President Biden’s uphill task on US health care Episode 6 of the Health Foundation podcast

Dr. Jennifer Dixon: President Biden has a lot to fix: the economy, the environment, public services, and infrastructure, and then there's health and inequalities and America's deep cultural and political divisions. On health and care alone, there's a long list of wrongs to rights and urgent progress to be made. The recent Lancet Commission report, public policy in the Trump era, was searingly critical of Trump's legacy, not just in managing the pandemic, but in reversing progress on covering uninsured Americans and much more. What can the Biden administration really do? What will its priorities be, and what lessons might there be for us in the UK as ideas come across the pond to us?

To shed some light on the Biden administration's thinking, I'm joined today by two policy experts. Dr. David Blumenthal is president of the Commonwealth Fund of New York, a foundation carrying out independent research on health and social policy issues. He's a very distinguished physician and academic, and amongst many other things. He's published a book which really is essential reading for us policy wonks, The heart of power: Health and politics in the Oval Office.

Dr. David Blumenthal: We here at the Commonwealth Fund, sit on edge waiting to see whether the Supreme Court will affirm or overturn the Affordable Care Act, and if it overturns it, chaos will break loose in the United States.

Dr. Jennifer Dixon: Professor Ashish Jha is currently Dean of the School of Public Health and Professor of Health Services Policy and Practice at Brown University. Ashish is on the front line of the COVID-19 response, leading national and international analysis of key issues and advising state and federal policymakers.

Professor Ashish Jha: The moment calls for a very aggressive global response, and I don't quite see that yet coming out of the Biden administration, so there are places where I think it needs some work.

Dr. Jennifer Dixon: Hopefully, both David and Ashish are very familiar with the NHS, so welcome to you both.

Dr. David Blumenthal: A pleasure to be here.

Professor Ashish Jha: Thank you so much, Jennifer, for having us.

Dr. Jennifer Dixon: Perhaps we can just start off with a rather broad question. We over here have been agog, looking across the pond for the last four years at the Trump administration, and in the last year about the pandemic. What is broadly Trump's legacy, both the last four years and also on the pandemic, and what's Biden inheriting? David?

Dr. David Blumenthal: Well, thank you for that question. I would say we're agog here as well. Obviously, the Trump administration has left us with a catastrophe in the pandemic, with 20% of the world's deaths, spending twice as much as any other country on health care, so it's been a catastrophe from that respect. Ashish has been on the front lines of recording that catastrophe. He's also undermined what modest protections we have against financial catastrophe for those who are ill by undermining the Affordable Care Act. Two to three million additional Americans, perhaps more are uninsured now than were when President Trump took office.

With respect to the delivery system, he has pursued a pathway of reform that is not so different from that which preceded him. On that score, at least, I would say that he has continued the process of experimentation that was begun before he arrived and was initiated actually under the authorities of the Affordable Care Act.

Dr. Jennifer Dixon: Ashish, what's your take, given you've been in pretty much in the frontline of the pandemic response, at least in the last year?

Professor Ashish Jha: Yes. It's hard to know what to add to David's comments. I mean, catastrophe is a very good description of the situation. It's been stunning to all of us who've been watching this and being involved in this, how much the Trump administration, it's a combination of both active undermining and just sheer incompetence. The general strategy by the Trump administration was to let every state more or less figure it out. It was a strategy, really born out of a political strategy that if things went badly, that the states could be blamed. It didn't work, and it didn't work because I think the American people fundamentally didn't buy the idea that for a global pandemic, which could have a 50-State strategy, everybody figuring it out on their own.

The other part of it is that for a long time, long-standing partnership in the US on public health has been that States lead, and the federal government plays a really critical role in supporting the States, providing resources, technical capacity, et cetera. The Trump administration gave up on that partnership, and so States weren't just asked to formulate their own strategies, but to do so on their own with very little help or support from the federal government. What you saw, therefore, was some states more or less figured it out and did okay. Other states really struggled, and as a nation, we've done terribly. On the broader issues of health care, we saw on several circumstances, the foibles and the challenges of the US healthcare system, really undermine our ability to have an effective pandemic response. That came up as well during this pandemic.

