May 14, 2021
Dear Interested Readers,
What Is Joe Going to Do?
I am waiting to have President Biden give us more information about how he will move us closer to universal access to care. During the Democratic Presidential Primary Debates, one of the most discussed topics was how each candidate proposed achieving universal access to care. Bernie Sanders, Elizabeth Warren, and Kamala Harris all were in favor of what came to be called “Medicare For All.” Mayor Pete Buttigieg coined the phrase “Medicare For All Wo Want It ” other candidates except for Joe Biden fell into various forms of transition away from commercial employer-sponsored insurance toward public financing of universal care. Biden persisted in his advocacy for building on the ACA with a “public option.”
The debates did settle a couple of issues. First, Democrats unanimously stood for the concept of healthcare as an entitlement. Second, there was general agreement that the government was wasting an opportunity for great savings by not using its bargaining power as the payer for medicines to obtain great savings from the drug companies for a huge population of Medicare and Medicaid recipients. Attempts to discuss the finance of any program, especially Medicare For All, were complicated. Bernie Sanders tried hard to make the point that all money was fungible. He did not have much success convincing people that the sum of their taxes and healthcare costs would go down with Medicare For All even though their taxes might be a little higher.
There were other transitional issues associated with “Medicare For All.” It is never easy to see an industry and its employees become irrelevant even if there is an opportunity to replace the ineffective product they sell, in this case, health insurance, with a more efficient product that is publically financed. This is a debate that goes back to the time of FDR and Harry Truman both of whom advocated for some program of public financing of universal coverage similar to what can be seen in Canada, Great Britain, and most other developed countries. The AMA and most of the controlling interests in the healthcare industry have aggressively resisted any new program that would expand the role of government. George W. Bush got Medicare Part D passed by promising that the government would not use its leverage to seek lower prices on drugs. The government “pays retail prices” for the drugs it buys for all 61 million Medicare recipients.
During the general election, no issues were effectively debated. President Trump had no platform and his bellicose approach to the debates denied everyone the opportunity to have a clearer idea about what he would do if re-elected. Joe Biden did not need to better describe the sequence of steps that he would take to move us toward the goal of giving everyone the care they needed if he was elected because in the end the election was settled on two issues, Trump’s disastrous management of the pandemic, and his lack of fitness for office.
As we try to process what Joe might do next, we have to think back to the first Obama administration. President Obama made passing the ACA his primary objective between his election and the 2010 midterm elections. The ACA was passed minus the public option that should have been part of the bill, but the cost to Obama was high. The divisive effort to pass the ACA along with the anger over the financial bills passed in the wake of the Great Recession lead to huge midterm gains for the Republicans in both houses of Congress and the loss of the House. Obama was left weakened and the possibility of much meaningful social legislation during the next six years was canceled. Without control of Congress Obama was left with executive orders as his only tools for improvement. Joe enters office with the memory of what happened to Obama and a very small majority in the House and no real majority in the Senate. Obama made real efforts to be bipartisan to no avail. Biden pledges to make a good faith effort at bipartisanship, but it is already clear that the Republican strategy is to make sure that nothing good will happen and then run in 2022 and 2024 on the premise that the Democrats and President Biden are ineffective.
My guess is that President Biden has no desire to repeat that history and for that reason improvements in healthcare will not appear in one obvious package like the ACA. We will see many incremental efforts that will give millions more Americans access to care, but it is also true that by 2022 and 2024 there will still be many millions of poor, lower middle class, and undocumented Americans without access to care. We have seen the improvements in access and help with the cost of insurance spread out over the 1.9 trillion dollar American Rescue Plan Act (ARPA) and proposed as part of the American Jobs Act and the American Families Act. The president has already used executive orders to reverse many of President Trump’s executive orders designed to undermine the ACA.
My answer to the question that is the title of this piece is that I do not expect to see much more happening to directly increase the number of Americans having health insurance. That statement should not be equated with the idea that nothing can be done. It just means that I am not holding my breath for tectonic change. There will be many changes that will improve the situation, but the strategy will be to make many small changes that will add up to something better. There is a recent analysis of what has been done and other things that may likely happen soon in a piece written by Katie Keith and published on the HealthAffairs blog in late April that was entitled “Biden’s First 100 Days: The ACA And The American Families Plan.”
