Democratic advisers expect new (and some continued) healthcare policies under Biden

• Presumptive President-elect Joe Biden may build on the Trump administration’s initiatives in price transparency and drug cost control, say Democratic advisers.
• The new administration may push — within limits — more initiatives to address social determinants of health.
• Bipartisan policy options could include a fourth COVID-19 relief package.

A Biden administration and a potentially divided Congress face short-term COVID-19-response challenges and longer-term healthcare reform challenges that may drive both new approaches and expansions of Trump administration policies, say Democratic advisers.

“The Biden administration will not reject Trump’s work, whether it is relative to COVID-19 or whether it is relative to [the Affordable Care Act] or executive branch functions, etc., on cost containment, etc., just because it started with the Trump administration or was part of the Trump administration,” said Chris Jennings, president of Jennings Policy Strategies and a former healthcare adviser in the Obama White House.

Similarly, a Biden administration may build on Trump administration initiatives on price transparency and prescription drug cost containment.

“Execution and implementation of all these rules and regulations and potential inadvertent disruption, you will have to think through,” Jennings said in reference to price transparency initiatives. “That will be the filter by which that occurs.”

Speaking during an Alliance for Health Policy webcast, he complained that a lack of cooperation during the transition by the Trump administration may partially slow policy realignment that would take place during Biden’s administration.

The COVID-19 response will be an early priority

Rachel Nuzum, vice president of federal and state health policy for The Commonwealth Fund and a former healthcare policy staffer for Democratic senators, said the federal government will need to bolster Medicaid providers by helping states that are in pandemic-related financial distress.

“We’re hearing stories of primary care physicians and pediatricians with only a week or two weeks of capital on hand after making all the investments they had to make, in terms of PPE and taking care of their own staff,” Nuzum said.

Expansions of health insurance coverage as established in the Affordable Care Act (ACA) will need improvement as well, since the law has proved insufficient to prevent disparities in pandemic-related care for racial and ethnic minority groups, she said.

“COVID has exacerbated what we always knew was there, that we were kind of hoping expanded coverage could address — and it did in some [cases], but not all the way,” Nazum said.

More initiatives on social determinants of health could be in store

Kavita Patel, MD, a fellow at the Brookings Institution and a former Obama White House official, highlighted the potential of the Accountable Healthcare Communities model from the Center for Medicare and Medicaid Innovation, even though the CMS actuary found the program did not provide broad Medicare savings.

“Everyone has taken from the example of Accountable Healthcare Communities the concept that more explicitly measuring the [SDOH] or finding a way to incorporate that into claims data is valuable,” Patel said on a Brookings webcast. “Payers are asking for it.”

She noted that employer-sponsored insurance plans also have taken an increasing interest in integrating SDOH information in their benefits.

“So, a Biden administration is going to work to kind of pull all levers,” Patel said. “Anytime you have the opportunity to do it, you try to do it in multiple different settings.”

Widely varying payment policies between state Medicaid programs complicate the ability for providers to be paid for various SDOH approaches, she said.

“I am looking for a new Medicaid director at CMS to be a little more sophisticated” in using waivers to integrate funding streams from multiple programs to address SDOH, she said.

Challenges in implementing such approaches include “hard budgetary realities,” Patel said.

For instance, programs to address employment and housing — two of the most important social determinants — may be difficult to enact.

“It’s all good and fine when it’s Lyft vouchers to and from the clinic, but when we’re talking about incredibly either higher stakes or more dollars, it becomes harder,” Patel said.

The Biden administration could follow the lead of the Trump administration in using value-based payment models to address funding for SDOH. For instance, a Medicaid waiver for North Carolina has allowed beneficiaries to receive six months of rent payments to prevent homelessness among discharged patients, said Len Nichols a nonresident fellow of the Health Policy Center at the Urban Institute. 

“I don’t actually expect a tremendous amount more movement in allowing Medicaid dollars to be spent on housing,” said Nichols, who served in the Clinton administration.

But a Biden administration likely will continue such efforts and seek to improve coordination between federal departments to allow for wider patient benefits, he said.  

Patel also noted that hospitals and health systems will be challenged in the near term to financially support SDOH initiatives due to the steep losses inflicted by the pandemic and accompanying policy responses.

“Almost every health system I am talking to is in billion-dollar red deficits because of COVID-19 and the delay or changes in elective surgeries and other procedures,” Patel said.

Areas of common ground

Early healthcare-related efforts that could draw bipartisan congressional support, according to Clay Alspach, JD, a principal at Leavitt Partners, include:

• Allocating $150 billion in unspent Paycheck Protection Program grants
• Funding more PPE
• Providing a fourth COVID-19 relief package

“Maybe we get back to a spot where we can run the trains on time, where they can at least function,” Alspach said. “At least it would help provide certainty for a lot of stakeholders and businesses that are trying to operate. They can’t operate, especially [given] the federal government and its role in healthcare. It’s huge.”