Immediate Priorities for the Next Administration, Congress, and States

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)

Kathryn Martucci:

Hello and welcome to the second session in the Alliance’s 2020 post-election symposium. I’m Kathryn Martucci, director of policy and programs for the Alliance for Health Policy. For listeners who are new to the Alliance, welcome. We are a nonpartisan resource for the health policy community dedicated to advancing knowledge and understanding of policy issues. Throughout this two-day event, a range of experts will discuss how the election results could influence the health policy agenda in 2021 and beyond. I want to take a moment to thank our 2020 post-election symposium series sponsors. We appreciate their support in making this event happen. And I also encourage you to join the conversation on Twitter using the #AllHealthLive and follow us @AllHealthPolicy.

Kathryn Martucci:

Please be sure to register for and attend tomorrow sessions, where we will continue to analyze the election results with futurist Dr. Ian Morrison, as well as perspectives from the ground. We also want you to be active participants in this discussion. So please get your questions ready. You should see a dashboard at the bottom of your screen with some icons, use the two-speech bubble icon labeled Q&A to submit questions you have for the panelists at any time. We will collect these and address them throughout the broadcast. You can also use the Q&A icon to submit any technical issues you may be having. And finally, please check out our website, allhealthpolicy.org, for background materials, including speaker bios, resource list, experts list, and recordings of completed sessions will be made available there soon.

Kathryn Martucci:

And now, I am so pleased to introduce Ms. Julie Rovner to moderate today’s discussion. Ms. Rovner is the Robin Toner Distinguished Fellow and chief Washington correspondent at Kaiser Health News. She joined KHN and after 16 years as a health policy correspondent for NPR, where she helped lead the network’s coverage of the passage and implementation of the Affordable Care Act. In 2005, she was awarded the National Press Foundation’s Everett McKinley Dirksen Award for distinguished reporting of Congress. Ms. Rovner, thank you so much for joining us. I know these panelists are a handful. So I’m very glad to hand over the reins to you.

Ms. Julie Rovner:

I think I can handle it. Thank you and welcome everyone. We are here to discuss the gaps in our healthcare system that COVID-19 has exposed and how that might impact the priorities of the incoming administration, Congress, states, and the federal courts. That’s a lot. We’ll try to get through it in an hour. Thank you so much to the Alliance for assembling this impressive group of experts today, who I will introduce as we go. We’re going to hear some opening remarks from each of them, then the four of us will chat for a while and then we will turn to your questions. I already see one in the Q&A and it’s a good one. So I’m looking forward to getting there.

Ms. Julie Rovner:

First up, we have Chris Jennings. Chris is founder and CEO of Jennings Policy Strategies, a health policy consulting firm here in Washington. Chris has been working in health policy in Washington, D.C. for more than three decades. I’ve actually known him that long. He’s worked in the White House, Congress, and the private sector. He served as senior advisor to both the Obama and Clinton administrations and was instrumental in passing and implementing the Affordable Care Act. Chris, what’s the view from today?

Chris Jennings:

Wow, you diving in, introduce anyone else. Well, thank you. Julie, it’s always good to see you and it’s good to see everyone on this panel. Well, I have to convey to you, in all honesty, a great frustration at this moment. I have not seen ever a time, and I’ve been here since 1983, where we’ve gone through a transition period where the outgoing government was not cooperating constructively and collaboratively with the incoming. And while national security has gotten a whole bunch of attention about the briefing book or not for the president-elect, clearly COVID-19 is equally essential. And in fact, frankly, the transition laws should just be implemented across the board. It’s the only way to ensure a smooth transition of governments to serve the public. And it’s certainly the case that it’s long overdue. And in my view, it outrageous as it is unconstructive, if not destructive.

Chris Jennings:

It will delay and it will undermine an effective transition in the middle of a pandemic. So you start off, I’m an unhappy camper. I’m certainly happy after the election that president-elect Biden has become the president-elect. And he’s got extraordinary team, an incredible number of people who are very much interested in serving. I can tell you that. He has started his own transition, but he can not talk to any of the agencies or any of the career political people who inhabit it. Now, let’s start with where we’ve been and where we’re going.

Chris Jennings:

Certainly, in my view, the president-elect won the primary, actually on healthcare, people forget that in 2019, in many issues, we had our own internal debate over which direction we should be going to finally address affordability across the board in this country. He prevailed that maybe one of the very few issues that people remember the debate being about. And then just as we entered in 2020, another huge healthcare issue, a pandemic, took over and maybe the reason why the president-elect won this election.

Chris Jennings:

I will say that as we’re going forward, the huge issue that was unveiled by the COVID process you suggest was one, an absolute lack of preparedness and inability to coordinate nationally and across the states well, huge problems in terms of production and distribution, incredible equity and disparity issues, vulnerability of first responders. But also, it unveiled the potential for creative responses in technology, alternative use of workforce, and the need for change, frankly, which my hope is that that’s going to kick us into a substantive conversation early into the Biden administration.