Dr. David Blumenthal: If I could add an analogy to Ashish’s very apt remarks about the federal-state relationship. I think you could loosely compare this to the beginning of World War II and imagine our president then, Franklin Roosevelt, I know this has resonance with your listeners. After Pearl Harbour, Roosevelt had gotten up and said, December 7th is a day they will live in infamy, we're at war with the Axis powers, that the federal government will manufacture artillery and airplanes, and all the necessary equivalent of vaccines, and then we'll give them to the States, and the States will conduct the war. That's exactly what the federal government did in so many words in dealing with the pandemic.

Dr. Jennifer Dixon: Well, what's I think quite interesting is that there have been debates in many countries, haven't there, about the federal and local equivalence of political power in handling a pandemic. We've certainly had them in Britain with the central government versus regional and local government, for example. I know in Germany, they also have had similar debates. It sounds from what both of you said is that really, President Biden and his administration is left with a mess from which one then has to impose some now order. Where are we now with what Biden has said his priorities will be given the campaign and his plan to fix some of the problems?

Dr. David Blumenthal: One of the things I've learned from the book that you mentioned earlier Heart of power, is that presidents get to do one or two big things in their first four years, and maybe in their eight years in the presidency. In healthcare, they certainly only get to do one thing, if that is their choice of focus. I think President Biden has looked at the situation, looked at his possible legacy, looked at the immediacy of the crisis facing the United States, and he has gone all out on dealing with the pandemic. He has put everything else on the back burner. That's not to say that he's doing nothing in other areas, but it is very clear that if you look at his $1.9 trillion American rescue plan, it is all in on the pandemic, but that it's a focus on other issues, like expanding coverage dealing with the 30 million uninsured Americans is taking a distant second place.

Dr. Jennifer Dixon: Ashish, what's your view about the Biden's priorities to fix COVID now, and David mentioned the rescue plan. There's also the national strategy for the COVID response that came out to the White House in January to where some of the priorities were listed. What's your take on those priorities? Are they the right ones, given the wreckage that he's inherited?

Professor Ashish Jha: Yes, so I was recently speaking to a group and was asked both to give the first six weeks of the Biden ministration a grade, and the grade I gave was an A-minus. I want to explain about the A and then the minus part as well. Obviously, by such a grade, and this is not meant to be grade inflation, I do think they're doing a very good job of getting to the heart of the issues of the pandemic.

One of the few things that the Trump administration did right was in scaling up manufacturing of several of the vaccines, and the Biden team has begun with that, but then done much, much more, and so we are going to have a plethora of vaccines in the United States, certainly by May, if not earlier. The things that the Trump ministration did badly on the vaccine, they really had little to no planning on how it was going to get rolled out, how it was going to get distributed. There's a lot of good effort there.

There's good work happening on trying to maintain policies around social distancing. One of the biggest failures, and it's hard to overstate because there's so many failures of the Trump response to the pandemic, was the constant refrain of this pandemic is going to be over any day now. The Biden team has clearly taken a very different approach, tried to be much more realistic in terms of setting expectations with the American people. All of that is good.

Why the minus? I think there are a couple of things. One is that there are important parts of the pandemic response where I feel like we're not seeing enough. Again, it's six weeks. We probably can give them a little more time, but they really do need to do a lot more around testing. There is a lot of work that needs to be done there where I feel like the administration has not been adequate. Then on the global front, even though they are such a dramatically better than the Trump administration, the moment calls for a very aggressive global response. I don't quite see that yet coming out of the Biden administration. There are places where I think it needs some work, but overall, I think they've got the right general strategy. They're focused on the right stuff. I have a few quibbles around the edges of things that they should be doing more.

