Post Election Symposium: Day 1

Session 1 Transcript

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

Catherine:

… at Politico. In this role, she has led an expansion of its healthcare coverage, tripling the size of the team. Joanne continues to write for Politico, Politico Magazine, and the Agenda. She also regularly appears on KHN’s What The Health? Podcast. Joanne, thank so much for joining us. I’m so glad to be leaving this discussion in your very expert hands.

Joanne Kenen:

Thank you. Thank you, everybody who is joining us. We’re going to talk about the election results, and what it might mean for healthcare. I have two esteemed experts. They’re both familiar to you. Robert Blendon is the Richard L. Menschel Professor and Senior Associate Dean for Policy Translation and Leadership Development at Harvard T.H. Chan School of Public Health. I think he’s now emeritus in some of his roles.

Joanne Kenen:

He also directs the Harvard Opinion Research program, which focuses on garnering a better understanding of public health knowledge, attitudes, and beliefs about healthcare and other major policy issues. And he’s somebody who’s taught me a lot about how to think about healthcare and politics.

Joanne Kenen:

We also have Liz Hamel. She’s the Vice President and Director of Public Opinion and Survey Research at the Henry J. Kaiser Family Foundation. She directs KFF’s polling work, including the monthly health tracking poll that lands in all of your inboxes every month. Thank you for joining us. Bob, let’s start with you. We’ll have some slides, I believe.

Robert Blendon:

In a moment. It’s terrific to appear, both with Joanne and Liz. What I want to try to do briefly is do a weather forecast of the next year and a half, with a lot of humility. As you know, the weather forecast has not been particularly good, and the polling ones have not been much better.

Robert Blendon:

So for this, and I want you to understand two stories that have appeared front page in the media since the election results are mostly over. One said that the new administration will lead sweeping changes in health and health policy. And then the next day, you pick up the paper and it says, “President faces serious gridlock challenges with Congress. Little of significance will happen.”

Robert Blendon:

And I want to explain to you, over the next year and a half, how both those headlines are correct. And I want to explain what’s actually happened in the country, how it affects the election results, and how it’s going to affect health policy. So, since the 1990s, the mid-1990s, what’s happened in this country, if you survey people on simple questions: “What do you want the federal government to do to solve the big problems facing the country?”

Robert Blendon:

People who said they were Republican and Democrat in 1994 were this far apart. They were not together. Please, let’s not pretend there was another America. But they were that far apart. Now, they’re that far apart. It’s doubled since 1994. And the answer to the simple questions, “What do you want the federal government to do about this?” And this would all be interesting, except one other thing happened that, if you’re in healthcare, you often don’t pay a lot of attention to.

Robert Blendon:

The parties really became different. So, if I’m a Republican and I ask you one other question, “How do you see yourself politically?” 72% say, “I’m a political conservative.” If you’re a Democrat and I just say, “I just want to know. Give me one answer. How do you see yourself politically?” If 53% now say, “I’m a political liberal, or in the modern term, progressive,” for that.

Robert Blendon:

And so, what happened is not only the switch, but people decided that if they were Republican or Democrat, that you could only vote in primaries if you’re one or the other. I don’t want a senator or congressman that doesn’t reflect my views. So, since the mid-1990s, if you’ve noticed, we’ve been challenging Republicans and Democrats who were incumbents. And conservatives have been winning on one side, and more and more liberals and progressives on the other.

Robert Blendon:

Massachusetts just had a major election between two Democrats for that, which was decided in the primary. But really, there was no Republican opposition. And so, where that leads is that, and I’m very sympathetic because I’m part of this other world, if you want to predict what the Congress is going to do, and I’m going to focus on that most, you have to understand that in today’s world, the Congress follows the majority of the party views, not all of the public.

Robert Blendon:

And it’s overwhelmingly significant. A whole group of political scientists have published papers which study the votes of members of the Congress, and show it doesn’t correlate with public opinion. It correlates with the Republican or Democratic opinion, whosever in the majority.

