Wednesday, November 11, 2020

President-elect Biden wants to make health care better, but it won’t come easy

 When ACP released its Vision for a Better US Health Care System in January, we could not have anticipated that a global pandemic would soon reach our country, and 10 months later, be responsible for deaths of more than 240,000 Americans, many millions more being sickened, and hospital beds and clinical staff again in short supply because of another dangerous surge in cases.

But it turns out that ACP’s vision was prescient in identifying fundamental deficiencies in US health that have worsened the toll from COVID-19.  Losing your insurance because you lost your job.  Living in a state that has not expanded Medicaid.  Being faced with high deductibles and excessive prices even if insured. Discrimination and racism that contributes to poor health. Living in communities that are underserved, neglected, and poor.  A failure by the US to invest and support public health and primary care.  These are all risk factors for getting sick and dying from COVID-19, just like being old and having chronic conditions like diabetes and heart disease. 

You might even say that the United States itself has multiple chronic diseases of its health care system, making it far more vulnerable to COVID-19 than many other countries.

While many issues influenced how Americans cast their votes on November 3, the performance of President Trump and his administration on COVID-19 certainly was one of them. By electing Joseph R. Biden as the next president, and Kamala D. Harris as the next Vice President, voters elected the candidates who promised a major shift in how the US government addresses health care. Voters may have hedged their bets, though, by maintaining GOP control of the Senate, depending on the outcome of two special elections in Georgia.  Democrats have to win both Senate seats up for grab in Georgia on January 5 to split the Senate 50-50, with Vice President Harris being available to cast tie-breaking votes. Should the Republican candidate win either or both, Senator Mitch McConnell (R-KY) will remain the Senate’s Majority Leader and be able to impede much of a Biden administration’s legislative agenda.  The filibuster will still require 60 Senate votes on most legislation. The House of Representatives will remain under Democratic control, but with a smaller majority.

The Biden transition website, Build Back Better, lists COVID-19, racial equity, and climate change, and economic recovery, as the top 4 initial priorities for the new administration. Getting Congress to enact legislation to advance policies in these and other areas will be difficult.  Still, there is a lot a Biden administration can do to make health care better, even without Congress:

COVID-19: President-elect Biden already is charting a different course on COVID-19 than President Trump, announcing a COVID-19 Task Force composed of physicians and other health experts, co-chaired by former Surgeon General and ACP member Vivek Murthy.  He is expected to seek a national mandate to wear masks, using the administration’s regulatory authorities to require it in federal facilities and contractors and in public transportation, while seeking support from the states’ governors for a broader mandate.  He pledges to have science and scientists lead the public health response, rejoin the World Health Organization as recommended by ACP, address lack of supply of personal protective equipment, and expand testing and tracing.

Coverage and cost:   A Biden administration can use its executive authority to expand coverage under the ACA, in ways recommended by ACP in its New Vision papers and other policy statements. It can begin to reverse Trump administration rules that allow sale of plans that do not cover the 10 categories of essential benefits required of other ACA-compliant plans. It can increase funding and support for ACA outreach and enrollment and stop states from imposing work requirements as a condition for Medicaid coverage. 

President-elect Biden’s more ambitious plans to move the country closer to universal coverage will face an uphill battle. Congress would need to enact legislation to expand Medicare to persons aged 50 through 64, create a public option available to everyone, automatically enroll people in non-Medicaid expansion states in the public option, and lift the income caps on federal subsidies to buy health insurance coverage.  Of these, lifting the income caps might be more likely to command bipartisan support, because it would extend subsidies to people with incomes over 400% of the Federal Poverty Level, many of whom have been priced out of coverage.  A Biden administration will seek to rein in prescription drug prices, but Congress is unlikely to allow the federal government to negotiate Medicare Rx prices, or eliminate the tax deductibility for direct-to-consumer advertising.

Immigration: As President Trump has shown, presidents have a lot of power to shape immigration policy, without needing to go through Congress, and the courts generally defer to the executive branch.  The Biden administration will begin reversing immigration policies that have an adverse impact on health, one of ACP’s top priorities.  President-elect Biden has promised that on the first day of his administration, he will terminate the Trump administration’s ban on travel from 7 majority-Muslim countries, restore the DACA program to protect “Dreamers” from deportation, end the practice of separating children from their parents at the border, and appoint a federal task force to re-unite immigrant children who were separated—all actions strongly supported by ACP.