She begins by saying:
President Biden marks his first 100 days in office this week. Unsurprisingly, health care issues—especially the pandemic—have dominated his term thus far. During his first 100 days, President Biden signed the American Rescue Plan Act (ARPA) into law, issued executive orders, nominated cabinet secretaries and federal judges, and coordinated a national response to the pandemic. His administration has also responded to pending litigation, taken steps to implement ARPA, revoked state waivers, and issued new guidance and regulations. (Several news sources quantitatively compare Biden’s first 100 days to his predecessors and are worth reading.)
This post summarizes the first 100 days with an emphasis on the Affordable Care Act (ACA). These activities have been discussed in detail in prior posts, and many of the Biden administration’s actions have been consistent with predictions about what would happen to the ACA under a Biden administration and Democratic Congress. This post also discusses the White House’s highly anticipated American Families Plan proposal which was released on April 28 and could signal what comes next in Congress.
Keith gives a great review of the bits and pieces of improvement embedded in the American Rescue Plan that was passed very quickly with no votes from Republicans. She writes:
As discussed in more detail here, ARPA extends ACA premium tax credits to middle-income people who did not previously qualify (for 2021 and 2022); increases ACA premium tax credits for lower-income people who already qualify (for 2021 and 2022); offers maximal subsidies to those who receive unemployment benefits (for 2021); and prevents individuals from having to repay excess ACA subsidies at tax time (for 2020). ARPA also subsidizes COBRA continuation coverage for laid-off workers (from April 1 to September 30, 2021) and includes new incentives for states that have not yet expanded their Medicaid programs (for two years).
Those changes will help many people but most of us will pay little or no attention to what they accomplish. It is possible that the sum of all of the things done will add 800,000 people to the number of Americans who are covered, and perhaps more importantly the changes will enable even more Americans to continue to receive the care that they have for a lower cost.
There is a stepwise pattern to Biden’s legislative agenda. Many of the “improvements” in ARPA are temporary but reappear in the American Families Act for continuation. What should not be lost in the complexity is that while the sum of all the proposals does not add many millions to the list of those who have access to care is that the proposals would substantially decrease healthcare disparities and go a long way toward the protection of the health of our poorest children. Keith writes:
As with prior packages, the American Families Plan is broad and would fund new programs or initiatives for childcare, universal pre-school, higher education, paid family and medical leave, school meals, and unemployment insurance. Many of these policies promote health: early childcare and education, for instance, is linked to positive short- and long-term health outcomes. The White House emphasizes these impacts throughout its proposal..The only specific health care or coverage-related policy in the White House blueprint is to make the ARPA’s premium tax credit enhancements permanent.
The slowly unfolding plan is built on strategic political realities:
If ARPA’s subsidies are not extended, millions of Americans would learn of premium hikes for 2023 (as their subsidies were phased out) during the open enrollment period that begins in November 2022. This is at the same time as the 2022 midterm elections.
Keith points out that though things seem to be moving at a slow pace President Biden has not lost sight of the ultimate objectives.
…his address to a joint session of Congress, President Biden specifically called for lowering deductibles and using Medicare to negotiate lower prices for prescription drug. But the American Families Plan proposal notes only that President Biden “has a plan” to let Medicare negotiate drug prices, reduce individual market deductibles, create a public option and an option for people to enroll in Medicare at age 60, and close the Medicaid coverage gap.
Healthcare and the economy may not be the most important issues before Congress this year. There are two important laws pending that protect everyone’s right to vote and the assurance of fair elections. They are the John R. Lewis Voting Rights Act and H.R.1 and S1, The For The People Act. They are the most important “healthcare” bills before Congress. These bills to assure fair elections and protect the rights of voters will probably determine the outcome of future elections and future elections will for sure determine the pace of progress toward the Triple Aim, healthcare equity, and the reduction of healthcare disparities.
As was true during the last six years of Obama’s presidency, and the four years of Trump’s presidency, the mechanism for immediate change will be through executive actions executed by CMS. I am concerned that Chiquita Brooks-LaSure, the president’s nominee for CMS Administrator has yet to be confirmed by the Senate due to ongoing Republican hesitations and delays. Many of those executive orders are waiting for new “rule-making” processes to be completed by HHS and CMS. The delay in confirmation of Brooks-LaSure has strategic implications. If nothing else the delay makes it longer before the resultant benefits can be realized and a shorter time for the positive impact of those changes to be appreciated before the midterm elections.