Robert Blendon:

So, what’s important to understand, and we have not settled this yet, though we’re fighting when the president’s going to turn over the advisory authority to President Elect Biden, the Senate isn’t fully settled. There are two Senate seats that are up in Georgia, that will be voted on in January for that.

Robert Blendon:

If the Republicans win one, they are in the majority. Every chair of every committee is Republican, and the policies will reflect that. The Democrats, if they were to win both, would just have an edge in the Senate. But I need to make this point very clearly, and then I’ll show you why it really matters.

Robert Blendon:

Republican senators were not elected in this election to help President Elect Biden implement his health agenda. Question after question. “No. No. That’s not what I want to do. That’s not where I want to go.” So, if I am Mitch McConnell and I am chair of the Senate Finance Committee and the Health Committee, and I am a Republican, I did not get elected. And if I have a primary challenge, those primary challengers are going to hold me to what it means to be a Republican, and in the House, a Democrat.

Robert Blendon:

So quickly, just so you see this, what does this mean in real life? So, after the death of Supreme Court Justice Ginsberg, the question was, “Do you fill the seat before the election’s over?” The poll results said 57% of Americans said, “Wait.” But if you look very carefully, 80% of Republicans said, “Fill it.”

Robert Blendon:

Well, if you know what happened, the Republican leadership didn’t wait two hours to fill that job. Just to be bipartisan here, understand that when the ACA was enacted, the majority of Americans told pollsters they didn’t want it enacted. The majority did not favor it.

Robert Blendon:

The majority of Democrats overwhelmingly favored it. It passed closely. But the Democratic leadership with both houses did not wait for majority opinion. And so if you want to look at what’s going to happen over the next year and a half, two things can happen. And I’m going to actually drag Joanne into this, because Politico is more of an expert in this than I am.

Robert Blendon:

We have left the Presidency with unbelievable executive powers in this country. I don’t think many people realize, over the last decade, how many things the President can do without calling the Congress. So, day one, we’ll be back in WHO. Day two, we’re going to back in the Paris Agreement. No Congress, none of this. Wake up, the head of WHO will be sipping Coke with the President for that.

Robert Blendon:

And so, there are a whole series of issues, which I hope Joanne’ll cover, where you can expand the ACA. You can enter into some price negotiations. You can change the environment for Medicaid. You could use demonstrations, which look like you’ve changed the law, except they’re called a “research demonstration,” which requires that they have to hire Liz or Bob to come by and bless them every six months, “Oh, we’re studying how all of Oklahoma’s going to change its payment system.”

Robert Blendon:

So, there are dramatic things the President can do, and I’m going to leave you with questions in a moment. I’ll hit the issues, but will not solve, but I want to you show one slide. And the minute you move your eyes from “all” to “Republicans” and “Democrats,” you see exactly what the climate’s going to be.

Robert Blendon:

So just, “Do you favor universal coverage or not?” You notice that the professor doesn’t spend any time looking at “all.” Republicans, no. Democrats, overwhelmingly. So, just tell me who’s in charge and I’ll tell you in the Congress. Okay, big health reform. “Do you favor expanding and improving the ACA?” 24% of Republicans, 89% of Democrats.

Robert Blendon:

How about Medicare for All, whatever that turns out to be? 24% of Republicans and 63% of Democrats. How about expanding Medicaid to really cover more people and pay for more services? 25% of Republicans, 63% of Democrats. We’re going to talk about COVID and the question period. Who should be in charge of really running and making the decisions? Who closes you down? Who says if you have …

Robert Blendon:

Republicans want state and local officials to lead. Not Democrats. They want the President to have mask mandates and everything else, right out of Washington. Also, just so I can show you what the pictures will be that’ll change, Republicans and Democrats differ in their trust in medical scientists in the public interest.

Robert Blendon:

And so, you’re going to go from President Trump leaving at some date to President Biden, and you’re going to find the Oval Office surrounding with white coat scientists. It’s going to look like Grand Rounds at the NJH. President Biden is going to say, “I’m credible because Dr. [inaudible 00:10:54] that scientists from that flying in or advising me.”