The new administration can take action to address the backlog in visas for international medical graduates (IMGs) seeking permanent residency status, and to ensure the effective and efficient processing of visas for IMGs seeking to enter the United States.  It can also begin the process of reversing the public charge rule, which denies residency to legal immigrants if they are likely to use public programs like Medicaid, which ACP has said is a major barrier to legal immigrants getting the health care they need.

Women and LGBQT health: The Biden administration is expected to begin to reverse restrictions on federal funding for Planned Parenthood and on physicians who counsel women on abortion or provide abortion services themselves—as called for by ACP.  It may seek to expand the ACA’s essential benefit requirements to ensure coverage for the full range of women’s health, and roll back so-called employer conscience exemptions that allow them to exclude contraception from coverage, although a Supreme Court decision may stand in their way.  President-elect Biden pledged to codify Roe v. Wade into federal law, as a hedge against future Supreme Court decisions to overturn or curtail the constitutional right to abortion; this though would require that such legislation pass both the House and Senate, which is very unlikely.  Similarly, the Senate would likely reject his call for Congress to end the Hyde rule, with prohibits federal funding for abortion.  As ACP and other organizations representing frontline physicians have advocated, the new administration is expected to reverse federal regulations and executive actions that weaken protections for LGBQT persons

Climate change: As called for by ACP, President-elect Biden has promised to rejoin the Paris Accord on the first day of his administration, which would recommit the United States to specified targets for reducing carbon emissions.  He can begin the process of reversing Trump administration regulations that eased restrictions on carbon emissions and opened up more federal lands to drilling for oil.  His more ambitious plans to promote green technologies and achieve a carbon-free power sector by 2035 likely will be stymied by the Senate, although the new administration can be aggressive in using its executive authority to achieve as much of this agenda as it can. 

Racism and health:  There are many things a Biden administration can do to address racism, discrimination, and related health disparities, only some of which require legislation from Congress.  It can reverse a Trump administration Executive Order that prohibits implicit bias training for federal employees and contractors as called for by ACP and AAMC, redirect federal funding and priorities to addressing social drivers of health, prioritize persons that are at the greatest risk of COVID-19 because of where they live and their race or ethnicity, have the Department of Justice address inequities in sentencing and legal representation particularly for capital offenses, and seek bipartisan solutions to system racism in law enforcement, although much of the latter likely will require legislation at the state and federal levels.   As important as specific policies are, President Biden and Vice President Harris can speak to the need for the United States to extend justice, fairness, diversity, equity, and inclusion to all and support Black Lives Matter, rather than seeking to undermine such goals. ACP welcomes the opportunity to advocate for policies to address the impact of racism and discrimination on health care.

Rolling back regulations that have been finalized by the previous administration won’t happen overnight, since by law they have to go through an entirely new round of agency rulemaking with public comment; many could remain in effect in the meantime.  The Biden team, to be sure, will be exploring ways to halt, delay or modify implementation of rules it seeks to reverse or modify, as quickly as possible.  Executive orders that have not been finalized as regulations likely can be reversed with the stroke of a pen of the new president, and new policy directions for federal agencies can be created by new Biden executive orders.

There are initiatives from the Trump administration that ACP will urge the Biden administration to continue, or even expand, including implementing higher Medicare payments for office visits, putting patients over paperwork, easing documentation and reporting requirements, and expanding coverage and payment for telehealth visits and phone calls.

In Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians, we wrote that “U.S. health care costs too much; leaves too many behind without affordable coverage; creates incentives that are misaligned with patients' interests; undervalues primary care and public health; spends too much on administration at the expense of patient care; fails to invest and support public health approaches to reduce preventable injuries, deaths, diseases, and suffering; and fosters barriers to care for and discrimination against vulnerable individuals.”  [Disclosure, I was the lead author for this Call to Action].  COVID-19 has shown us how true this is.  President-elect Biden now has the opportunity to advance polices to make health care better, and ACP stands ready to assist him, no matter how difficult it may seem.