Health Care Reform in the Age of Partisan Deadlock and Tribal Politics
Focused on health care reform prospects in the midst of a pandemic and the most bitterly contested presidential campaign in modern history, the latest virtual seminar of the Leonard Davis Institute was backdropped by stark realities summed up in quotes by two of its distinguished panelists.
"We are at a precipice on tribalism in this country," said Rodney Whitlock, PhD, Vice President of McDermott+Consulting and former Health Policy Director in the Office of Senate Finance Committee Chairman Chuck Grassley (R-IA).
The gathering was a continuation of the virtual seminar series on health care and policy issues organized by LDI shortly after the emergence of the COVID-19 crisis earlier this year. Titled Prospects for Health Care Reform: Pandemics, Politics, and Public Opinion, this latest forum was moderated by Ezekiel Emanuel, MD, PhD, LDI Senior Fellow and Chair of Penn's Department of Medical Ethics & Health Policy.
The four panelists joining him included a former U.S. Senate Health Policy Director, a former Acting Administrator of the Centers for Medicare and Medicaid Services (CMS), Director of the Satcher Health Leadership Institute, and Director of the Wesleyan University Media Project.
One major discussion topic was the future of health equity — or continuing lack thereof — throughout the nation's insurance coverage and health care delivery systems.
"We have a huge disparity in coverage and COVID has exposed it further," pointed out Emanuel. "Despite the Affordable Care Act (ACA) narrowing differences on coverage between whites and African-Americans and Hispanics, the differences are still large. There are big differences in access to care even once you have insurance. And there are big, big differences in health outcomes among African-Americans and whites. I will just note one that boggles my mind. If you look at the COVID-19 mortality rate of whites, 15 percent of it is in people under 65. On the other hand, for African-Americans, it's 30 percent. That's really a difference. COVID is taking away many, many more younger lives among the African-American community."
Panelist Daniel Dawes noted, "the Biden campaign has taken a robust health equity lens to their work. And I think that's really important. It's the first time in US history that we've had such a robust prioritization of health, equity and health policies."
Dawes, JD, Executive Director of the Morehouse School of Medicine Office of Government Relations, Policy and External Affairs, spoke about the "triple pandemic" the country is currently struggling through: the COVID pandemic, a racial and social reckoning, and a mental and behavioral health crisis exacerbated by those two.
"There were sixty two provisions in the Affordable Care Act that were focused on the advancement of health equity," Dawes said. "Many of them, though, have not been implemented or enforced; some of them have actually been undermined. We need to repair and build on those moving forward. Over the next 20 years, the life expectancy in this country is expected to decline twenty one places to sixty fourth in the world. And a main reason for that is behavioral health issues, mental illness and substance use disorders, and suicidality. There is a lot of great work going on at many of our historically black medical schools where resources could really create a lasting impact. Bringing those institutions into the fight would be helpful."
Panelist Rodney Whitlock, PhD, a widely recognized authority on the Republican side of Capitol Hill, was asked about the Trump administration's past and future approach to health care policy.
Republican health care record
"I'm going to list a number of things here," said Whitlock. "Some of these have happened. Some have been challenged in court. Some of are aspirational. When you take them in total, they are actually an agenda. We've seen the zeroing out of the individual mandate; the end of cost-sharing reductions; implementations of alternatives to ACA plans like short-term, limited-duration insurance plans, and association health plans; and things like providing states the opportunity to do different things with their Medicaid programs including the use of work requirements. We've seen the repeal of taxes on health care providers, health care insurance, and medical device taxes. We've seen those go away."
"Thinking about a second term, I think its important to point out that Bush and Obama each had a signature first term accomplishment," Whitlock continued. "So they didn't have to implement the Part D drug benefit or the Affordable Care Act. Generally, this administration will work with a much cleaner sheet if they have a second term."
To which moderator Emanuel asked, "Doesn't the fact that they have a 'cleaner sheet' mean that they haven't done very much actually, and all the things you mentioned don't really amount to a lot?"
"I don't think we'll get long into a second term before they actually go forward with some of these executive orders as actual real regulations," Whitlock responded.
Speculating on how a Biden administration might focus its health care policy, panelist and former CMS administrator Andy Slavitt, MBA, said that question is hard to separate from the overall COVID crisis which has become the anchor of current health care. There is also the pending California v. Texas litigation over the ACA's constitutionality now before the U.S. Supreme Court.
COVID response policies
"In terms of the pandemic, I don't think there's a particularly Democrat or Republican response to the COVID," Slavitt said. "There's a good response and a bad response. It requires commitment and thoroughness, and I think you'll get that from Biden."
"Biden's aspirations on the health care side will be interesting in light of the cracks that have appeared because of COVID-19," Slavitt continued. "There's the massive health equity issue, and other holes in our infrastructure, such as the way insurers were left holding the money and care providers were left holding the bag; or the inexorable link between employment and insurance which hurt a lot of people who lost their jobs. All of these are opportunities for repair work. But that's likely to come in the form some might view as incremental because I don't think it is Biden's intention to try to run a very partisan administration should he win."
If the ACA is upheld in the latest Supreme Court challenge, and Biden comes out of the election controlling both houses of Congress, a legislative approach may work to change policies relatively quickly.
Mixed Congress implications
"But if there's a mixed Congress and Biden as President, that's a very different scenario," said Slavitt. "I think that would be, quite honestly, a 'not a lot gets done' scenario."
Panelist Erika Franklin Fowler, PhD, who heads the Wesleyan University Media Project that tracks and analyzes political advertising in real time during elections, focused her comments on health care as a current campaign issue.
"The Kaiser Family Foundation health polling data has consistently shown that the views about the Affordable Care Act have been very stable and very consistent with the exception of when the ACA was under attack, in which case, it became more favorable and it has and has stayed there. There's also a concern about the variety of misinformation that we are likely to see surrounding the health care issue. And that's challenging to combat in any cycle, but especially this one."
Public messaging strategies
"One of the questions from the audience asks if there is room for public messaging that can get beyond the divisiveness," Fowler noted. "A number of organizations, like the Robert Wood Johnson Foundation, are putting a great deal of effort into attempts to cut through the partisanship and move the conversation in a more health equity direction. But I'm also a realist and, as a political scientist, I have to say that partisanship is the overwhelming dimension here."
As the seminar's final question, Emanuel asked Whitlock for the advice he would offer Biden if Democrats take the election.
"After the last four years," said Whitlock, "we're at a precipice on tribalism in this country. On a political level, Biden would have two choices: he could listen to the left that wants revenge on the folks who have run things for the last four years. Or he can try to find more middle ground and push those who only see things through a partisan lens further and further to their respective sides. Because if he doesn't, I'm not certain that four more years of this doesn't end up in a place where all truth is partisan, which means there is no truth."
The need for affordable health care has never been greater than now, as nearly 27 million people have lost their employer insurance and COVID cases continue to surge. This LDI seminar explored the political landscape and potential paths forward for health care reform and health care equity.