isgur, head of PwC’s Health Research Institute, told Fierce Healthcare.
Biden's campaign has proposed the creation of a public insurance option similar to Medicare for customers on the individual market. But a public option would require an act of Congress.
It remains unclear whether there would be enough support in Congress to get a public option approved, even if Democrats retake the Senate in November. The Obama administration tried to add a public option to the Affordable Care Act (ACA). However, while the House passed a version of the ACA with a public option, it wasn't able to get enough support in the Senate.
The same scenario could occur this time around if strident Republican opposition to a public option holds firm.
But prospects for a public option could greatly improve if Democrats gain control of the Senate next year and decide to eliminate the legislative filibuster. Some Senate Democrats have threatened the move after Senate Republicans took up the nomination of Judge Amy Coney Barrett six weeks before the election to replace Justice Ruth Bader Ginsburg, who died late last month.
If Biden were to win, it's also expected he would employ a series of moves to shore up the ACA's insurance exchanges. The administration could also pursue a change in eligibility for the subsidies to ensure more people qualify for income-based tax credits that lower the cost of premiums, Isgur said. They could also fully fund marketing of the exchanges after cuts from the Trump administration.
The moves would be a stark departure from the Trump administration, which has supported lawsuits and legislation challenging key elements of the ACA. Trump has previously said he'll release a comprehensive replacement plan but has not unveiled anything as of yet.
In December 2019, a federal district court in Texas ruled the landmark healthcare law's individual mandate is unconstitutional but punted on the question of whether that mandate can be excised from the remainder of the law.
A collection of blue states appealed the decision to the Supreme Court, which will hold oral arguments on the case on Nov. 10. A decision by the court is expected in June at the earliest.
Early on, the administration cut funding to ACA marketing by 90% when it took office and also cut funding by $26 million to the ACA’s navigators, which assist consumers in picking plans. Enrollment in the ACA's exchanges has remained relatively stable despite those cuts, and private insurers who retreated from the exchanges a few years ago due to financial losses have started to return and offer plans.
However, enrollment among the population that doesn't get income-based tax credits has plummeted.
Isgur said a Biden administration could do research into why the unsubsidized population has dropped so steadily.
The administration could look into whether there is a "larger structural issue where there is a gap where people who work for larger employers and people who may be self-employed and trying to understand what kinds of strategic changes to be made," he said.
2. The push for value-based care
The transition from Medicare fee-for-service to value-based care generally has bipartisan support. Several experts say that will likely continue no matter who occupies the White House.
“I think the push to value-based care has been very consistent around the Obama administration and to the Trump administration,” said Dan Mendelson, founder of consulting firm Avalere Health. “It is largely a nonpolitical agenda.”
But the speed of this transition to value-based care could vary greatly depending on whether Biden defeats Trump.
Centers for Medicare & Medicaid Services Administrator Seema Verma has said in several speeches recently that the agency wants future value-based care models to require providers to take on more financial risk. One recent example is the Pathways to Success program that requires accountable care organizations to take on more financial risk. The administration's latest model, called Direct Contracting, also calls on primary care physicians to take on risk.
“The Trump administration has been pretty aggressive with regard to risk,” said Lisa Hawke, an attorney with Holland & Knight and a member of the firm’s healthcare team during its virtual event in early October. “Whether we will see some dialing back of that in a Biden administration, [I am] not sure. But it is certainly possible.”
The Biden administration could also place a major emphasis on lowering racial disparities, especially in the wake of social injustice protests that occurred this summer.
“There is a lot of interest on closing racial disparities that are definitional in terms of value,” Mendelson said.
Biden's health plan includes several proposals aimed at closing gaps in healthcare among racial groups, including boosting funding to community health centers.
"In 2015, 59% of patients at community health centers were people of color and one quarter were uninsured," the campaign said. "The Biden Plan will double the federal investment in these centers, expanding access to high quality health care for the populations that need it most."
Mendelson said one move the administration could make is to pay provides more for taking an active role in addressing racial disparities. The Biden administration could also include more accountability and appeals mechanisms in Medicare Advantage to give people more chances to appeal coverage decisions.
The Trump administration has yet to issue a report on how it plans to combat racial disparities in healthcare despite requests from Democratic lawmakers like Sen. Elizabeth Warren, D-Massachusetts, for such a plan.
3. Lowering the Medicare age
One of the goals of Biden’s plan is to lower the age that seniors become eligible for Medicare from 65 to 60.
If Biden succeeds, which would require an act of Congress, it could greatly expand the populations of beneficiaries eligible for both Medicare and Medicaid. “For providers, you would have a number of folks leave their commercial plan at age 60 and join Medicare if it is financially more attractive,” Hawke said during the recent webinar.
Medicare traditionally pays much lower rates than commercial plans. Whether this change would adversely affect a provider will depend on their payer mix.
“If you have a heavy commercial payer mix between 60 and 65, that could be a loss to you,” Hawke said.
But if a provider serves a high number of uninsured or is a safety net hospital, then “coverage for some of the uninsured that you have right now might look rather attractive,” she added.
The Trump administration, on the other hand, has not endorsed the move and instead focused on several moves to lower drug prices for Medicare beneficiaries. The administration is exploring regulatory moves to tie drug prices to the average prices paid by countries overseas.
To be sure, any change to the Medicare eligibility age would require an act of Congress and would likely not engender much Republican support. Republicans generally point to reducing spending in Medicare to help rein in government spending.
However, the change could occur if Senate Democrats get control of the chamber and decide to jettison the legislative filibuster that requires 60 votes to remove any barriers to legislation.