Chris Jennings:

Certainly, that will be the first priority, the second priority, and the third priority of the Biden administration I look forward to talking about in some detail. The last point I’ll just quickly go to is that we cannot forget that just under the COVID debate is this real fear about economic and health security. And these two clearly are linked. They always have been linked. They haven’t always been communicated particularly well, but a big part of healthcare security is affordability. And previous to the COVID-19, we saw the extraordinary exposure of people to out-of-pocket costs and their frustration. We saw prices significantly varying across marketplaces and certainly in comparison to internationally. And it was raised as a very, very high priority for the vice president when he was running.

Chris Jennings:

I assume he’ll continue to propound and propose policies in that areas. We can talk about that as we go forward, and he will have a very aggressive executive action orientation as did president Trump. So I’ll stop with that because I know I don’t have a lot of time and then I’ll look forward to those comments of others and then we can open it up for Q’s&A’s

Ms. Julie Rovner:

Great. We will come back to you. Next up, we have Clay Alspach, a principal at Leavitt Partners, also a policy consulting firm founded by former Utah governor and HHS secretary, Mike Leavitt. Clay specializes in federal healthcare policy and advocacy related to the FDA, Medicare, Medicaid, and private health insurance. Prior to joining Leavitt Partners, Clay served as chief health counsel for Chairman Fred Upton of the US House of Representatives Committee on Energy and Commerce. Clay?

Clay Alspach:

Well, thank you very much, Julie. It’s great to be with you and with the other panelists. And thank you for the invitation to be here today. So I’m going to talk a little bit more about Congress and what the priorities may be. And as we look at that, I still think we’re looking… There are some major data points missing. That’s probably what we’ll discuss a lot today. But there are some early indications as to what we can expect. I mentioned some missing data points, like what are those? First and foremost, it’s Georgia. The Georgia runoffs, we don’t know who’s going to control the Senate. And with that, as folks will know, the Senate and who controls the Senate has tremendous impact on the floor and what gets on the floor, as well as who control the committees and what hearings they hold and what bills they prioritize.

Clay Alspach:

I think that goes a long way to what Chris was talking about with respect to president-elect Biden and where his agenda may sit. There’s a lot he can do administratively and through the regulatory process. But there’s going to be some legislative wins that he wants to get, and that Georgia runoff will play a large part into the extent of those victories. In addition to that, there are some other data points that I think that we need to look at, particularly who’s going to be in control of and who’s going to control the major health committees. Just to go over that briefly, if you look at the Senate Health Committee, Chairman Alexander, he’s actually retiring. So on the Republican side, they’re trying to figure out who is going to be and lead that panel. Is it going to be Senator Burr? Is that got to be the Senator Paul?

Clay Alspach:

And I think as you look at these leadership, it’s not just about Republican/Democrat, every member, he or she, will bring with them a set of policy priorities. It’s going to be different, even if it’s Republican Party or Democratic Party. And the health committee is just a really good example of that, where you have pandemic preparedness. That’s something that Senator Burr has been a leader on for a number of years. I think if he were to get that health chairmanship or ranking member position, he would prioritize that and you will see a lot of activity out of that committee on that issue. Energy and Commerce Committee on the Republican side has a similar dynamic, where you have Cathy McMorris Rodgers and Dr. Burgess contending to lead that panel on the ranking member side.

Clay Alspach:

Again, it’s the ranking member on the House. So it’s not as important as the chair. But those relationships between the chair and the ranking member, especially in an environment where the margins are so close, it’s a razor-thin majorities on both sides of the Capitol. I think is an important thing that we’ll need to watch as to what issues may get through, where we may see bipartisanship. And then finally, if you look at the House Appropriations Committee, which has control of billions upon billions of dollars that go toward healthcare-related funding, you have at the chair position, Nita Lowey retiring. And so who’s going to take over that committee? Rosa DeLauro, she’s been a force on the healthcare issues for a number of years. She may be the chair of that committee, and that’s something we’ll want to watch as well.

Clay Alspach:

So I’ve talked a lot about the missing data points, but I think there are some indications as to where priorities are going to be for Congress. Chris touched on it. I think COVID is going to be front and center, the major area of activity, especially early in the Congress. Even if there’s a lame duck related deal that the parties are able to come to, I still think Congress is going to want to revisit and look at that. That’s not only a priority for president-elect Biden. It’s a priority for Democrats and Republicans too. They may have different views on what should be prioritized, whether that’s liability reform or state and local funding, or on levels of spending. But I think there’s a clear need, especially as we’re seeing the surge across the country. The pandemic is much as we got some good news on the vaccine front, which I think Avik will cover, but that’s great news. There’s still a long way to go. So with that, I think that’s something to watch.

Clay Alspach:

And then as we look at other priorities that are there, there are a number of, I think… Chris touched on this too. I think there are a number of advancements which we have made advancements, but Congress is going to want to lock them in. Especially in the digital health side, you look at telehealth, it’s a lot of bipartisan interest there. And then there are some issues that frankly that pandemic exposed on the equity side as well as the disparity side that Congress is going to want to look at as well and see if they can legislate or at least provide strong oversight on.