Dr. Jennifer Dixon: David, in your book which you referred to, the most important thing for a new administration is to go in hard and go in quickly on the major things that you want to do, is what you said earlier. This $1.9 trillion rescue plan is ginormous, isn't it? Is it not a bit of a missed opportunity then, do you think, if they go all out for the pandemic and the pandemic response and the way you and Ashish have talked about rather than sneaking some things in there that could expand coverage more significantly, because that has been a major priority, hasn't it, in the presidential campaign?

Dr. David Blumenthal: Yes. That's a very astute observation. That package is mostly dedicated toward economic recovery and combating the pandemic, but there are a few relatively modest, but I think important expansions of coverage for the American public. The Affordable Care Act has been basically frozen in Amber since the Obama administration left office. They have added some expansions to the Affordable Care Act and some other measures that will likely add several million Americans to the ranks of the insured. That is, they will expand that AC benefits some, and that's to the good, but they did apparently make a calculation that they were not going to go whole hog and go for the major attack on the remaining level of ‘un-insurance’ in the United States.

Dr. Jennifer Dixon: Do you see, what we call here, the levelling up agenda being written all over that stimulus package, or do you think that Biden will return to that after this first initial pandemic recovery phase?

Dr. David Blumenthal: There are some elements of his agenda today that clearly fit the levelling up pattern, and they involve more funding of what are called our safety net institutions that provide care for uninsured and underinsured patients. I think there are a lot of things administratively that the Biden administration can do to emphasise equity, one of which would be to launch pay-for-value experiments in which equity is a value measure. That is where organisations healthcare providers are asked to measure the equity of the care they provide and are compensated for improvements. I think there's a lot that can be done, but the most important thing we could do in the United States would be just expand insurance coverage to poor Americans. There are tens of millions of Americans who could get access to care tomorrow, who don't have it if the 12 States that haven't expanded Medicaid were to do so.

Dr. Jennifer Dixon: For the UK listeners, the Affordable Care Act obviously was passed under President Obama. It had two broad bits to it. One bit was to expand coverage for uninsured and under-insured Americans, and the other was to have a whole suite of delivery system reforms to try to improve quality and value of health care, if I can put it briefly. In a sense, it's the delivery side that's more relevant to us in the UK, I suspect. Given that we've just said that we don't think that anything major is going to be tagged to this rescue plan, are there other things that can be done from this point, not related to this rescue plan that can slowly but incrementally increase coverage over a four-year term?

Dr. David Blumenthal: I would say there are, as Ashish has indicated, there are a bunch of things that the Biden administration can do to whittle away at that 30 million remaining uninsured. When the Obama administration left office, there were about 27 million uninsured Americans. Now there are about 30. I think we should be able to bring that number of 30 back to 27 through a series of executive actions, things like making it easier to enrol. The Trump administration put obstacles in the way of enrolment, and already the Biden administration has begun to roll those back.

The big thing that the Biden administration could do, the really big thing that it could do, is to make our Medicaid program, which is the program that we have here in the United States that is oriented toward the poor, and it's a joint federal state program through which people under the level of federal poverty or somewhat above it can be at get insurance through a combination of federal and state payments. That could be dramatically expanded, but it would probably require legislation.

Dr. Jennifer Dixon: If one approach to increase in coverage is encouraging states to expand the coverage of Medicaid, what about the other suggestion in the presidential campaign, which is to lower the eligibility age and criteria for Medicare, which is the universal federal program near universal for older people? Ashish?

Professor Ashish Jha: Let me build on something David said and maybe offer a bit more of an optimistic view of where we might end up at the end of the first term of President Biden. I do think pandemics have profound effects on societies and certainly the history of the 1918 pandemic, for instance, is often credited for leading a lot of countries to instil national health systems and try to offer health insurance. I think the political landscape around coverage is going to change over the next few years. I would not be surprised if there are more rapid changes in coverage, but just because of what the period of time we've been going through is, and that could substantially lower the number of uninsured.