President Biden has taken many COVID-19-related presidential actions and issued several health-focused executive orders. Most directly relevant to the ACA and Medicaid, President Biden issued an executive order on January 28 that directed the Department of Health and Human Services (HHS) to expand access to ACA coverage and bolster the Medicaid program. these executive orders do translate into more people being able to benefit from the existing advantages of the ACA. Keith gives us a good example:
President Biden also directed HHS to consider establishing a broad special enrollment period for HealthCare.gov. The agency promptly did so, initially providing a three-month special enrollment period before extending it to six months, from February 15 to August 15. As of the end of March, enrollment had already risen by more than 528,000 people in the states that use HealthCare.gov. (In his address to a joint session of Congress, President Biden noted that an additional 800,000 Americans had enrolled during the special enrollment period, so we should expect updated data soon.) HHS separately committed to spending $50 million on outreach and education, which was recently doubled to $100 million to increase awareness of enhanced ARPA subsidies. HHS also provided an additional $2.3 million in funding for current navigator grantees and announced that it will invest $80 million in navigator funding for 2022, which represents the largest-ever investment in navigators.
The final area where President Biden has been able to use the power of his office to protect the fragile access to care that millions enjoy is by changing the government’s stance regarding the cases against the ACA that are currently being litigated.
The sum of all that has happened and is likely to happen is that there will continue to be real political barriers to positive changes in access to healthcare. I wish that there was a possibility that the filibuster could go away. At a minimum ending the filibuster would assure passage in the Senate of the For the People Act and The John R. Lewis Voting Rights Act guaranteeing fair elections in the future. I have the sense that President Biden is going forward cautiously while hoping that the Republicans will continue their path toward self-destruction. I think that we can expect that some aspects of the American Jobs Act will probably pass utilizing the reconciliation process which is probably not applicable to the American Families Act. The future is not certain. Progress will remain painfully slow, but there is some hope that with a strategy of taking it one step at a time we will move forward slowly. I am hopeful, but Joe needs our prayers and support if his administration is ever to ultimately succeed in making healthcare an entitlement that every American enjoys.
Bicycle Adventures
Back in May 2010, I came to the end of my running road. After waiting six weeks for things to get better, I saw an orthopedic surgeon who told me that I needed a total knee replacement. I told him no thank you so he gave me a “load shifting” knee brace that cost over a thousand dollars, injected my knee, and sent me to physical therapy. I started riding a bike and swimming. About a year later I threw the brace away because I could walk over six miles and do a slow jog for at least three miles with no knee pain or swelling. Things actually got even better. I eventually was able to jog five miles at a ten-minute a mile pace which was as satisfying as I when I could run five miles in half the time back in the early eighties.
I guess that I should be happy that I got an extra decade of walking which added up to about 13,000 more miles. Nothing lasts forever. I have a new orthopedic appliance that keeps my foot from flopping when I walk. This one only cost me $26.95 plus shipping. I am back on my bike, and I am eagerly anticipating the day when the water temperature gets up to the high fifties. I have a good wet suit, but at water temps below sixty, I still have trouble. I guess that what I am saying is that I am waiting for another miracle.
One thing that I am enjoying is putting together new biking routes. The hills here are challenging. Some bicyclists actually come here in groups to train on our hilly roads. For the moment my favorite ride is around my lake then up a big hill into town to Colby Sawyer College which I think is the highest spot in town. I go home with a little variation in my route but on both ends of the ride, I pass the New London Historical Society which you can see in today’s header. If you clicked on the link you would read.
In 1963, Walter Bucklin donated farmland on which the society could build its Old New London village, which has evolved over the years as buildings were moved to the site. Sixteen buildings host exhibits that depict aspects of 19th century life in the New London area. Most of the structures date from the early or mid-1800s. The Meeting House, Hearse House, and Violin Shop are modern reproductions. The Transportation Building is a climate-controlled museum opened in 2001.
If you come this way someday, the village is a nice stop. Down the street toward the center of town and a few yards off Main Street about a half-mile beyond the Barn Playhouse is the Ice House Museum where you can see an amazing collection of antique cars.
I hope that this weekend you will be out and about getting a little exercise and discovering what is near you. The weatherman says that here in New London the sky will be a bright blue with pretty puffy clouds, just like the picture. I will be out and about on my bike.
Be well,
Gene