Robert Blendon:

There was no white coats surrounding the President before that. And so, we’re going to see a shift. And so, in the period when we open up, I can answer questions about what it might mean for universal coverage, COVID, race and disparities. And I will just make this point and then we’ll go back to it later. Basically, even though there are conflicts in the Senate, basically President Biden would not have gotten the nomination without Black voters. You have to understand this.

Robert Blendon:

It’s totally different than public views. He went into South Carolina as somebody who was going to teach at Harvard when he was through, and he left South Carolina as the absolute winner, and went through the South, primary after primary, and why did he win? It was Black voters.

Robert Blendon:

And so, this administration and every act that it takes, with or without the Congress, is going to enter an oversight regulation focus on race and health and disparities. And it’s not just the policy. It is that this is downright politics. The President is there because of Black voters.

Robert Blendon:

We’ll hit drug prices. We’ll hit gun control, and then I just want to make one other point. Many state and major cities next year are going to have horrendous deficits, and somebody just put out a chart. It’s slightly better, but the deficits will be very large.

Robert Blendon:

They’ve been borrowing from this, and while we’re talking about how Democrats are going to expand spending in 54 different areas, you’re going to discover cities without help, laying off teachers, laying off public health people, cutting back mental health services, unless the Congress and the President give special emergency aid to states and local governments.

Robert Blendon:

This is going to be an incredible, controversial area, and very hard for the public to understand because Biden talked about trillions for this and trillions of this, and why is New York City laying off people? So, let me quick turn it over to Liz, and we can take questions on every issue of how this will play out. But the point I just want to leave you with, polarization has led, if it’s Republican Senate, to be in a very different place than people who voted for the President Elect.

Joanne Kenen:

Liz, why don’t you give us your overview and then we will follow up on some of these questions.

Liz Hamel:

Great, thanks. And I do have a few slides. Thanks for that, Bob. It sounds like we have a lot to tackle, and I’m going to show a few more data points. I’m more of a visual person, so I do have a few charts. But I promise to keep it brief, and I look forward to getting on with our discussion. So, if we can have the first slide?

Liz Hamel:

Just looking back at what has happened over the last several election cycles, healthcare has been an important issue to voters, and that’s mainly been centered around the passage, implementation, and calls to repeal the ACA. We saw in the 2018 midterms after the failed attempt at repealing and replacing the ACA, that the issue of preexisting condition protections became a dominant theme in the midterm election advertising in 2018.

Liz Hamel:

And early in the 2020 election cycle, our KFF polling back in February found that healthcare and the economy were the top two issues that voters said would be most important to their vote for president. If you think back, this was during the Democratic Primary debates, and it seemed like everything we were hearing about was Bernie Sanders’ Medicare For All plan. Are you going to be able to keep your private insurance?

Liz Hamel:

That all seems like ancient history now by October, following the rise of the pandemic, the economic crisis, the summer of protests over racial justice. When we asked voters in October about the most important issue in their vote for president, you see healthcare sort of fell down the list, and was a second tier issue among some of these other issues.

Liz Hamel:

Obviously, this is a little bit of an oversimplification. These issues are overlapping. The pandemic is a healthcare issue, and with the focus on rising costs, healthcare is also tied up with the economy. But certainly, the healthcare issues being discussed in the campaign in October were a far cry from those being discussed in February.

Liz Hamel:

If we can go to the next slide, I just need to say that, issues aside, we have lots of data points showing that the presidential race was largely a referendum on Donald Trump. So, during the Democratic Primary, more voters said they’d prefer a candidate who could defeat Donald Trump than someone that agreed with them on the issues.

Liz Hamel:

I don’t know if that next slide is coming up yet, but I have some data from the AP VoteCast survey of voters, and you can see that President Trump was the dominant factor in the election. About half of Biden voters said their vote was mainly against the President. About eight in 10 of Trump supporters say their vote was in support of him.

Liz Hamel:

I’m not seeing the slides moving, but I’ll go on and talk about the data points on my third slide. That’s the second one. If we can move to the third one? However, just because it’s a crowded issue environment, and just because Trump was a dominant factor in the election, it doesn’t mean that voters don’t care about healthcare.

