Marc Samuels, J.D., M.P.H., is the CEO of ADVI, a strategic advisory services lifesciences firm in Washington, D.C., and a member of the 

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With the 2020 election season nearly behind us, conventional wisdom is that we will have divided government: a Democratic president, a Republican Senate and a razor-thin Democratic majority in the U.S. House of Representatives. That combination is a recipe for compromise on President-elect Joe Biden’s healthcare priorities; namely, the federal response to the COVID-19 pandemic and adjustments to the ACA.

The president-elect’s first priority is COVID, COVID, COVID. The COVID-19 task force that Biden created includes well-regarded former officials from the FDA and HHS. It seeks to promote national mask wearing and mandatory social distancing and to deploy a “textbook” public health approach to contact tracing and testing — a nationwide pandemic dashboard to display transmission rates of the virus in regions across the country. But Biden has stressed that lockdowns are not part of his plan.

As far as the ACA is concerned, the goal of the president-elect is to expand the law’s coverage provisions. Biden’s proposals would, by various means, expand coverage to include those who are out of work, those who are caught in the gap between Medicaid eligibility and qualifying for ACA subsidies, and those who have been systemically uninsured and uninsurable.

While there is potential for congressional compromise on Biden’s plans for COVID-19 and the ACA, the president-elect’s other policy proposals will meet swift and sure opposition in Congress, both from Republicans in the Senate and deficit hawks in the House. Legislation creating a “public option” will be difficult to pass, even though from the Democrats’ point of view the public option is a moderate plan and, politically, a way to deflect for the progressive wing of the party’s Medicare-for-all agenda. Biden’s proposal to tie ACA subsidies to the cost of more generous gold plans, as opposed to silver plans under the current law, also looks to be too big of a political lift. The policies could cost taxpayers upward of $750 billion and $200 billion over 10 years, respectively. Biden also proposed to lower the age of Medicare eligibility to 60 and to raise the income limits for ACA subsidy eligibility. They are also on the unlikely side of the political possibility spectrum.

The new administration figures to be aggressive about Medicaid expansion. Getting legislation passed is unlikely if the Republicans stay in control of the Senate. But Biden could use regulatory levers and financial incentives to move the dozen holdout states into the Medicaid expansion column. The president-elect has also indicated he’d take a hard line against approving new Medicaid work rules, which President Donald Trump’s administration deployed in numerous states for the first time in the program’s history. Formal requests from several states are still pending, and it’s unclear whether the Trump administration will finalize those waivers before departing in January. It’s also likely that incoming leadership at CMS will take a closer look at the work rules that have been approved and elect to rescind the regulations.

Drug pricing looks to be another area of contention. Biden has proposed allowing Medicare (and possibly Medicaid) to negotiate prices with drug manufacturers. House Democrats have passed and support such negotiations and reference pricing, which ties the price of physician-administered medications, and possibly other drugs, to prices paid in other countries.

Trump used executive orders to advance his health agenda with mixed rules. Biden’s goals are different, but the Democrat will also be using executive orders as a means to his ends. Biden’s orders may include demonstration authority to expand coverage and control costs, executive action to roll back restrictive policies in the Medicaid program and reinstatement of anti-discrimination protections for the LGBTQ community.

At the end of the day, these are best guesses based upon Biden campaign promises, conversations with people close to the campaign and transition, and historical beliefs of each party. The only thing we know for certain is that a new Congress will be installed on January. 3, and Biden’s inauguration will take place on January. 20.

Marc Samuels is CEO of ADVI, a strategic advisory services firm in Washington, D.C., that focuses on life sciences. He is a member of the 

Articles

With the 2020 election season nearly behind us, conventional wisdom is that we will have divided government: a Democratic president, a Republican Senate and a razor-thin Democratic majority in the U.S. House of Representatives. That combination is a recipe for compromise on President-elect Joe Biden’s healthcare priorities; namely, the federal response to the COVID-19 pandemic and adjustments to the ACA. 


