Biden, Trump offer distinct healthcare agendas that leave some questions unanswered

As the fireworks displays dissipated, the muted fanfare of live-streamed party conventions left questions important to the healthcare industry unanswered heading into the presidential race’s home stretch.

Former Vice President Joe Biden and President Donald Trump undoubtedly cast drastically different visions of their healthcare agendas. Biden touted the landmark law that the Trump administration wants to strike down in its entirety. Trump offered vague bullet points as his agenda, while Democrats released a 91-page platform document.

As both campaigns shift into high gear, industry leaders will be on the lookout for more details to emerge on policy initiatives that could reshape payment, coverage and overall operations in the coming years.

The proposal that has caused the most hand-wringing for the industry is Biden’s plan for a public health insurance option. His agenda presents the public option as a solution to several healthcare policy issues, including providing coverage to low-income individuals in states that have not expanded Medicaid, and as an alternative for those with employer-based insurance coverage.

The Democratic platform outlined some key contours of the public option:

• Available on the health insurance marketplaces
• Administered by the federal government
• Open to all Americans with auto-enrollment options for low-income people who live in states that haven’t expanded Medicaid

But two important questions remain unanswered: how much providers would be paid, and whether their participation would be mandatory.

“The elephant in the room that nobody wants to talk about is that without mandating pricing and participation, we won’t have a public option that moves the needle on price,” said Billy Wynne, executive director of the Wynne Health Group’s Public Option Institute.

The Biden campaign’s website says that reimbursement will be determined by negotiations between the government plan and providers. What that pay rate ends up being is a major factor in the overall impact on health spending.

An Urban Institute analysis published in March showed that if hospitals and physicians were paid at Medicare rates, a public option available in both the employer and nongroup insurance markets could decrease total health spending by all payers by $239.5 billion, compared with $72.8 billion if hospitals were paid 60% more than Medicare rates and physicians were paid 15% more.

Whether or not healthcare providers are mandated to participate in the public option plan would be a big factor in negotiating leverage, said Kaiser Family Foundation Senior Fellow Karen Pollitz.

“If providers must participate, that is a different negotiation field than if it is up to you, take it or leave it,” she said.

The healthcare industry isn’t taking chances on final policy details and has instead chosen to flat out oppose any sort of public option policy at both the state or federal levels. Insurers, hospitals and drugmakers banded together to form a dark-money spending group that’s lobbying against the policy. Industry groups are also concerned about Biden’s proposal to begin Medicare eligibility at age 60.

“In those plans, the devil is in the details,” said the executive director of Partnership for America’s Health Care Future, Lauren Crawford Shaver.

The biggest question of all is how much political capital Biden would expend on passing a public option plan, Wynne said, given the relative popularity of more modest policies to boost the Affordable Care Act and the monumental public health and economic challenges the country will likely still be facing in 2021.

Trump, on the other hand, has unapologetically supported a lawsuit that could strike down the entirety of the ACA and has offered little insight into his plans to further shape healthcare coverage.

On Nov. 10, exactly one week after Election Day, the Supreme Court will hear oral arguments in the closely watched case challenging the ACA’s constitutionality. If the court decides to reverse the decades-old law and Congress can’t agree on how to replace it, disruption across the industry would enormous. Not only would it upend the individual insurance market, but such a decision could jeopardize many of Trump’s first-term healthcare priorities, said Georgetown University health law professor and ACA expert Katie Keith. Those include hospital and insurer price transparency, which are based on the ACA statute, and drug-pricing policies that would be piloted through an innovation center created in the ACA.

Republicans haven’t offered a comprehensive replacement plan for the ACA in case it is struck down since their failed repeal and replace efforts in 2017. Trump has repeatedly claimed a proposal for a comprehensive healthcare plan was imminent for months, but no such plan has been released, as of deadline.

Trump has also repeatedly promised to sustain protection for preexisting conditions, including making an “ironclad pledge” to Americans to continue the protections during his State of the Union address earlier this year. And in early August, he teased an executive order that would require health insurers to cover all preexisting conditions. At deadline, the order had not been published.

While the Partnership for America’s Health Care Future has so far focused its attention on opposing public option proposals and Medicare for All, Crawford Shaver said the group may get involved in the ensuing political fight if the ACA is struck down in court.

American Action Forum Healthcare Policy Director Christopher Holt said the administration likely sees the totality of the rulemaking they have proposed, executive actions and policy ideas as a comprehensive enough healthcare platform, and having a point-by-point replacement plan for the ACA likely isn’t necessary before the election.

“It’s not something that’s going to turn votes,” Holt said.

Much of Trump’s healthcare policy record was achieved through the rulemaking process, including expanding short-term, limited-duration insurance plans; attempting to cut Medicare expenses through site-neutral and 340B pay cuts; creating a framework for Medicaid block grants; and pursuing hospital price transparency.