We will see how this all plays out, but there could be some political momentum around, because being uncovered during a pandemic is, I think, particularly atrocious, and feels politically to a lot of people particularly unacceptable, so we'll see where that goes, but I'm maybe more optimistic that we will see real movement on that.

On the issue of lowering the age of eligibility for Medicare, in a part of it, as I go back to thinking about the people who are going to control the policy levers in the Senate, I don't see much in the way of political appetite, and David has a much better read on this than I do, for substantial changes to the Medicare program, and including expanding it or improving, getting access to other people who are not currently eligible.

It's an interesting idea, but I don't think it will end up having a lot of purchase. I think the movements on coverage will come from states and will come from tinkering with the ACA.

Dr. Jennifer Dixon: David, presumably, if the Medicare expansion is not in this rescue plan, then the path in future to get this passed when your political capital is decaying, and also presumably political appetite to spend more is decaying, the path will become more perilous to get that passed the House, the Congress?

Dr. David Blumenthal: Absolutely. The Medicare expansion is expensive, and it would have added to the $1.9 trillion figure, as would much more aggressive Medicaid expansion. I think that this is a political calculation that the Biden administration has made, and in the large, from a large perspective, for a larger perspective, they have decided that they will be judged historically, and the country's welfare will be most influenced by whether they control the pandemic and recover from its economic effects. That that will determine his midterm fate and his re-election prospects. He's right on that, and I think if I were with him, I would make the same call even though healthcare is my passion.

Dr. Jennifer Dixon: Quite apart from the political motorway way of getting stuff through the Senate, meantime, over in legal land, there are always, aren't there, legal lawsuits about the ACA that are making their way through the system, including something called California versus Texas supreme Court ruling. This is over whether a president can expand subsidies to States that don't want to expand Medicaid. I guess the question here is, are these legal lawsuits just sideshows, or could they somehow derail or strike down the ACA?

Dr. David Blumenthal: The California versus Texas lawsuit must be very peculiar for your listeners to hear about this, that two States are suing each other, and the result could be the overturning of a federal law. It is true, without going into the legal details, that the Supreme Court has heard arguments, and we are every day waiting to see what they will rule about the constitutionality of the Affordable Care Act. There are all kinds of reading of tea leaves, suggesting from comments that were made during oral arguments before the court, that the court will not overturn it on mass, but might overturn one relatively small piece of it, but that remains to be determined. Someday, the court tends to give its opinions on Thursdays, and every Thursday, we here at the Commonwealth Fund, stand, sit on edge, on the edge of our seats, waiting to see whether the Supreme Court will affirm or overturn the Affordable Care Act, and if it overturns it, chaos will break loose in the United States.

It will totally change the healthcare system. It will unravel our insurance, much of our insurance system, and the Congress will have to come very rapidly, and the President will have to very rapidly pivot to figure out what the heck to do in response to that decision. It is a hugely momentous possibility, and one that whose consequences are almost impossible to determine. I just got apparently, today is Thursday, and the Supreme Court did not decide California versus Texas today.

Dr. Jennifer Dixon: That's great timing.

Dr. David Blumenthal: Another week to wait and wonder.

Dr. Jennifer Dixon: Ashish, the question here is then, we're on the edge of our seats every Thursday, but how likely really is it that somehow the ACA is going to be derailed in this way?

Professor Ashish Jha: I think it's a low likelihood, but a couple of things have happened. The court has decidedly become more conservative, and I think that is not to be underestimated. That three much more conservative justices under President Trump. The second thing is, as David said, it's hard to think through all of the consequences of invalidating the Affordable Care Act. I don't even know what invalidating it would mean beyond it would cause a lot of chaos, and would certainly take 25, 30 million people and make them uninsured relatively in short order. To what extent is the court going to think through those things? I don't know. It could be that it could be a moment for a much more substantial health reform, but given how polarised our country is and the political structures, I don't know if it would be. I'm hoping that the Supreme Court ultimately passes on such a momentous move.