Clay Alspach:

And then finally, I think there are a set of issues where they were priorities, but then the pandemic hit. And so Congress is going to want to revisit those and see if they can get some long-term related solutions. The healthcare extenders are really good example of that, where December 11th they’re actually expiring. May see a short-term extension of that. Coming Congress is going to want to revisit to see what can happen with respect to a long-term deal on community health center fund or some of those Medicare and Medicaid extenders.

Clay Alspach:

So I touched on it and I’ll close with this where we are going to see a Congress with razor-thin majorities. I think that’s going to pose a lot of pressure and a lot of challenges on leadership, whether you’re in majority or in the minority on the Senate or House side. I think it’s going to be very extreme to watch, and we can get further into it on the panel as to whether that’s a recipe for some kind of gridlock, or is that some kind of promise around bipartisanship that we haven’t seen, or maybe most likely some incremental change on issues where there are some advances made, but maybe not as far as either party would want to go on those issues. So thank you again for the opportunity and look forward to discussion.

Ms. Julie Rovner:

Thank you, Clay. I will just mention that I’m old enough to remember when bipartisanship was the rule and not the exception, but that is certainly not the case anymore. Now, we turn to Avik Roy, president of the Foundation for Research on Equal Opportunity. Avik has advised three Republican presidential candidates on health policy. He’s currently the policy editor at Forbes and manages The Apothecary, a blog on healthcare policy and entitlement reform. Avik also serves on the advisory board of the National Institute for Health Management and is a senior advisor to the Bipartisan Policy Center. Avik, talk.

Avik Roy:

Sure, Julie. I suppose I should be happy to talk about COVID rather than the University of Michigan football team, which is another shared passion of mine and Julie’s. I’ll say a couple of things. One, I appreciate that it’s a universally held view in Biden’s orbit. And Chris articulated earlier that we needed a national strategy on COVID. I don’t see the evidence that a national strategy would make a significant difference when it comes to things like economics restrictions or lockdowns. Cases are spiking in California, they’re spiking in New York, they are spiking in New Jersey, they’re spiking in Michigan, they’re spiking in all these states where the governors are doing the things that the Biden coronavirus task force is telling everyone to do.

Avik Roy:

The charts look pretty much the same in the Texas as in the Florida’s as they do in these blue states. So it’s not clear to me that lockdown policy really will make a difference if it’s a one-size-fits-all strategy from the top, rather than a state-by-state approach. Where a national strategy can be useful is in the things that Trump administration has been doing, like Operation Warp Speed, which obviously has been fairly successful today in terms of pre-funding the manufacturing ramp up for the vaccines that end up working, whether they end up working or not. And obviously, we’ve had some good news on that front from some of the mRNA-based treatments from Pfizer and Moderna. That’s great.

Avik Roy:

Another area where there can be a national strategy is in managing the supply chain around PPE and testing supplies. And that is something that the Trump administration has done. A team led by Jared Kushner operating out of the Federal Emergency Management Administration has been doing that nonstop and has had a pretty successful approach in terms of given all the incredible constraints that we’ve had with testing supplies, they’ve overcome a lot of obstacles that has not gotten as much attention perhaps as it should. So in the areas where a national strategy can be useful, the Trump administration is doing that in the Biden plans such as it is basically the same as what the Trump plan was. When it comes to economic restrictions, yes, incoming Biden administration has a different approach than the Trump administration, but the efficacy of the Biden approach is yet to be determined. And I’m personally quite skeptical that it will really make that much of a difference.

Avik Roy:

Let me then switch gears a little bit to talk about the broader health reform opportunities here. One thing that I’m interested in Clay talk obviously about the Georgia runoffs, I think there’s a lot of reasons to believe that Republicans will win that runoff based on historical trends, but of course you never know. I’m assuming that they’ll get at least one of the two, if not both. So the real question becomes what can Biden either do with McConnell-led Senate and/or do through executive action? I think on the Senate-based piece, there’s a limited universe of stuff. McConnell’s not going to go for a public option. McConnell has shown that he’s not that interested even in bipartisan drug pricing reforms. So the bill that came out of the Senate Finance Committee last year and this year, McConnell did not want to bring that to a vote. I don’t see McConnell wanting to bring it to a vote if Biden is president versus Trump being president. I think he’s going to basically have the same approach to that.

Avik Roy:

So I think on things that would really make a huge difference in terms of health reform that would be statutory in nature or congressional in nature, I’m not saying we’re going to see a lot in this first two-year stretch. If Biden campaigns on something in the midterms that maybe pressures Republicans as we get into 2022, where Republicans have a lot of seats they’re defending, that might be the kind of the wedge that opens up some opportunities for Republicans to vote along with what Biden wants. But that remains to be seen. I think what’s going to be really interesting aside from many potential executive actions by Biden that are just from a standing start, does he continue some of the things that Trump has done that are not that ideological and that in fact a lot of Democrats support, such as the IPI or most favored nation status approach to drug pricing in Medicare, part B and potentially Medicare part D in this most recent Trump executive order? That’s going to be very interesting.