Liz Hamel:

We asked voters in October about a variety of different healthcare issues, and how important each one would be for their vote. You can see them here, and you can see that a big majority say that all of these issues are at least somewhat important, and majority say many of them are very important, with protections for preexisting conditions at the top of the list.

Liz Hamel:

So, voters may not be making their voting decisions based on the details of candidates’ health plans, but they do care about healthcare. They want to hear candidates talking about it and making them feel like their concerns are heard. And this is one reason why we hear candidates on both sides of the aisle talking about protecting people with preexisting conditions, even if the details of their plans or lack thereof couldn’t really be further apart.

Liz Hamel:

On the next slide, Bob showed some of the deep political chasms between Republicans and Democrats on questions of healthcare policy. This is true in a broader sense as well, particularly when it comes to the pandemic. Here’s one example from the AP VoteCast survey. You can see that a majority of voters said it’s more important for the government to limit the spread of coronavirus even if it damages the economy. About four in 10 said the reverse.

Liz Hamel:

But look at the big divide. 89% of Biden voters saying it’s more important to limit the spread of the virus, 71% of Trump voters saying the other thing. This kind of echoes what we see across our KFF polling work. Over the course of the spring and the summer, those partisan divides on questions about the virus, everything from mask-wearing, personal risk perception, trust in public health officials, those divides grew over time.

Liz Hamel:

And it highlights a massive challenge for the Biden team when they take office. They need to combat rampant misperceptions, repair public’s trust in public health agencies, and perhaps most importantly, they need to try to convince people it’s not a trade-off between dealing with the economy and dealing with the virus. You need to control the virus in order to get the economy back.

Liz Hamel:

Finally, just one slide highlighting one more challenge for the incoming administration. It’s especially timely given the positive vaccine news we’ve heard over the past week. For a vaccine to be really successful, we’re going to need people to take it. Multiple surveys have shown a decrease over time in the share saying that they would take a vaccine, although I saw a Gallop release this morning that, in their data at least, it was bouncing back up a little, and that was from data before the election.

Liz Hamel:

We’ll see what happens now that we have some news of an actual vaccine, but what we have seen in our polling and others is that there are two groups that are more hesitant to take a vaccine. One is Republicans who are less likely to think the virus is a big deal. But perhaps more concerning, among Black adults, this is a group that’s been disproportionately impacted by the pandemic, they’re less likely than White or Hispanic adults to say they’d be willing to get vaccinated.

Liz Hamel:

And this isn’t because of a lack of concern about the virus, but it really reflects a distrust of the medical system and concerns about racism and mistreatment that have been persistent in the Black community. So, besides political divisions, this is another challenge ahead for the incoming administration. So, that’s all my data. I look forward to squeezing in a discussion of all these interesting points.

Joanne Kenen:

Okay. As we converse, I’m going to work in some of the audience questions at the same time. These are two related questions. We’ve gone from a country that Bob said we were this divided, to further than you can reach divided. Does that mean we’re in for a period of complete and total whiplash? Every four years, our national policies are just going to go … And also, what is the role of independents? Are people really independent, or are they really a party member or consistent voter in one party, but they like to say they’re independent?

Robert Blendon:

So, briefly, first, independents are wonderful, except they don’t vote in primaries. They also give less contributions. They also don’t man booths to get people to turn out the vote. And so, as more and more people enter primaries with very strong opinions, there are a lot of people who are in retirement because they said, “My campaign is running for the independents.”

Robert Blendon:

It turns out if you can’t get the nomination, you’re not going to get that. So, there is more and more … Yes, in the two weeks before the election, “What can I do to appeal to independents?” But to not have a primary challenge, to have to spend $50 million with somebody in my primary is saying, “I am hugging one party or the other.” We’re not leaving that period at the moment.

Robert Blendon:

Secondly, I am very guilty. I warn everybody, “Please do not attend sessions that say, ‘What is healthcare going to be 10 years from now?’” Because of this political polarization, we are going to back and forth. Just remind people historically, Clinton won and [inaudible 00:21:48] “This is the new era, everything else.” Two years later, he lost the House and Senate.