Dr. Jennifer Dixon: Just one last point on this. I mean, if all the talk has been here, certainly and in the US about we could have been better prepared for the huge emergency insult that COVID-19 has been. What about similar logic applied to the low likelihood but high risk of an Affordable Care Act being struck down significantly? Should there be a plan B? Is anybody working that up? Or is that really just something that you simply cannot plan for? Ashish?

Professor Ashish Jha: The one thing I would say is after 2020, we probably should never say, well, that's so unlikely that we won't plan for it. Somebody should probably be thinking through what happens, how quickly does it happen, or the short, medium and long-term fixes. I don't know. David may know. Maybe that planning is happening, but I haven't seen much of that discussion yet.

Dr. Jennifer Dixon: David, Plan B.

Dr. David Blumenthal: I haven't seen anything about that. It hasn't emerged in any discussions I've heard about formally or informally from the Biden administration. I suspect they're hoping for the best. What I can speculate widely on what could be undertaken, we actually have done a lot of modelling of alternative ways of getting to expanded coverage in the United States, and I think the options are well understood. The question will be what's politically feasible. If I had to guess, I would say that what's likely is that congress would restore some measure, some form of the Affordable Care Act, because it is in fact as conservative market-oriented and private sector-oriented approach to coverage as can conceivably be put in place and meet the minimum needs of the American people.

Dr. Jennifer Dixon: Let's then move on to, if we can, to the other bits of the Affordable Care Act, which is about the delivery system reform, which includes payment reforms. What were the major, could you just say for our UK listeners, what were the main aspects of the delivery system reform in the Affordable Care Act? What happened before we then think about what lessons for the UK?

Dr. David Blumenthal: Sure. well, the Affordable Care Act, as you've indicated, Jennifer, was actually two Acts. One was about coverage and the other was about reforming our healthcare system and its delivery, trying to make it more efficient. The perhaps most notable provision of that law that ended the point in that direction was the creation of a national research and development arm called the centre for Medicare and Medicaid innovation, which has launched dozens of experiments, and also put in place some significant reforms. Some of which are promising, but many of which have proven less exciting.

In general, what the most important reform that has been promulgated and pursued, actually pretty much on a bipartisan basis, has been the move toward what we call value-based payment, which is really about paying prospectively or predictably in advance for care that is lowering costs and higher quality, and involves transferring some risk from the financer of care, which would in the United Kingdom be the government. In the US, it could be either the federal government or state government, or in some cases, the private sector payer transferring some of that risk to the hospitals and doctors and other facilities that care for patients. Saying to them in effect, if you meet certain quality measures and you are allowed to keep any savings that you make, if you care for patients at less than the amount of money that is expected.

Dr. Jennifer Dixon: When you say assumption of risk, you mean that if you make savings, you can keep them, but if you make losses, you have to own them.

Dr. David Blumenthal: That's right. It's actually that fear of loss that is probably more motivating than the opportunity for gain, humans being humans.

Dr. Jennifer Dixon: Yes, indeed. Ashish, I don't know whether you can expand a little bit on the accountable care, the ACO experience and the findings there, because in a sense, if there's any parallel, it's not quite the same. We have emerging path here towards integrated care organisations, or ICS as integrated care systems which is slightly, it's not the same, but it's the idea of having an overall capitated payment for patients throughout the pathway of care is very much part of the ICS idea. Can you just say a little bit more about the ACO experiment, how extensive it is and what impact there has been?

Professor Ashish Jha: Yes, absolutely. One of the really interesting things about the pandemic is in the middle of the biggest health crisis, you saw for the first time in decades hospitals laying off staff, you saw primary care physician practices closing. Our payment system didn't work in the pandemic. You would have thought that the healthcare system would have done financially well because of all the illness, and didn't. There is going to be a lot of going back and looking at what went wrong, and our payment models don't work under normal circumstances all that well, and they're a disaster during pandemic times. I see the pandemic as substantially accelerating all of the trends that we've had, and what might have taken us another 5 or 10 years on this journey will happen in the next couple.