Avik Roy:

I know that the Biden team, and Chris can talk about this, has some slightly different ideas of how to approach drug pricing in Medicare. But the simplest thing to do if you’ve already got a rulemaking process in place is just to continue it. So I’ll be interested to see if Biden decides he just takes advantage of the work that’s already been done because it would save him a lot of time to work on other priorities. The other two areas I’ll mention in that vein, one is the price transparency stuff. So there’s a bunch of price transparency regulations that have been finalized in the Trump administration. They’re going through the courts right now. So far, the courts have upheld them. That is going to be a revolution healthcare. The most significant health reform of the last four years has been the transparency regulations because they will enable entrepreneurs and Silicon Valley employers, researchers, Julie Rovner to identify discrepancies and provider prices and other things that could lead to a lot better optimization of pricing of healthcare services. I think that’s going to be really, really interesting and important.

Avik Roy:

The other area is CMMI, the Center for Medicare and Medicaid Innovation. So the Obama administration tread very lightly with the CMMI because they were worried about Republican objections to the use of executive power to unilaterally change the way Medicare work. The Trump administration on the other hand was fairly expansive in its use of CMMI’s powers. That might make the Biden administration feel like they now have the permission or the license and say, “Hey, if Trump’s going to use CMMI to do a lot of stuff, why don’t we do the same?” I think that might be an area of real focus. If I were a Biden administration, that’s certainly a set of tools I’d want to use. Let me stop there.

Ms. Julie Rovner:

All right. Finding my mute button. Thank you very much. All right. Finally, we turn to Rachel Nuzum, vice president for the Federal and State Health Policy Initiative at the Commonwealth Fund, where she works closely with policymakers at the state and federal level. Rachel has over 15 years of experience working in health policy at the federal state and local levels of government as well as in the private sector. Rachel, that cleanup for us.

Rachel Nuzum:

All right. Thank you. Well, thanks, Julie. Thanks to the Alliance and thanks for all the panelists for setting me up really well. I share Chris’s frustration a little bit and speak on behalf of every state, every Medicaid director, every governor who is really trying to grapple with what’s been… We’re going on a nine-month continued crisis. So when we look at where states are post-election, we see a really similar phenomenon that Clay and others laid out in terms of Congress, a really closely divided country, all incoming governors won their reelection bids. We’ve got 27 Republican governors, 23 Democratic governors. The legislature stayed very stable. We saw very little change over there.

Rachel Nuzum:

So what does that mean in terms of their priorities? The top three priorities for states right now are COVID, COVID, COVID. We’re going on nine months, like I said, of massive disruption, school closure still happening, COVID cases are surging, the decreasing tax base and the revenue issue and gap for states is real. States have to balance their budgets. They don’t get to play the budget games and the deficit games that happen sometimes on the federal government side. And so that’s very real. I think there’s a lot of concern for state leaders as they look to what may or may not be happening in Washington right now in terms of another COVID relief package. Right now, states are working on… They submitted draft distribution plans for an eventual vaccine. So thinking through how to do that in a productive way, the infrastructure that they need and how to distribute a vaccine equitably is top of mind.

Rachel Nuzum:

Also, if you’re a state leader, you are watching with one eye the Supreme Court and the upcoming ruling on what the Texas versus California case might mean. Obviously, not just for the states that have expanded Medicaid, that could be a big factor. But 10 years of really structural improvements or streamlining or changing of the way things are done at the state level in terms of the regulating and providing of healthcare coverage are on the line. So you’re watching that and wondering how that’s going to go. Chris and Clay and Avik but all touched on the priority of the Biden administration around public option. I think one of the things that we might see and what we’re starting to hear conversations about is an approach where states are encouraged to look to carry on public option efforts on their own through 1332 waivers, through 1115 waivers. So we may see some action there in 2021.

Rachel Nuzum:

See my second point about very real fiscal constraints because those will hit each other and have to be reconciled. And so thinking through this desire to expand coverage, especially during a pandemic, and how do you do that, and how do you control costs at the state level, and how does that set up dealing with your provider reimbursement rates when, especially for Medicaid providers, these are some of the providers on the front lines of meeting the COVID demand, but also have the slimmest margins and are oftentimes in very real fiscal distress? So it’s a really tough position for them to be there.

Rachel Nuzum:

My final point is definitely not least important, but maybe most important. And that’s that what we’re seeing is also a trend with the federal side, and that is that we’re hearing more states taking real steps to addressing equity and systemic racism. So I think we’ve been seeing that for the last couple of years in pockets, in targeted areas around health disparities, around things like maternal mortality and morbidity. What’s happening now is I think a little bit broader, a little bit more of a recognition that thinking through the implications of policies and making sure that we understand the impacts across different populations is really critical and can’t just be siloed off into certain areas.

