When he’s sworn in as president on Jan. 20, Joe Biden will have razor-thin majorities in the House and the Senate to try to advance his legislative agenda. He’ll also continue building out his team at HHS, which will be focused on the COVID-19 pandemic. Chip Kahn, president and CEO of the Federation of American Hospitals, which represents the for-profit side of the sector, talked with Modern Healthcare Managing Editor Matthew Weinstock about what the industry can expect during the early days of the Biden administration. The following is an edited transcript.
MH: Given everything that unfolded with the storming of the Capitol, can you put things into context? Do you think there’s going to be any sense of unity? How does Congress come out of this situation as we look toward Jan. 20?
Kahn: Frankly, the last four years with (President Donald Trump’s) leadership has been exceptional. It’s been different than any experience I had over the 40 years I’ve been in Washington, and these few days leading up to the inauguration are no exception to that exceptionalism. We’ve seen drama at a level that is completely unprecedented. So it’s really hard to say what happens in the period right after Jan. 20. I hope we return to some level of normalcy and civility in Washington, even with the razor-thin majorities in both houses of Congress.
I think there is an opportunity for legislation, and there is an opportunity for somewhat of a honeymoon, particularly for someone like Joe Biden, who has been talking about unity. But we’re going into that period over the next few days with such a different kind of environment, an environment we wouldn’t have expected, that it’s really hard to predict what’s going to happen.
MH: Where do you think there might be some common ground for the parties to work together on health policy?
Kahn: There’s a general consensus that COVID is both a health crisis and an economic crisis, and that we won’t get the economy going again at the level that we need it until COVID, the health crisis, is solved. The attention of the Trump administration to COVID has been inconsistent, at best. I think we’ll definitely get a different kind of leadership starting with the new administration. Their focus on COVID will be a good start because if nothing else got done over the last year, there was COVID legislation.
I’m a bit optimistic that we will start off the year with some kind of COVID stimulus bill that may get a lot of support. Hopefully, out of that, two things will happen. One, we’ll further our effort to deal with the crisis. And two, we’ll begin to set precedents of relationships between Republicans and Democrats and Congress and the White House that will bring about a new day of working together. Now, what the bounds of that working together are, we’re going to have to test, because the gulf between Republicans and Democrats on many, many issues remains very deep.
MH: Are there some things that you would like to see in a COVID package?
Kahn: In comparable economic crises, you saw some attention to health insurance for the newly unemployed. We have a framework in (the Affordable Care Act) that could provide an easy avenue to help protect many millions of Americans who have lost their insurance. So I think job one, beyond the testing, the vaccines, the treatment, or bringing people funds to help them survive economically, is to make sure they have health security, and we can bring them that through making sure that this ACA framework works.
MH: And you’d like to see that in a COVID bill, some sort of coverage extension or subsidy enhancement?
Kahn: I think there are a lot of different avenues they could take. They could change the rules on the exchanges and add more subsidies. They could help those who are still eligible for COBRA with subsidies. Some of these provisions were in earlier Democratic bills—the Heroes Act last year and some of the other legislation that was offered up, or at least the proposals.
MH: What about liability protection, which is a big thing for Sen. Mitch McConnell? How much do you think that’s going to play into any negotiations?
Kahn: From the standpoint of the hospital … liability protection is extremely important. This is a 1-in-100-year kind of event. Our caregivers need to be protected as we work to treat our patients. So we’re very strongly for liability protection.
I have my doubts—because this is one of those issues that sits on that divide—that we’re likely to see much progress here.
MH: Outside of COVID relief, how much do you think the Democrats will rely on budget reconciliation, which only needs 51 votes in the Senate?
Kahn: We don’t know what their strategy will be yet, how much they’ll try to do in a COVID bill, and how much they’ll try to do in budget reconciliation. They may decide to put everything in a reconciliation bill so that they can control the bill. It’ll be more of a Democratic bill. I think that will be divisive. On the other hand, if they can get to 51 in the Senate and get the 218 in the House, then they will pass Democratic legislation.
My gut is that the stimulus bill, the COVID bill, is more likely to be a bill that at least there’s an attempt to make it bipartisan, and then they’ll hold reconciliation in abeyance or in reserve if negotiations break down. There are limits to what they can legislate in reconciliation … whatever you’re doing in the legislation has to be either spending or revenue raising. After a 10-year period of the budget window, you can’t raise the deficit … it limits your flexibility. Insurance reform and other areas like that don’t fit well into a reconciliation bill because they might (deal) with private-sector rules and not with public-sector spending or revenue increases. I think taxes will be the big issue. If the Democrats decide they want to raise taxes, for whatever reason that fits into their equity agenda or their agenda to reduce the deficit, that’ll be of great difficulty, but that would have to be in reconciliation.
MH: There will be so much focus on COVID at the outset, but at what point can the Biden team pivot to some of the other things he campaigned on, maybe a light version of a public option, or changing Medicare eligibility age?
Kahn: He has the right message now and he’s going to stick with it, which is COVID, COVID, COVID. None of us know, whether by the summer or the fall of this year, that COVID will be moved aside, there’ll be sufficient vaccination that you’re going to move away from worrying about hospital crowding, you’re going to be moving away from the economic effect. Will restaurants reopen by the summer or the fall? We could go through all the aspects of the economy. Will we get to 6% growth, which we would get to if, in a sense, all of economy got going again? I don’t think he can get to big changes until we get to that point, unless they decide that they’re going to go for the gusto in a reconciliation, but I think that comes with great risk.
I brought up the taxes issue. That probably would go hand in hand with any kind of change in coverage that you described. From the provider standpoint, from the hospital standpoint, our view is that those changes, whether it be the public option or expansion of Medicare is unnecessary, would cause more problems than the coverage they would create, and that we have a framework within the existing ACA that can get us to universal coverage in a way that’s much more compatible with our private system.
MH: We’re waiting for the Supreme Court to rule on the ACA. Do you expect this Congress, early on, to try to take care of the individual mandate question so that the case in front of the Supreme Court is deemed moot?
Kahn: This will be one of those questions for whether Republicans are willing to cross some Rubicon and give up that great divide. I just don’t know how high a priority that’s going to be because … the (oral arguments) that took place a few months ago in the Supreme Court seemed to indicate that there really wasn’t much interest for most of the judges in following this sort of peculiar theory that the plaintiffs came up with to try to dismantle the ACA.
Now I could be completely wrong. In June, we could get some kind of majority for going after the entire law. But I think, at least at this point … and I think most commentators would guess, there’s a low probability. It could be resolved by simply taking the individual mandate and repealing it, and I think it’d be a great idea. I just don’t know … whether that will be something that people want to contend with, considering all the other priorities we have.
MH: We don’t have Biden’s pick yet for a CMS administrator, but in terms of what FAH members might be keeping their eyes on, are there two or three things that you’ll be watching early in the administration?
Kahn: In the (Trump) administration, there was some language on physician-owned hospitals. It was problematic regarding expansion. I’m hoping that could be walked back. I think in terms of the implementation and the specifics on transparency, that could be clarified so it really would serve the patient and not some other purpose.
Finally, in the area of Medicaid, we need to get back to principles. Medicaid needs to be used and designed to cover as many low-income people as possible. The work requirement and some of the other changes that were made through waivers, we think, are counterproductive and will only lead to narrowing rather than expanding coverage. For those low-income Americans, their link to healthcare is through Medicaid. That’s the important part of the ACA framework that we need to make sure is expanding rather than contracting.