On the issue of ACO, this has been one of the real bright spots of the various experiments of the Affordable Care Act. Accountable care organisations, they come in two flavours, and one flavour has done much better than the other, which I do think also has lessons for the NHS. The two flavours they come in. One is hospital ACO, accountable care organisations, which are pairing up of physicians and hospitals. They have actually not done all that well. They've been fine, but they have largely not saved much money, not improved quality all that much.

The other is physician-led ACOs, ambulatory care providers banding together, physician groups banding together and saying, we're going to take care of a population. They have done well on saving money, reasonable amount of money, and improving quality and leaving people more satisfied, better off. It really raises an important set of quotations about what do we mean by integrated delivery systems. To what extent do physicians and hospitals have to be part of the same corporate entity? Should they be separate? Physician-led ACOs really have done very well. I do think you're going to see more efforts on that, and that actually lines up pretty nicely with what is happening in England with the reforms and integrated care systems. I think that's a model that really does seem to have real benefits.

Dr. Jennifer Dixon: I'm interested in that. Why should ACOs that are involving hospitals do less well, or be more resistant to ACO type of incentives than physician led AC0s? What is it about hospitals that could be causing that resistance or obstruction, if that's the right way of thinking of it?

Professor Ashish Jha: I think it's simply about the incentives. Hospitals on hospital-led ACO's have a complicated set of incentives because on one hand, if they can save money, they could keep some of it, but they're running these large high fixed cost entities called hospitals, and for them, they want to keep those beds full. Physician-led ACOs that don't have a hospital have very clean incentives, and the way they largely save money is by preventing hospitalisations. It's hard to get a hospital to put a lot of money and effort and time into preventing hospitalisations, and I think that's the biggest difference. Hospitals certainly talk a lot about this, but the evidence says that they're not very good at it.

Dr. Jennifer Dixon: David, can you say a little bit about this interesting example, the primary care, continuing care at home form of integrated care? Presumably, is that a physician-led type of ACO?

Dr. David Blumenthal: It's not an ACO per se, Jennifer. It's a model of care building on the current system. Some ACOs undoubtedly employed this model, but you don't have to have been an ACO in it. What it mostly involves is the deployment of resources that would normally be in a facility to the home of the patients, especially multi-morbid, very sick patients, and paying for care that would not normally be paid for in the home, but paying for it there. It's the transfer from an institutional setting to a home setting of primary and continuing care for highly complex patients.

Dr. Jennifer Dixon: Ashish, if I could just ask you to summarise where you think the direction for delivery reform will be given what we've learned from so far with the Affordable Care Act.

Professor Ashish Jha: Yes, absolutely. Again, and I keep coming back to the pandemic because it has such a profound effect on the delivery system and payment reform. We're seeing hospitals across the country, a lot of them financially struggling. I think there's going to be a push towards more mergers, more integrated, more systems coming together. I think we are going to see acceleration of payment model changes. The other part that it cannot be understated is how much of an impact technology has had. We often talk about telemedicine. That's the easiest one to point to, but there are a lot of other technological changes that this pandemic has accelerated. Put all of that together, and what I see is more momentum and more movement on both payment and delivery reform in the United States than we've probably had in a generation.

Dr. Jennifer Dixon: I'm going to leave it there, but as you can hear, there's no doubt, Biden and his teams face a truly uphill struggle, and we'll be following their progress with great interest over the coming years. Thank you both, Ashish and David, for all your insights and for helping to translate what might be useful to our server here as we recover from the pandemic. If you've enjoyed this discussion, there's background reading in the show notes and lots of resources on our website at health.org.uk.

That's all, folks, for now. We look forward to seeing you next time.