Rachel Nuzum:

And so a lot of statewide activity on equity taskforce is thinking through how the payment and delivery systems reinforce the outcomes that we want to see. I think is going to be both an area where states are already ramping up their activity, but a place where a Biden administration can really send a message and say, “I’m serious about doing this. Here are some tools and really help amplify state efforts.” So I’ll leave it there and look forward to questions and conversation. Thanks.

Ms. Julie Rovner:

Well, that was a lot of information in a short time. Thank you all panelists. Before we get to my questions, does anybody want to respond to something that somebody else said before we start? Chris, I see you raising your hand. Unmute yourself please.

Chris Jennings:

Well, Avik won’t be surprised I want to respond to him only. I think he had his Wheaties or he must be on the West Coast early morning time or something. But I did want to say a few things. One is that the way that the president-elect really views this is not a blue-red issue. It’s a kind of all country in flames issue. I don’t want to say one state’s done worse than another state. I think that some states have been very, very, very good in their interventions and they still are facing challenges and increases, but the per capita is still lower. Again, this isn’t a comparison game. We need to target where the problem is.

Chris Jennings:

And the second thing I just want to mention, or two things, there is no one in the orbit of the president-elect talking about national shutdown, I mean, an officially designated person. They’re talking about reviewing and looking at each state at where they are and providing resources and support where they need and to take targeted interventions where appropriate. That can include anything and everything, particularly if the population is at huge risk. Unlike the Trump administration, the Biden ministration… This goes to maybe over its hope that the Biden administration will not reject Trump work, whether it’s relative to COVID, or whether it’s relative to ACA, or executive branch functions, et cetera, on cost containment, et cetera, just because it started with the Trump administration, or was a part of the Trump administration.

Chris Jennings:

I think he’s right to suggest that there should be a review of all of these things. Now, one of the problems, of course, is that the administration isn’t allowing him to review with the agencies as to what they’ve done. And if they wanted to be a little bit more constructive, we might actually be in a better position at the time that the president-elect becomes president. And lastly, I think Avik may be the only one in the United States who thinks the Trump administration has completely well and exactly mirrored the Biden approach to or vision of managing COVID. I will commend the Trump administration on how they did Operation Warp Speed and on vaccines. I don’t know anyone independent who believes that’s the case for testing therapeutics or PPE. So I’ll stop with that, but I just needed to have a little bit of a response to all this, whatever it was.

Ms. Julie Rovner:

Okay. Well, I actually want to pick up on something that Clay said and something that Rachel said. Clay talked about how these very small majorities and we don’t know exactly how big they will be yet, or in the Senate who will have the majority. But they could either cause gridlock or a chance for real bipartisanship. And then to layer onto that, something that Rachel said, is it what right now I think everybody can see there’s are enormous needs in so many areas and very few resources. The economy is still not in a great place. So you have a closely divided Congress and not very much money. Is that going to spark creativity or fighting?

Clay Alspach:

I can start. I think on the COVID front, there’s the economic component of it and there’s the response component of it. On the economic side, I think what you hear from Republicans around the Paycheck Protection Program around UI, around unemployment insurance, around others, is a sense that we need to move forward. Whether it’s unlocking, there’s a bunch of money leftover in PPP that’s over $100 billion, I think like 150 that could be utilized in businesses, especially if we’re looking at shutdowns across the country which are being implemented right now. They’re going to need money to be able to survive to when the vaccines come forward. So I think you can see Republican interests there.

Clay Alspach:

And then on the Democratic side… And there are some Republicans who I think would resonate with as well. The states and localities, I think what we are struggling in it, they had their budgets and their budget bait before COVID. But now, they’re entering into a whole… starting in July, a whole year where it’s going to be directly impacted there. And so as they look to what kind of PPP they can provide, or how they sustain some of their efforts, I think there’s going to be a Democratic interest and some Republican interest to provide help there. I think all of that, there could be a recipe for finally a COVID Ford yield coming forward. We’ve been waiting for it for a number of months now. And then on that, that could be under those auspices. You could see other policy come forward under that as well, to the extent that could be a vehicle. So I think that’s the most likely place for bipartisanship.

Clay Alspach:

Julie, I appreciate your comments earlier, like when you were saying, “Hey, I remember when bipartisanship… what it really meant.” I think part of this is our expectations for it. In recent times, we’ve gone through places where I think we never thought we’d be, looking at chip when chip didn’t get done on time, had expired. Nobody thought that was possible. Some of the extenders, nobody thought that was possible. We’ve gone through numerous shutdowns, which aren’t uncommon necessarily, but they’ve been more and more frequent.

Clay Alspach:

So maybe we get plugged back to a spot where it’s actually they can run the trains on time, where they can function. And not that that should be a huge victory, but at least it would help, I think, provide certainty for a lot of stakeholders and businesses who are trying to operate. They can operate especially with the federal government and its role in healthcare, it’s huge. If they can’t count on and don’t know where that money’s coming from or how they can provide that treatment, it takes all the inequities and problems that we talked about and just exacerbates them that much. So that’s at least some comments on that and what we may see. Appreciate the other thoughts as well.