Robert Blendon:

Obama wins, “It is the future direction and the ACA is going to set everything …” He lost the House and Senate in two years. President Trump was going to change healthcare and regulation. He lost the House in two, for that. And we are likely to see huge variations for it.

Robert Blendon:

And something that’s very important, that I didn’t hit. Republicans, if they could ever get their act together, have a preference for state policy making. And in their world, if they could agree … and simply, the reason why they can’t come up with a policy, is that they have half Republicans who don’t think you should do anything around universal, large-scale coverage.

Robert Blendon:

You have the other who think you can’t get away with it, Richard Nixon’s view, without doing something, but it should be run by states. And so, Republicans, to a degree, that are in authority, are going to try to push whatever exists into the more private sector and into the states. So, I do believe we’re going to have cycles for at least a decade, and it’s really going to matter. And I love independents, and if you can catch a primary, it would be really helpful.

Joanne Kenen:

One of the things that’s been interesting, and maybe underappreciated, as we’ve had these bigger and bigger chasms over healthcare, to the point that even a pandemic is politicized, right? We can’t even agree on basic science. There’s also been a big shift in that, even though we don’t believe as a country, we really haven’t come to an agreement that healthcare is a human right or a basic right, we do believe in covering preexisting conditions now. That’s across the board.

Joanne Kenen:

Trump didn’t actually come up with a policy that would do it. I mean, he has an executive order saying it would be really nice, but there isn’t an actual Republican plan to do it. But at the same time, the ACA has survived and taken root in ways … I mean, even the Supreme Court was surprisingly … They’re not usually that clear about what they’re going to do, and they’re not going to throw it out.

Joanne Kenen:

So, are you seeing any polling data, either of any emerging other areas that may be a surprising agreement? Or what does this preexisting condition consensus say about maybe being able to not have whiplash on everything, and that some things do settle down?

Liz Hamel:

Yeah. I think one of the things about the preexisting condition issue is that it just really touches a lot of people. When we ask people, you can look at estimates of how many people actually have conditions that would have been deniable prior to the ACA, but if you ask people, “If you or someone in your household has a condition that would be considered a preexisting condition,” we get a majority saying, “Yes.”

Liz Hamel:

But voters are not going to look at the details of a plan to decide if it really is going to protect preexisting conditions. President Trump just had to say that he was going to do it, and his constituents, his base believed that he would. I think if we look at other issues where there’s consensus among the public, and we might see some movement in Congress, it’s surprise medical bills and prescription drugs.

Liz Hamel:

I think we said, after 2018, those were probably the two areas where Congress could do something. We saw maybe a little bit happening on prescription drug, but I think now, given a divided Congress and administration, I think those are still the two areas, and certainly areas where the public wants to see action.

Liz Hamel:

We know that surprise medical bills are a big source of economic anxiety for people, and prescription drug costs are something, when we ask about varieties of ways to lower prescription drug costs, you get 80% of the public saying, “Yes, this sounds like a good idea.” So, I think those are probably the two areas where we could see something happen.

Joanne Kenen:

I’ve had some questions, and there’s obviously been a lot of discussion. I know Bob feels really strongly about not analyzing what went wrong the political polls until we know that researchers are looking at it, and we know it’s going to take a while to figure it out. There’s a second kind of poll when you’re polling on public policy or you’re polling on issues. Do we know if … Liz, what role do they still have, and can we still count on them? Because the electoral ones …

Liz Hamel:

Yeah. It’s a crisis for those of us who do issue polling every time we have an election, because the expectations for how accurate those election prediction polls are going to be, and when we’re so closely divided, it’s inevitable you’re going to have some misses.

Liz Hamel:

Some of those problems are particular to trying to figure out … When you’re doing election polling, you have to guess who your popUlation is going to be. The type of polling where we’re doing of the general public, we know what the general public is. We know what the demographic are and how to weight the data, so we’re not dealing … Some of the problems facing election polling still face our field.

