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.