Ms. Julie Rovner:

I feel like everybody has talked about COVID and we’ve talked about other things. But we haven’t really talked about how COVID impacts those other things, which is the point of this panel, I believe. Obviously, COVID has uncovered a lot of things that we already knew, but it’s brought them to the fore like the problem if you don’t have coverage and the problem of our completely fragmented healthcare system. What else and are there things that COVID has highlighted that might make it easier to address going forward?

Rachel Nuzum:

Julie, I’ll-

Avik Roy:

Let me jump into… Go ahead.

Ms. Julie Rovner:

Go ahead, Rachel. You first and then Avik.

Rachel Nuzum:

Okay, okay, thanks, Avik. I think the two things from my perspective is, one, the discrepancy in the Medicaid reimbursement rates for Medicaid providers and it’s really at the heart of what we’re seeing unfold. Medicaid is designed to be a safety net program. Its enrollment is supposed to increase when we have an economic recession. This is exactly the way the program is supposed to work. And yet we’re hearing stories of primary care physicians, pediatricians with only a week or two weeks worth of capital on hand after making all the investments that they have to make in terms of PPP and taking care of their own staff. That seems like a major problem.

Rachel Nuzum:

The other issue that the Commonwealth Fund has done a lot of work as have others in documenting is the issue of disparities and inequities due to race and ethnicity. There is no way to avoid when you look at the maps of where the cases are the fact that COVID has exacerbated what we always knew was there. We were hoping that expanded coverage could address and it did in some, but not all the way. And it’s just a clear reminder that our work has only just begun in that space. It’s definitely not over.

Ms. Julie Rovner:

Avik?

Avik Roy:

Well, I’m going to leave Chris’s stuff to the side here. We can always litigate that later, but I vigorously contest some of his descriptions of my views and the views of others. The thing that I’m very concerned about when it comes to the aftermath of COVID is hospital consolidation. Hospital consolidation has been a huge problem in terms of regional monopolies that basically charge whatever they want to people with private insurance. And the strains that COVID has put on particularly rural hospitals may encourage a wave of consolidation that makes the problem of consolidation worse. I think that’s an area where there should be a lot more attention, especially given how much federal aid hospitals have received through the CARES Act and other legislation. If hospitals then turn around and take advantage of that aid to raise prices on consumers and patients and employers, that’s a real problem. So my hope is that both by the Biden administration and Congress will do the oversight necessary to ensure that we aren’t seeing a wave of consolidation and price hikes as a result of the last nine months.

Ms. Julie Rovner:

Who else? I’m curious to get everybody’s opinion on this one. Chris?

Chris Jennings:

Well, of course, if you are uninsured or you became uninsured as a consequence of COVID, you’re feeling extraordinarily insecure, both from a health and economic perspective. And of course, for the states who never did expand Medicaid, we’ve seen there’s no place in any meaningful way to go, unless they can claim they have a COVID-related dynamic. And as we know, there’s lots of people who are suggesting that this isn’t COVID, so we’re going to charge you out of pocket and people just then don’t get the care that they need. This has, of course, dramatic and disparate effects on populations of people of color that we continue to still ignore.

Chris Jennings:

And this is something that the president-elect feels very strongly about. He thinks it’s an absolute moral imperative and a stain on our country that we haven’t moved in this area. I hope that we can find some creative ways to build across some party approaches a little bit new, some different approaches to deal with this. And as much as Avik and I argue and disagree, we actually agree more than we disagree on both not just even the objectives and the goals, but even some of the interventions. It’s just that I have to correct them every time when he’s wrong.

Ms. Julie Rovner:

Clay, what’s COVID uncovered here?

Clay Alspach:

I would just say I agree with everything that’s been said. Another part of this conversation is going to be how we prepare for the next COVID. I mean, the amount of damage it’s done to our country, both in terms of health, mortality, as well as just economic. Making sure that we’re not in this situation again is going to be an imperative. And I think as you’ve heard on this panel, there are different approaches to that. President-elect Biden will be more of a federal approach, whereas Republican maybe state empowering states.

Clay Alspach:

I think looking at lessons learned around that it’s going to be really important as well as looking at our public health infrastructure. It’s under a tremendous amount of strain and arguably it wasn’t funded or wasn’t there for us when we needed it. What steps we can take or need to take in order to ensure that that’s in the best spot possible is going to be important as well. I think next Congress, it’s already been done. I think there’s been a lot of focus from a Democratic and Republican side in Congress on that. But I expect you’ll see a lot more conversation and necessarily so around them helping us be better prepared.

Ms. Julie Rovner:

We have an audience question that I actually also wanted to ask. Avik, you talked about the price transparency rule and I’m going to actually merge a couple of questions. What do you all think, and Chris, I don’t know how much you actually know about this, but about how the Biden administration is going to deal with some of these regulations that the Trump administration either has recently finalized or is about to finalize, things that do have some bipartisan support like price transparency?

