At the beginning of President Biden's term, Advisory Board posed a series of questions to help leaders across the health care industry prepare for the Biden era: How would Democrats leverage their unified control of the political branches of the federal government? How would they approach Covid-19 response? What non-Covid health care reforms are on the table? Though many questions remain unanswered, we are now more than 100 days in, and we've gotten some clear signals from both Biden and Congress as to Democrats' health policy priorities.
Over the past few weeks, we've had the opportunity to speak virtually with a host of health care executives about Biden's first 100 days in office and share our takeaways through a series of invitation-only executive briefings and a Stay up to Date webinar earlier this month. Below, we round up our team's four key takeaways from the new administration and Congress—and what we're continuing to watch moving forward.
1. Regulatory wheels are churning—and Biden's health policy goals are taking shape
It's important to remember that no new administration assumes office with a blank slate. The first 100 days of most presidencies are spent reviewing the previous administration's policies to determine which to keep, which to alter, and which to eliminate. And the Biden administration has been no exception. While Congress works through Biden's long list of cabinet nominees, HHS, CMS, and FDA have been busy. The health care agencies have taken steps to rescind or delay several Trump-era policies, such as Medicaid work requirements, changes to the "Title X" family planning program, and a medical device premarket notification rule that would have exempted several artificial intelligence devices from FDA review.
Equity also has emerged as a big priority for the Biden administration. It was included in Biden's day one executive orders and we've seen requests for information on ways to incorporate equity into existing quality payment programs. It also seems likely we could see an equity lens applied to the Biden administration's approach to value-based care. For executives, this signals it may be time to think about how your organization approaches equity.
2. Democrats are learning the limits of their narrow majority—and how to wield it to make big policy moves
Democrats have a razor-thin majority in the Senate, with just 50 votes plus Vice President Kamala Harris. What we've learned is Biden and congressional Democrats are willing to be more aggressive with the budget reconciliation process and exert their unified control to pass legislation.
We saw this take shape with the American Rescue Plan. Biden on inauguration day stated that he preferred to pass a bipartisan Covid-19 relief package. But when it became clear that Democrats and Republicans were too far apart on overall spending, Senate Democrats did not hesitate to use the budget reconciliation process to pass the bill without Republican support. And Democrats are now considering whether they can use that procedural tool again to pass additional legislation (budget reconciliation traditionally is a procedural tool that is only used once per year).
But this is a delicate process. If Democrats determine they can move forward with additional reconciliation packages, they cannot afford to lose a single member of their party without gaining Republican support in the Senate. Practically, this means far-reaching health policy proposals such as a federal public option and Medicare for All are off the table, at least for now.
Which brings us to our next takeaway.
3. The Affordable Care Act is Biden's vehicle of choice for coverage expansion
Throughout the presidential campaign Biden made clear that he does not support Medicare for All proposals put forward by Sen. Bernie Sanders and other Democratic presidential contenders. And while he did propose creating a new public health insurance option, those plans appear to have taken a backseat to the Affordable Care Act (ACA). The Biden administration and the Democrat-controlled Congress have taken several actions to build on the ACA.
They have doubled down on the ACA's exchanges, launching a special open enrollment period that has seen at least 1 million new sign ups since February 15th, restored funding to the exchanges' navigator program and outreach efforts, and temporarily expanded and increased federal subsidies for those who purchase coverage on the exchanges.
They have created new financial incentives to expand Medicaid. Among the American Rescue Plans many provisions, was one to give states that newly expand Medicaid under the ACA a 5% increase in their federal medical assistance percentage (FMAP) for the traditional Medicaid population. While we have yet to see any states take the CMS up on the increased funding, it's possible we could see CMS take both a carrot and a stick approach using its waiver authority.
Again, it's important to make clear that what we do not hear in this Congress—even from longtime proponents—are realistic calls for Medicare for All or even a federal public option.
4. Health care as 'X'
Health care has been headlining news for more than a decade now. Under former President Barack Obama we had the ACA passage and implementation, under former President Donald Trump we had repeal and replace. But as we noted above, Biden does not have a big ambitious health care reform plan.
Instead, we are likely to see more action through the administrative and regulatory side—and for health policy to be embedded into other, broader bills. We are seeing this take shape with the looming infrastructure package. Traditionally, we think of infrastructure as construction (i.e., bridges, roads, railways). But Democrats are currently considering a two-part legislative process that includes a "human infrastructure" package—and this is where we are likely to see health care policies take shape. The exact policies on the table are still being discussed and Democrats have yet to release any legislative text, but everything from drug pricing reform to paid family and medical leave is being actively debated and discussed.
What we have not yet learned
Of course, there are still many unanswered questions. The Biden administration and Congress have been, understandably, focused on the pandemic response. This has potentially slowed down progress on Senate confirmations, such as CMS administrator, and even nominations, such as FDA administrator, which could be why we have seen less clarity from those agencies on key issues such as value-based payment.
With so much focus on Covid-19 recovery and near-term priorities, one of the biggest questions on the table may wait until the next Congress: Medicare Trust Fund solvency. The latest Congressional Budget Office forecasts suggest the trust fund will become insolvent in 2024, up from their previous projection of 2026 due to the pandemic. We'll be watching to see how, and if, Congress and CMS make strategic changes to generate new revenue and cost savings to prolong the trust fund.