Liz Hamel:

We’ve had declining response rates. We have ways to deal with that, but if there is a systematic non-response from conservatives, that will affect our issue polling as well. But it’s not quite as much of a challenge for us as it is for the polling that’s trying to predict elections.

Joanne Kenen:

Does the public like … I mean, we know they like being divided because they vote for extreme … Well, people who vote in primaries tend to be more at the extremes of their party, and that distorts who ends up getting on the ballot. But do we know whether people really like this sense of division we have?

Joanne Kenen:

We look at it and we say, “Oh, they’re so divided.” Do you have any sense of people thinking, “Hey, it’s time that we start coming together”? Or are there … I mean, we know what Twitter’s like, but that’s not the real world. I referred to “President Elect Biden” in a tweet, and I got, “Ah, he’s not President!” Blah, blah. But does the country look at themselves the way we look at the country?

Robert Blendon:

Yes and no. So, as a whole, the general public would like the country to come together. The problem is in actual behavior. It’s just like, “Are you worried about obesity?” “I am.” “What are you getting for your children’s Thanksgiving?” “Well, of course, I’m getting cakes and I’m getting ice cream and blah, blah, blah.”

Robert Blendon:

So, the people who choose to vote in primaries are people who feel very strongly that their candidate represent them. And so, they’re not against if the other party wants to shift their view, but they feel very strongly that they want their candidates … and if you look at the challengers to Democrats recently, “Yes, let’s bring America together, as a progressive.”

Robert Blendon:

They’re not interested in saying, “No, I’m going to throw out my views about the Green New Deal and this, so we can all be together and do moderate policies.” So in reality, people who vote and elect have very strong feelings that they want their candidate to represent their view.

Robert Blendon:

So, there are lots of nonpartisan issues. And we identified some, and opioid abuse. There’s others and the NHS is for that, where people don’t want to do it. But basically, the strength of opinion of people who are politically active in their party has increased, not decreased, for that.

Robert Blendon:

And what Pew has shown is that people who are attached to their party have decided, socially, they don’t like people from the other party. There’s actually a poll that says, “I won’t date somebody who is either for or against Trump. I really don’t like to talk at family matters about politics, because I disagree with it.”

Robert Blendon:

That’s not a sign of, “Let’s all come together.” If you can’t get your family around the table to feel comfortable about talking about this, I don’t see the Congress for that. So, we’re going to be in a period, I believe, where we are going to have sharp divisions.

Robert Blendon:

And the question is to find issues and approaches to policies that can move, but also back to … I’m going to get this to you again, President Biden’s got to go walk in the White House and say, “Give me 80 things I can do by executive order. I’ve had enough having dinner at the Senate. Well, it used to be a wonderful place and John McCain hugged me and it was great. Not so much anymore. So, give me 80 things I can do and not have to go visit the Senate.” That’s your job, Joanne.

Joanne Kenen:

I think it’s … Well, very briefly, I think we should remember that President Trump ran on repeal and replace. And not only did he run repeal and replace, he said he was going to do it on day one, right? He was going to call a special session of Congress and all that. And Congress spent a year huffing and puffing, and they did not blow it down.

Joanne Kenen:

But that doesn’t mean he didn’t have an imprint on the ACA. He had a big imprint on the ACA, and a big imprint on Medicaid. And there’s some things Biden can do really easily. Some executive acts would be easy, should he choose to do them. Some are going to be more difficult, more contentious, and would end up in court.

Joanne Kenen:

One really easy thing he could do is, Trump didn’t do a lot of outreach on the ACA. He cut back the navigator budget. He cut back outreach. I think a lot of the country doesn’t even know right now that AC enrollment is … You don’t even see anything about it. It’s six weeks. We’re already partway through it. We’ve got one more month. It’s coming in.

Joanne Kenen:

The early numbers, that it’s low. Biden could do … This season will be over before he takes office, but it’s under his power to create a special enrollment period, or to change the dates. And certainly, just talking about it, restoring the navigator. There’s a lot of things he could do right there.

