From the coronavirus to the future of the Affordable Care Act and the Supreme Court, healthcare is front and center for voters in this week’s election. Modern Healthcare Managing Editor Matthew Weinstock spoke with Rick Pollack, president and CEO of the American Hospital Association, about what’s at stake for the industry in a lame duck session and beyond. The following is an edited transcript.
MH: There’s a lot of uncertainty in this election and we may not know the results for a little while, but what are some of the healthcare issues that you think are resonating with voters? Obviously, coronavirus is one of them.
Pollack: Certainly COVID-19 is at the very top of the list. As we’ve seen in the campaigns, certainly for one party, they want to make sure it remains at the top. Of course, for us, it’s been almost all COVID all the time, not only for our front-line heroes who are out taking care of people, but also from a public policy perspective. We’ve been so focused on relief, both in the form of financial relief and regulatory waivers; we’ve been focused on recovery—how can we be in both a state of emergency readiness that’s constant but also COVID-safe to take care of people for regular illness and injury, and how we are trying to think about what do we learn from this experience to create a better healthcare system.
So certainly COVID is on everybody’s minds. We know that it touches every single person in this country, and it’s something that affects our way of life, whether it’s as a result of a business or homeschooling or a family taking care of folks. It’s front and center. Then the second one, from a healthcare perspective, that’s gotten an awful lot of attention and we’ve seen it in the deliberations over the impact of (Justice Amy Coney) Barrett, is the Affordable Care Act and what will happen … to preexisting conditions, keeping kids on policies until they’re 26. Clearly those two are on the top of the list, and most of the polls confirm that.
MH: Staying with COVID, the AHA and other health associations sponsored a mask-up campaign. How does the politicization of masking and social distancing factor into your approach to talking about those issues?
Pollack: Our view has been we have to follow the science, we have to listen to our clinicians, we have to listen to our public health experts. There’s been no question in terms of what the advice is from those folks relative to the need to follow the guidelines, whether it’s social distancing, good hand hygiene or masking up. So regardless of the political crosswinds, we’re going down that road, we will continue to go down that road in following the science and following the public health advice. I’d add that we need to be prepared to do that as well when it comes to the vaccine.
We have to obviously work very hard to make sure there is integrity in the process of ensuring that the vaccine will be safe, but once it’s passed all of those milestones in terms of safety, there are going to be people out there who are very much opposed to vaccines and people getting vaccines. We see it already for other vaccines. Once again, we will stand with the clinicians, the scientists and public health experts, but that will be the next generation of where we have to stand tall for what’s right to do from a public health perspective.
MH: On the ACA, the Supreme Court is going to be hearing that controversial case on Nov. 10. How do you think that will resonate with voters?
Pollack: I think it’s going to be a great concern because of some of those key provisions that affect so many that could be put into jeopardy. We’ll have to see how the ruling goes, obviously, and we’ll have to see to what degree there is severability in terms of provisions that would get thrown out, and then, let’s face it, as a practical matter, if the law does go down in any significant way, it’s going to be putting Humpty Dumpty back together again to preserve what was good about the ACA, and also perhaps an opportunity to improve on the foundation that was there. (The ACA is) not all that perfect, but it was a good foundation. It extended coverage to millions of people. It put in place a series of delivery reforms that were very important.
One way or another, we’re going to have to take a good look and see where we stand (after the ruling).
Typically, the ruling won’t come out until sometime in the middle of next year, and I suspect that nobody will pull the plug (immediately if they overturn it). Our hope is that it holds together. We supported it initially. We’ve defended it twice in the Supreme Court. This is the third time. We feel, again, that it is a solid foundation on which we just need to continue to build, improve and expand, particularly on the coverage side.
MH: Are the AHA and its members starting to think about what a post-ACA world looks like?
Pollack: We know what it would look like. We know that the Medicaid expansions and the coverage things could be rolled back rather significantly. We know that coverage will suffer greatly in the absence of an ACA in place. We know, again, parents who have kids that could stay on their plans until 26, preexisting conditions—all of those things will create problems. So again, the question will be, what is the legislative remedy, if there needs to be one? If the court throws it out, we will regroup and we will pursue everything that’s necessary to make sure that those coverage provisions remain intact.
The irony of all this is that if the whole law were to go, there are a lot of things (in it) that both the Obama administration and the Trump administration have been proponents of. All of this movement toward value-based payment, there’s no daylight between the parties or the previous administration or the current administration on that.
MH: The Partnership for America’s Health Care Future, which the AHA is a part of, ran some targeted ads against the public option. What are your concerns if Joe Biden wins and the Democrats take the Senate?
Pollack: There is no question, whether it’s a Medicare buy-in or it’s a public program, that will certainly be on the table and get a lot of consideration. Our view is that we need to make the existing structures work better, and that if we could just bring back the appropriate role for enrollment with the navigators and all the support that goes with that, if we can increase the Medicaid match for the new states that come in to that, if we can increase the subsidies for people in the exchanges so that they can use the exchanges more effectively, it would negate the need for a public program or Medicare buy-in.
Our hope is that we could work with the Democrats, if there is a President Biden, work on what he says is his priority, which is to build on and improve (the ACA). If we build on and improve it, we think that it negates the need for those other types of approaches. For us, of course, it’s a question of math. The math just doesn’t add up in terms of Medicare, Medicaid paying far less than the cost of delivering services. It just adds to the cost-shift and makes the questions around financial viability just so much more difficult.
MH: Beyond that, what else is on your priority list going into next year?
Pollack: The first step is going to be a lame duck session of Congress where we’ll need to address several issues. It’s hard to determine right now what a lame duck session will look like until you know the outcome of the election, because in some respects, it could be the status quo and more of the same. On the other hand, if there is a Democratic flip in some way, particularly with the Senate, they may just do the bare minimum until they’re really in charge. Or alternatively, you can see the speaker of the House and the Senate saying, “Let’s clear the deck so that Biden has some smooth running room. Let’s get rid of the appropriations bills, let’s clear the brush so that he can start off anew.”
But for us, there are issues that need to be dealt with. They’re calendar related, which are usually the things that get done in a lame duck. So for instance, the Medicaid disproportionate-share hospital cuts that would go into effect Dec. 11 when the continuing resolution runs out. That’s got to be put back in place so that we don’t get hit with those cuts. Certainly, we want to continue the suspension of the Medicare sequester (which runs out at the end of the year). There are a couple of rules that are due to go into effect in early January, particularly around information technology. We would want an extension of the effective date for those rules kicking in, simply because we’re dealing with so many other issues relative to managing the pandemic.
Then, depending upon the political situation, and frankly, depending upon the COVID situation, a big question around COVID relief—CARES 4.0—that has kind of come to a standstill in the negotiations preelection. Will that be a postelection lame duck issue or not? If it’s not, then that certainly gets kicked into next year, and that’ll be a big issue on the agenda.
MH: And surprise billing, too, right? There’s been some talk that it might be part of a year-end bill, or certainly into next year. How worried are you about that?
Pollack: We’re worried about a bad solution to surprise billing. We think we have a good one. Our view is that patients should only be charged what their out-of-pocket exposure is. Whether they’re in-network or out-of-network, patients need to be protected from that out-of-pocket exposure, and then let us negotiate the rest with the insurance companies. The insurance companies have been very active in saying, “We want to impose a rate.” We’ve been saying, “Hey, protect the patient. Let us negotiate the rest.”