If Trump wins re-election but Congress remains at least partly under Democratic control, he could continue to move forward with regulatory actions that allow him to circumvent Congress, but have proved to be more vulnerable in court.

Another policy issue that could be at stake for healthcare providers this fall is antitrust enforcement. 

The Democratic platform calls for retroactive review of some of the mergers and acquisitions that took place during the Trump administration, including those in the pharmaceutical and healthcare industries.

Biden says his administration would aggressively use antitrust authority to tackle market consolidation in healthcare and scrutinize future acquisitions based on impacts on labor markets, low-income communities and racial equity in addition to prices and competition.

“In regards to ability to get a deal completed, with the way they have talked about antitrust, for sure the lens the Biden administration would view market concentration with will make it significantly more difficult to get certain deals completed,” said Michael Strazzella, federal government relations practice group leader at Buchanan Ingersoll & Rooney.

However, states still have significant discretion over which deals are approved. For example, vice presidential nominee Sen. Kamala Harris (D-Calif.) had a history of cracking down on healthcare mergers during her time as California’s attorney general. Dale Webber, an attorney and chair of the healthcare section at Buchanan, Ingersoll & Rooney, said it’s important not to overlook states’ roles, and that many healthcare mergers have happened in states with Democratic attorneys general.

The Trump administration has also been tough on some healthcare mergers, and forced DaVita, Bristol-Myers Squibb and CVS to make divestitures to get their acquisition deals approved.

However, healthcare antitrust experts were disappointed with the Trump administration’s vertical merger guidelines, which were rolled out this summer. The 14-page document suggests federal regulators will generally view vertical mergers as pro-competitive, even though there’s little proof they improve competition and considerable evidence to the contrary.

The candidates also offer very different plans for combating COVID-19. 

Biden laid out a plan for how he intends to respond to the virus, including:

• Increasing access to free COVID-19 tests and drive-thru testing
• Hiring at least 100,000 contact tracers 
• Creating a national system to acquire and distribute medical supplies, more fully using the Defense Production Act 
• Instituting hazard pay for healthcare workers
• Ramping up efforts to develop, manufacture and distribute vaccines 
• Rejoining the World Health Organization 
• Urging the Occupational Safety and Health Administration to set infection-control standards 
• Reopening ACA exchanges, offering subsidies to help people stay on employer-sponsored insurance

Democrats made Trump’s handling of the pandemic a centerpiece of their convention messaging, but Republicans focused on the issue less. Instead of pursuing aggressive containment strategies, Republicans have touted hopes to deliver a vaccine on an accelerated timeline. 

In Trump’s nomination acceptance speech, he promised that his administration will “produce a vaccine before the end of the year, or maybe even sooner.” The Trump administration’s flagship effort in vaccine development has been to pursue public-private partnerships under a strategy dubbed Operation Warp Speed. The plan entails investing heavily in several promising vaccine candidates, supporting clinical trials and building manufacturing capacity.

The administration also took rapid action to reduce regulatory burdens including introducing telehealth flexibilities, allowing the easier transfer of patients to non-acute settings, allowing states to apply for Medicaid waivers, and suspending some reporting requirements. But to Democrats’ dismay, the administration declined to institute a comprehensive national testing strategy and instead left the responsibility to states.

Before the pandemic, one of voters’ top healthcare concerns was the cost of healthcare. Both Trump and Biden included two salient cost issues in their healthcare agendas: stopping surprise medical bills and lowering prescription drug prices.

The administration has a mixed record on one of its banner issues: healthcare price transparency for consumers. While its hospital price transparency rule withstood legal challenges, courts blocked an effort to force drugmakers to put drugs’ list prices in television advertisements. A final rule to require price transparency for health insurers as of early September was under review at the White House budget office.

Trump has made drug pricing a talking point throughout his presidency, and has proposed a bevy of policies, including allowing drug imports from Canada, tying drug prices to those in foreign countries, and forcing plans to pass through rebates to consumers at the point of sale. All of those policies are still pending.

Even so, Holt said Trump could make an argument to concerned voters that he at least made an effort to quell drug-price increases.

“He seems serious about it. He can say, ‘I’ve met them halfway, offered many policy ideas, and gone in some cases farther left than Democrats had before. It’s not my fault they are not passing legislation,’ ” Holt said.

Biden has proposed allowing Medicare to negotiate prescription drug prices, which on its own is unlikely to produce substantial cost savings; regulating the launch prices of drugs without competition; limiting drug-price increases to the rate of inflation; and allowing personal drug importation.

Neither candidate offered any substantive policy positions that distinguish their strategies on ending surprise medical bills. Addressing the issue in principle has wide bipartisan support, but details on how to resolve pay disputes between providers and payers have stalled legislation in Congress for more than a year.

However, there’s a glimmer of a chance for Congress to make progress on surprise billing in a lame-duck session, which could take the issue off the table for the next president.