Joanne Kenen:

He can’t get the public auction through the Senate. He can’t get Medicare age changes through the Senate. He could probably do an awful lot to strengthen the ACA because there’s need out there. We don’t know how much many millions, but we know millions of people lost their jobs. Many, we’re not sure how many, lost their insurance as well.

Joanne Kenen:

There’s clearly uninsured people there, who were insured before the pandemic. So, I think that’s one area you could see. But I actually wanted to ask you both about the issue of trust. One thing that really struck me … We are so divided. I mean, masks are a political symbol, not a healthcare item, right?

Joanne Kenen:

Right after the election, we surveyed the governors who didn’t have mask mandates. And it was, “Hell no.” Right? It was like, “We’re not going to do that.” People were personally responsible, et cetera. In the last 10 days or so, four Republican … I think it’s four Republican governors, since the election, have either instituted a mask mandate, or strengthened a narrow one that they had.

Joanne Kenen:

So, when the tone changes at the top on public health, not on some of the things that have been contentious for years, but the tone changing at the top from Biden, combined with the fact that this virus is so everywhere now. There’s no part of the country that is not affected. The death rate is going up. The death toll is going up. We’re seeing a million cases a week a state now.

Joanne Kenen:

Is that going to change? At least, can we take baby steps toward trust in public health? And that’s probably my last question for the two of you. Think about that, or what is the area? If it’s not masks, if it’s not a virus, is there an area that we can begin to build, even if it’s unusual partnerships, to begin to restore … You’re not going to restore trust in this country. You’re not going to restore unity in this country in an inaugural speech. But are we seeing any kind of window now? Liz, do you want to start?

Liz Hamel:

Yeah. I will say, I did see one poll come out this morning from Axios and Ipsos that showed that Republicans were starting to take the virus more seriously, and this probably reflects those huge case load increases we’re seeing in rural areas and parts of the country that hadn’t previously had it.

Liz Hamel:

So I think when it hits home from people, they are going to take it more seriously. Of course, there were still big divides. But I think, to your point, I think we will see Republican leadership taking those steps when it’s not just rhetoric, when it really is about protecting lives in your state. I think we will see that, and I think we’ll probably see it among the public as well. It may never be completely … You won’t get rid of the divide completely, but it could change a little bit. And yeah, I think we only have a few minutes, so I’ll let Bob respond as well.

Joanne Kenen:

Have you ever seen anything in public health as divisive as this in your long polling career?

Robert Blendon:

So, first of all, we’ve had a national tragedy. This occurred around an election. And so, if it wasn’t around an election, I believe it would have been framed, as we do with a level five hurricane. It’s a natural, national disaster, of which Republicans and Democrats rally for [inaudible 00:35:21] or the fires, wildfires in California. For that, years ago, when we studied hurricanes, we asked who people trusted, it was head of the National Guard, about whether or not they should evacuate, or not.

Robert Blendon:

People, if they get in their heads, it’s a natural disaster. It’s something like we never had before. We got to deal with this, they tend to trust experts and authority figures around the natural disaster. But this got to be framed as whether or not you’re for the economy, or you’re for experts closing down their lives. And that is a terrible frame, and it entered the political stream in a way that other natural disasters just don’t, for that, and so we’re going to have to just try to escape the political frame.

Robert Blendon:

My God, when the hurricanes hit, you got to go to a shelter. “No, I’m against shelters because I’m conservative.” It’s absurd. Of course you’re for shelters. Conservative or liberal, you want to save people’s lives. Get off this. And church groups are running in, “We got to do all these things.”

Robert Blendon:

And this has got caught in this election, in a very vicious partisan election for that. So it’s going to be tough to get that. At the second time, I think if you just look at these surveys and over again, and the public health people are getting a little sensitive, and they surely are in Europe, closing down people’s livelihoods has a very significant impact.

Robert Blendon:

Wearing a mask does not. It annoys libertarians. It does not alter your livelihood, your kids’ chance to go to college. And so, if you watch Europe, these prime ministers are trying to say, “I have to moderate this. I have to find a way that we control some of this, but I can’t go back to telling you that the meat industry doesn’t open for that.”

