Trump and the Republicans vs. Biden and the Democrats on Healthcare

October 30, 2020
Joseph Burns
Joseph Burns

Here's what healthcare executives can expect depending who wins next week's election.

It’s difficult to imagine how the nation’s two political parties could be further apart on health care. With voters going to the polls early in record numbers and Election Day next week looming large in the country’s collective consciousness, it seems there is little, if any, agreement between the Democrats and Republicans on healthcare issues. The division has been widened by the COVID-19 pandemic, with President Trump saying the country is “rounding the corner” with respect to the pandemic and Democratic candidate, Joe Biden, calling for national mask mandate.

Republicans v. Democrats on the ACA, health insurance

The Democrats who have a list of what they see as the solutions to the healthcare problems that many Americans face as the cost of care rises and the economy wobbles because of the pandemic. Increasing unemployment has meant more Americans (perhaps as many as 12 million according to some estimates) have lost their employer-sponsored health insurance and the Democrats want to provide them with coverage. The Democrats would prefer to provide coverage under the ACA, which was signed into law in 2010 with the major provisions going into effect in 2014. They could do so through Medicaid — at least in the 38 states (and Washington, D.C.) that chosen to expand the state-and-federal health care program under the ACA. In addition, some progressive Democrats favor a sweeping Medicare-for-all, single-payer system. The centrists in the party, including presidential candidate Joe Biden, favor modifying the ACA. Biden has proposing increasing subsidies for people buying coverage on the ACA exchanges and allowing people to enroll in Medicare starting at age 60.

President Donald Trump and Republicans want to repeal the ACA. The administration supports the 20 states that filed a lawsuit arguing that the ACA is unconstitutional because the individual mandate provision was eliminated. The U.S. Supreme Court is scheduled to hear oral arguments in that case, Texas v. California, on Nov. 10.

In place of the ACA, which sets requirements on what health plans must cover, the Trump administration and the Republicans have promoted short-term, limited-duration (STLD) health plans and association health plans. The premiums for these plans are lower than plans that comply with the ACA, but they are limited in the services that they cover.

On its website, the campaign to re-elect President Donald J. Trump touts such accomplishments as expanding access to Association Health Plans (AHPs) to allow small business to pool risk across states and for allowing STLD plans to be extended for as long as 364 days for consumers seeking lower premiums and less robust coverage.

Under the Tax Cuts and Jobs Act of 2019, the Trump administration repealed the individual mandate that had been part of the ACA. On its website, the Trump campaign says the mandate forced consumers to buy expensive insurance. The website also mentions that the president signed a six-year extension of the Children’s Health Insurance Program to pay for health insurance for 9 million children.

Controlling drug prices top issue for Republicans

Controlling drug prices is a top health care priority of the Trump administration, says James C.

Capretta, a resident fellow and the Milton Friedman Chair at the right-leaning think tank, the American Enterprise Institute. “In the healthcare sphere, drug pricing would be number one,” he said. “Then other issues, such as price transparency and health reimbursement accounts, would follow behind that.

If Trump wins re-election and the Republicans control at least the U.S. Senate, then it’s safe to say that past will be prologue for 2021 if not longer, Capretta observes.

“The agenda for Republicans is almost certainly going to remain as it has been since 2017,” he notes. “By that I mean there will be a focus on administrative action related to loosening regulations.”

If there is a second Trump administration, executive orders and administrative changes are likely to be the main tools of its healthcare policies because Democrats are expected to retain control of the U.S. House of Representatives regardless of how the presidential vote turns out — and whether the Republicans keep their current 53-47 hold on the Senate.

“It’s possible that there could be some legislation in a second Trump term around drug pricing, but it’s more likely that the president and his team would push something around an international drug-price index,” Capretta says. During the second half of this year, Trump has signed a flurry of executive orders that would, among several things, tie prices that CMS pays for certain Medicare Part B and D drug to the lowest price paid by a comparable country. Trump has also signed executive orders that would facilitate the importation of drugs by individuals.

“The idea of any kind of Trump legislative initiatives making it through the Congress seems quite remote,” Capretta continues. “Moreover, I don't think they have a legislative health agenda that they would be ready and wanting to push as a priority.”

Among the administrative and regulatory changes they are likely to pursue is price transparency initiatives that HHS proposed in 2018 for hospitals and health insurers. “This is a huge priority for the administration,” he said. That means the Republicans will press for even more disclosures on price and ways to make price transparency useful for consumers.

In addition, the administration is likely to push for wider use of health reimbursement arrangements (HRAs) by promoting them hat as an option for consumers buying health insurance in the individual market and encourage that employers promote HRAs to their workers as a way to cut health care costs, Capretta suggested.

Expanding healthcare insurance coverage top issue for Democrats

While Trump and the Republicans will focus on drug prices and cost control, the Democrats will call for more health insurance coverage for those who are uninsured, including those who have lost their employer-sponsored insurance, says Daniel Mendelson, the founder of the health care consulting firm Avalere Health.

Healthcare is almost always a top priority for Democrats, and healthcare and COVID-19 are together because virtually all Democrats want to get the pandemic under control, Mendelson said.

When the pandemic took off this spring, most of infections and serious cases and deaths were in blue states, including Washington State, which is where the first outbreak occurred, California and New York where the most deaths occurred. But the pandemic started to affect red states this summer and fall. This week, the CDC is reporting that North and South Dakota, Montana, Arkansas and Tennessee are experiencing the highest rate of deaths per 100,000 population.

"As a result, it has changed from being a blue-state issue to being one that all of us share collectively,’ says Mendelson.

What that means, in Mendelson’s opinion, is that the government’s role in healthcare is likely to increase.

Layoffs and the loss of employer-sponsored health insurance will create an urgency for a public option, Mediare for all, or both, says Mendelson.

“Even before the recession, Medicare and Medicaid and then after the recession started, even more people became eligible for Medicaid,” he reported.

“Interestingly, the states are expanding Medicaid through ballot initiatives, and some of those initiatives have succeeded because voters in those states are concerned about the issues around uninsurance and the high cost of health care,” he noted.

Mendelson also noted that more seniors choosing to sign up for Medicare Advantage plans rather than traditional Medicare because they want more control over their health care expenses.

“Those two trends mean that the government role in health care is growing and health plans are very attentive to these trends,” Mendelson explained. “That’s one of the reasons they are focused on having great relationships with the state governments and with the federal government.”

For all these reasons, Democrats are likely to work to expand health insurance for more Americans, he predicted.

“If Biden wins, Democrats will want to expand coverage options through the channels that are in place now, such as Medicare, Medicaid, and the health insurance exchanges,” he said. “They are not likely to try to create massive new government programs or to put everybody into Medicare.”