Opinion: A Biden win, a Republican Senate and a slim Democratic majority in the House: That’s a recipe for compromise.

No matter who wins, the result will be divisive and impactful to the healthcare of millions of Americans, including those on commercial insurance. 

If elected, it is likely that a Biden presidency would lead to immediate expansion of health insurance coverage for Americans impacted by the COVID-19 pandemic, specifically those who are out of work, caught between Medicaid expansion and the ACA-eligibility (i.e., individuals over 26 who cannot remain on their parents’ coverage), and those who have been systemically uninsured and uninsurable. While “Medicare For All” may be a goal of a potential Biden administration, at minimum a public option is doable and would allow Biden supporters, such as union members, to keep their Cadillac plans. Similarly, this may appeal to rural parts of America. 

Biden has also promised to lower the Medicare age to 60 and allowing or mandating Medicaid coverage in the states that have not yet expanded their programs.

As has been seen during Trump’s first term, drug pricing is likely to be of paramount concern in a Biden administration. The Biden plan might allow Medicare (and possibly Medicaid) to negotiate with drug manufacturers on the prices of most prescription drugs and allow commercial payers to use these prices as a reference. House Democrats have passed and support such negotiations and reference pricing, so the price of physician-administered and possibly retail drugs would be equivalent to the prices paid in other countries.

What has been discussed infrequently is the notion that lower drug prices alone are not enough and that to achieve real savings a Biden CMS would need to curtail coverage, target drug inflation, and impose utilization management and other payer tools on federal healthcare programs.

If Biden wins but the Republicans keep control of the Senate, expect the same flurry of executive actions that Trump has used to be Biden’s tool of choice. Such actions may include but wouldn’t be limited to demonstration authority to expand coverage and control costs; executive action to roll back restrictive policies in the Medicaid program; and reinstatement of anti-discrimination protections for the LGBTQ community.

A second term for President Trump would center around what the President tried and failed to do even with a Republican majority: repeal and replace ACA, to the extent possible, through administrative action.

In Trump’s view, this action is necessary to provide Americans with more and better coverage choices that are less expensive. Such choices would be consumer-centric and allow for additional flexibility – for consumers, states, and the federal government. Unlike the Biden vision, Trump’s plan would be decentralized and tailored to the individual, not a federal, one-size-fits-all mandate.

Trump’s focus would remain on the consumer, which has been his stated priority since the beginning of his current term because he wants consumers to have more choices.

Similarly, Trump wants to eliminate federal mandates that increase the cost of health insurance across government programs. This is likely to mean additional private-sector options for health care coverage and affording states more power to manage their populations as they see fit including the Medicaid program, which is jointly funded by the states and the federal government.

Trump would balance better value, with lower prices, and more choice. He would continue to drive for value-based arrangements and other demonstration opportunities with the hopes of reduced costs like the Oncology Care Model and a model for curbing the costs of radiation treatments and imaging. 

During his second term, Trump would proceed with the implementation of his executive orders related to cutting the price of physician-administered and retail pharmacy drugs. He would also impose a similar reference pricing construct as Biden and the Democrats, using the cost of drugs in other countries as a ceiling. Finally, he and the Democrats would agree on other initiatives around drug pricing such as an inflationary cap and increased utilization management.

Marc Samuels, J.D., M.P.H., is the CEO of ADVI, a strategic advisory services lifesciences firm in Washington, D.C. He recently joined the 

A Biden presidency will mean the immediate expansion of health insurance coverage and perhaps a public option. A second term for President Trump would mean renewed efforts to repeal and replace the ACA and emphasis on consumer choice. 

Marc Samuels

Articles

Opinion: A Biden win, a Republican Senate and a slim Democratic majority in the House: That’s a recipe for compromise.

No Matter Who Wins, the Presidential Election Will Change Healthcare. Here’s How