Chris Jennings:

Okay, to be clear, in this and all context, I’m not representing the Biden transition. So this is Chris Jennings. I would say that, as I mentioned, I think he will evaluate each reg and rule on its own, as standalone. Transparency, on its face, of course, is always difficult to do anything other than to embrace who’s opposed. It’s like being opposed to fraud. Of course, we’re frauds. But execution and implementation of all these rules and regulations and potential inadvertent disruption you have to think through. So that will be the filter by which that occurs.

Chris Jennings:

I think another one that Avik raised was the issue of prescription drugs. Of course, that’s another area that the president-elect has talked about. Well, two days after he was officially called, he gave his speech around healthcare. He talked about both coverage and on focus on prescription drug costs. I agree with Avik that you should be looking at different vehicles to do those. There’ll be other policy areas that I’m sure there’s no doubt he would reject and if he has the power would rescind. Those will be evaluated on a case-by-case basis.

Chris Jennings:

There are people who ask me frequently the question, and I’m sure them the question, the Biden team, that is to comment on each one of these during the transition. I would recommend to them and I presume that they won’t comment on them until they get later in the process. And they’ve had a chance to really review the implications and weigh the pros and cons of doing each one of them. In some areas they’re already on record of saying, “I’m going to predict that as it relates to ACA changed directions.” But in these other areas, not as much, or they’ve even suggested more of an alignment. So it’s kind of a case-by-case basis.

Ms. Julie Rovner:

It’s also a matter of priorities. I remember being surprised at how long it took the Obama administration to unwind some of the George W. Bush administration’s regulation. It was more than a year and I assume that’s because that you set up… There are only so many resources, particularly when you have to go through the regulatory process and you got to set up a priority order, right?

Chris Jennings:

There’s a resource issue, but there’s also a legal and regulatory process. If I don’t like it, I’m just going to eliminate it. And if you do, you can be called into question legally about an overreach. There’s a combination of both of those things. Yes, Julie.

Avik Roy:

Let me just add to that, Julie.

Ms. Julie Rovner:

Please.

Avik Roy:

I think a lot of people don’t appreciate how hard rulemaking and regulatory changes are. They just think the famous phrase from Obama pen and phone, “I’m going to do everything by pen and phone.” It’s not that easy. There’s a lot of hoops legally you have to go through in order to get things just through the internal executive branch process, let alone through the courts and the public comment period and everything else. It’s a lot of work. And that’s why what Chris is saying makes sense, where that is to say where there’s rough alignment between what Trump has done and what Biden wants to do on a particular policy area, it’s much more efficient to take the Trump rules. And if you need to tweak them, tweak them. But basically, keep the chassis intact because that frees up that time and those legal resources and those personnel to work on something else you actually want to do.

Ms. Julie Rovner:

Anybody else before we move on? I have a question that I had not seen mentioned in a while. Somebody wants to know what the chances are for a COBRA subsidy. We’re obviously in another period of if not actual lockdown than impending lockdown, more people are presumably going to lose their jobs. And there is not the opportunity for insurance in some cases. There was a lot of discussion, I think, early in the summer about expanding subsidies for people who just want to stay on their employer plans and hopefully as a bridge to coming back to their jobs. Again, it’s a resource issue. Any thought that that might go somewhere?

Avik Roy:

I’m a skeptic that’ll go somewhere. You never know what kind of deals people hash out in Congress. But one of the things to understand about the Republican point of view on this is that Republicans are very aware that if certain states have aggressive economic restrictions and other states have moderate to mild economic restrictions and you have something like COBRA subsidies, what you’re effectively doing is asking, say, the residents of Texas and Florida to send their tax dollars to California, New York. And so those legislators from those states are very hesitant to do that unless the very reason.

Chris Jennings:

Actually, Avik, wasn’t raising another concern. Sometimes another issue that gets raised is are you subsidizing abortion-related issues and et cetera? They frequently raised some of these issues too. There’s a question of… I’m not going to get into that discussion other than to say that I do think ironically I’d be interested in what Clay would say about this, Republicans seem to be more open to COBRA than they were to providing resources to ACA. If there is a perception of a need for income support, you can see that. And of course, there’s a lot of business and Democratic support and labor support for COBRA extension. I should say for the record that I’m certainly aware that the vice president, when he was the vice president, now president-elect, did take a position in support of COBRA subsidies.

Ms. Julie Rovner:

A big picture question from the audience, “How will the federal government deal with the budget deficit, the Medicare trust fund insolvency, et cetera?” I wrote a story this summer about how people losing their jobs and not paying their payroll taxes is going to hasten the demise or at least the insolvency of the Medicare Part A trust fund and yet there’s very little attention being paid to that.