Robert Blendon:

So we’re going to have a period here of trying to find some way that we stop this virus until the vaccine, or doesn’t have an impact, without having the type of economic impact we did. So, the president will rely more on experts. But even, I’ve noticed, some of the experts have said, “We have to be much more precise. We can’t just close the economy.” They have learned that there is a practical implication of saying that, “We’re not going to have anything for that.” But we suffer from this having this occur in the middle of an election. It’s just awful.

Joanne Kenen:

Well, we are just about out of time. I could talk to the two of them forever, but there’s another session coming up. So, thank you for joining us today, and Catherine is going to tell you about how to move on to the next session.

Catherine:

Right. Thank you, Joanne.

Robert Blendon:

Liz, Joanne, take care.

Catherine:

Yeah. Thanks, Bob. Thanks, Liz. Thanks, Joanne. Great way to kick us off, and in the vein of polling, we also want to make sure our programming involves our community, so please take time to complete the brief evaluation survey that you’ll receive immediately after the broadcast ends, as well as via email later today.

Catherine:

And I encourage you to join us again for our other sessions, especially for one that’s happening in the next 15 minutes. And you should have a second Zoom link to join that second session. Thank you so much, and see you on the next one.

Catherine:

(silence)

Lori Reilly:

As we look at healthcare in 2021, one thing is certain: We need to beat COVID-19. PhRMA member companies are working around the clock to develop therapeutics and vaccines to treat and prevent this disease. We’ve seen some great news on their efforts in the recent days and weeks, and our early success is helping us move forward in our fight against COVID-19.

Lori Reilly:

We look ahead to 2021, we also to address patient out-of-pocket costs. In response to COVID-19, Americans have a renewed sense of unease around both the quality and cost of their healthcare. In fact, a recent poll showed nearly 60% of voters worry they don’t have adequate coverage needed in the case of a major medical event.

Lori Reilly:

There is an urgent need and desire for policies that ensure fairness, access and affordability, while also maintaining healthcare choice and quality. We stand ready to help in that effort, promoting policies that would lower what patients pay at the pharmacy counter, like capping out-of-pocket costs and deductibles, and allowing patients to smooth their costs over the course of the calendar year.

Lori Reilly:

Next year, PhRMA will continue to work with policy makers and regulators to put COVID-19 behind us, to advance policies that lower what patients pay, and to sustain and protect a robust innovation ecosystem that makes it develop new medicines. Thank you. As we look at healthcare …

Peter Leibold:

Hi, my name’s Peter Leibold. And on behalf of Ascension, and as a board member of the Alliance for Health Policy, I want to thank the Alliance for sponsoring and organizing this important discussion around health policy in 2021 and beyond. An important part of Ascension’s mission is to advocate for a more just and compassionate society through our actions and our words.

Peter Leibold:

We have done since our founding, and we will continue to do so in the years ahead. For that reason, we strongly supported the enactment of the Affordable Care Act. In 2021, and in the years beyond that, we will continue to advocate for policy changes designed to improve and expand the reach of the Affordable Care Act.

Peter Leibold:

In 2021, we will also advocate for continued financial and regulatory relief for hospitals and clinicians on the front lines of struggling with the COVID-19 pandemic. We will provide suggestions to improve emergency management and coordination to prepare us for the next pandemic or emergency.

Peter Leibold:

We will support efforts to expand and accelerate the tremendous progress we have made on virtual care, and we will engage in dialogue with the Hill and with the administration, so that we can provide care consistent with our values and our mission. So, thank you for allowing us to support and sponsor this particular dialogue, and thank you to the Alliance for promoting it.

Kelly Appenzeller:

Hi, everyone. This is Kelly Appenzeller with the Alliance for Health Policy. If you are still logged into this Zoom session, please close out of this Zoom window and make sure that you open the link that you received via Zoom roughly one hour ago for the session two link. This session will now end. If you need to, you can re-register at our website for panel two, or please look in your email for a message from Zoom about session two, and the link to access there. Thank you, and we will see you shortly.

 

Session 2 Transcript

(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.