Clay Alspach:

Sure. I can start. I think, and rightfully so, when you raise it in your article, this is the trust fund. There’s projections of it being depleted by 2023, 2024. I don’t know, maybe faster given the economic conditions as you cited, Julie. That one though, it’d be interesting to watch because that… And some of the ideas related to how to do that could come with either economic-related problems or issues that it can raise. If you’re raising taxes, or you’re doing something to that regard, or if you’re trying to fund it through some kind of beneficiary or provider cut in this environment, that does not seem tenable.

Clay Alspach:

So I would think, especially given where the Congress is, it may be something we’ll see not this coming Congress, but the following one, and Congress will deal with it when it absolutely has to. It just seems like such a… Not to say that that’s how it should be done, but realistically that may be what we are having to face because the pandemic is front and center right now, we got to get through it, and then we can address the other big challenge like the trust fund running dry.

Ms. Julie Rovner:

Now, I would say that this has been Congress’s modus operandi for the last decade or two to not address things until it absolutely positively has to. Rachel, I want to come back to you for a second. We have a question about how might race equity be addressed. Obviously, COVID has highlighted what we knew was an enormous problem in the healthcare system with inequities. Going forward, one of my colleagues at KHN last week had a story about how medical students themselves are pushing for changes in the curriculum, that there are still racial disparities that are taught as to how people present with illnesses. Obviously, it goes to the very heart of the healthcare system and the actual delivery, what else can be done?

Rachel Nuzum:

Well, I think having these broader conversations may seem like a frustratingly slow place to be when we see the numbers like we’re seeing when it comes to the COVID cases and the COVID deaths. But they’re really hard conversations to have and states are taking a much broader approach like I mentioned before. It is much more likely that states are evaluating their delivery models and their payment models and thinking through what is the impact on different populations. One great example is telehealth. We talked about is it going to be a matter of creativity or arguing? States have really been looking to telehealth as a tool and as a way to really get the care where it needs to be during the pandemic.

Rachel Nuzum:

But there’s very real research questions out there right now that we’re supporting other research to answer around whether or not increasing the use of telehealth is closing that gap for care or actually exacerbating it. Are we getting the people that need it most? I think the fact that we’re having those conversations, that research is underway thinking about what the impacts to some of those models are going to be and then getting to a point where you can tie reimbursement to some of those outcomes is where a lot of states are headed.

Ms. Julie Rovner:

Anybody else want to take a stab at the health equity question? We can move on. Someone asks, “How do you see a Biden administration differ from the Trump administration in its use of the Defense Production Act as a tool to fighting the pandemic. Obviously, it appears that the Trump administration has been loathed to use the DPA. And yet we’re still seeing lots of complaints now from around the country about lack of PPE and other things that presumably the Defense Production Act could have been used to manufacture.

Avik Roy:

They did use the Defense Production Act to produce mask and PPE and testing supplies.

Ms. Julie Rovner:

But there’s still shortage [crosstalk 00:53:12].

Chris Jennings:

Yeah. The difference between maybe Avik and me on this issue is it really is a matter of degree. I do believe that the Trump administration was loathed to initiate DPA and utilize it substantially and as broadly as, I think, a Biden administration clearly would, and specifically on PPE and testing. I think they were slow. And I think that there were perceptions of politicization of distribution that created huge problems. But I also want to underscore one other thing. The use of DPA is not in and of itself. It’s like an easy talking point, is an easy reference point. It is not an answer in and of itself. There are distribution channels, the issues that you have to work with in the private sector that you can’t just have the government just do what they’re going to be doing. There has to be very, very clear assignments of roles.

Chris Jennings:

Sometime, and I will tell you, Avik, there were people who were hoping… from the private sector who were hoping the DPA would be utilized so they could have a relief from their contractual obligations to people that they were sending supply [inaudible 00:54:28] going on. So I would just suggest to you there would have been and there could be a better way of doing it, but it is not a magic pill solution to anything. There has to be thoughtful collaborations between the federal state and private sector. The difference, I think, between the Biden administration view and the Trump record is that there would not be advocation.

Ms. Julie Rovner:

All right. Well, we are almost out of time. Is there anything that we didn’t touch on that you guys feel you need to say? But you have to keep it really short, like 30 seconds short. Anybody?

Chris Jennings:

And Avik can’t talk.

Ms. Julie Rovner:

All right. [crosstalk 00:55:19] This has been great. We have so many good audience questions that I couldn’t get to, I want to apologize. And I want to thank the panelists and the Alliance again, and I’m going to hand it back to Kathryn for some closing notes.

Kathryn Martucci:

Right. Thanks, Julie. And thank you… I’m echoing thanks to our panelists. Great way to close out the first day of our symposium. I want to encourage you all to please take time to complete a brief evaluation survey that you’ll receive immediately after the broadcast as well as via email later today. We truly value that feedback. I want to encourage you all to join us again tomorrow. We’re starting at 11:15 AM as we continue to break down the results of the election and the impact on health policy. And just a reminder that recording of this webinar and additional materials are on our website. And with that, I thank you again for joining us. Have a great day.