8 days. That is all that’s left until the Presidential election. 8 days until millions of voters go to the polls and decide the future of this country on a variety of issues. But at the center of all of it will be health care.
Note: We recognize that millions of voters have already voted early in this year’s election, breaking all previous records. Due to the record-breaking turnout in this year’s election, amidst a pandemic requiring additional precautions, if you can vote early please do so. Click here to find out additional information about how you can vote early.
Each election cycle, health care is always one of the top three issues that voters most care about. This year is no different. According to the Pew Research Center, almost 70 percent of voters say that health care is important in determining how they will vote. And for good reason. The United States continues to grapple with a surge of coronavirus cases, reporting 80,000 new cases in one day last week, the highest one-day total of new coronavirus cases since the start of the pandemic. Furthermore, hospitalizations have increased in 38 states, undermining the argument that the increase in cases is simply due to an increase in testing.
However, health policy in this election is more than just management of the COVID-19 pandemic. We’ve talked previously on the blog about how various COVID-19 centered policies will affect pharmacy and our patients, but in this post we wanted to focus more on the other significant health policy differences between President Trump and Former Vice President Joe Biden. Throughout this campaign, there are two key issues that both candidates have engaged each other on – The Affordable Care Act (ACA) and prescription drug prices. And while the two candidates have stark differences in their views on the future of healthcare in this country, there are surprisingly, some areas where the candidates agree. Like all things though, the devil is in the details.
The Affordable Care Act and Health Insurance Coverage
Let’s start with each candidate’s record on the ACA and their proposals for the future. President Trump campaigned in 2016 on the promise to “repeal and replace” the ACA. Although the ACA is still law four years later, the Administration has supported various efforts to repeal the law. On January 24, 2017, the President signed an executive order stating, “It is the policy of my Administration to seek the prompt repeal of the Patient Protection and Affordable Care Act.” It is important to note that Executive Orders cannot repeal existing laws. However, this order sent a clear message on what the President was going to focus on. Over the coming years, the Trump Administration supported various efforts by House and Senate Republicans to overturn the law such as:
- The Graham-Cassidy-Heller-Johnson Amendment
- The Health Care Freedom Act
- Obamacare Repeal Reconciliation Act
- The Better Care Reconciliation Act of 2017
- The American Health Care Act
Each of these efforts inevitably failed due to public outcry and lack of unity amongst Republicans. The ACA still remains popular with 55% finding it favorable to 39% unfavorable. After failing to repeal the law outright, the Trump Administration then focused on eliminating some parts of the law through regulatory and budgetary changes.
In 2017, President Trump signed the Tax Cut and Jobs Act, which reduced the individual mandate penalties to zero. This action has opened up a Supreme Court Challenge by the Texas State Attorney General in California v Texas. The case challenges the Supreme Court decision in the 2012 Supreme Court Case, National Federation of Independent Business v Sebelius, where the court upheld the individual mandate in the ACA as a part of Congress’s ability to tax. The plaintiffs here argue that since the individual mandate penalties are now zero, then the law is now unconstitutional and the law must be invalidated. The Supreme Court is set to start hearing oral arguments on November 10, 2020, one week after the election. The Supreme Court will also have 9 justices, pending the inevitable confirmation of Judge Amy Coney Barret, after Senate Republicans confirmed her, over Democratic opposition to the rushed process.
In the absence of repealing the law, President Trump has sought to make it harder for people to get coverage through the ACA. His administration has eliminated cost-sharing reduction payments to individuals who purchase health insurance through the insurance marketplaces and make below 250% of the Federal Poverty Level (FPL). He has also shortened open enrollment and special enrollments for individuals who lose coverage and want to sign up for insurance through the exchanges outside of the normal enrollment window. He has also cut funding for assistance and outreach resources to help guide consumers through enrollment. And finally, the President has utilized a part of the ACA called Section 1332, which granted Innovation Waivers for States “to pursue innovative strategies for providing their residents with access to high quality, affordable health insurance while retaining the basic protections of the ACA.” Unfortunately, the Trump administration has provided waivers to states that provide coverage that deviate from ACA requirements. These changes have essentially weakened ACA protections for residents in states, and have caused 1.2 million Americans to become uninsured since 2016.
For this election, the President has not laid out a clear health care vision for the future. Despite unveiling the “America First Healthcare Plan” he has done little to share actual goals. Instead the President has relied on broad statements without any specifics. For this post it was challenging to lay out what the President would seek to change going forward, but here is what we could discern as it relates to health insurance coverage. After repealing the ACA, the President says he wants to allow health insurance companies to compete across state lines as a way of reducing health care costs. However, without the essential health benefits and consumer protections required under the ACA, there is a chance that many of these new plans could end up like the Short-Term Limited Duration Health Insurance plans, otherwise known as “Junk Plans” that have flooded the market.
Former Vice President Biden
Former Vice President Joe Biden has taken a very different position, arguing that the country needs to build off of the progress made under the Affordable Care Act. The biggest addition would be the development of a Public Option.
Bidencare, as unveiled during the last Presidential Debate, would create a public option that would be available to all, including those individuals who currently reside in states that did not expand Medicaid. Remember, states were given the option to expand Medicaid eligibility and benefits to those individuals who were between 100 and 137 percent of the FPL, with greater federal financial assistance. For individuals who get coverage through the public option in non-expansion states, individuals would not be required to pay any premium and would be able to receive the full scope of Medicaid benefits. For states that have already expanded Medicaid, they would have the choice of moving the expansion population to the public option. These individuals would also not be required to pay any premiums, however states would have to agree to continue paying their portion of coverage for these patients.
Biden’s plan also addresses how individuals get enrolled into coverage. Under his proposal, any individual making under 138% of the federal poverty level would automatically be enrolled in the public option whenever they interact with certain institutions like public schools or programs for low income populations like SNAP or TANF. In this way, individuals who would benefit from coverage won’t have to wait for enrollment periods to get health insurance coverage.
Biden’s proposal also makes certain changes to existing ACA provisions. Specifically, his plan calls for expanding premium subsidies for individuals who make below a certain income level. Currently, the ACA calls for Advanced Premium Tax Credit (APTC) subsidies to be made available to individuals making below 400% of the PFL. Biden’s proposal would eliminate this cap and would focus on limiting the cost of coverage based on an individual’s income level. The plan calls for lowering the limit on insurance costs to 8.5% of income, over the 9.86% that is currently the policy under the ACA. Essentially this would mean that no family who buys coverage through the federal or state exchange, would pay more than 8.5% of their income on health insurance, regardless of income.
It’s important to note that while Biden’s plan does not call for a cap on income for APTCs, several bills proposed by Democrats that are currently in Congress call for a cap at around 600% of the FPL.
Biden’s proposal also would reinstate funding for consumer enrollment assistance that had been cut under the Trump Administration.
Prescription Drug Prices
When it comes to prescription drug prices, there are more similarities between the two candidates than there are with the ACA and health insurance coverage.
President Trump has spent a lot of the last few years focused on lowering prescription drug prices. As a candidate in 2016, Trump blasted the pharmaceutical industry for setting prices so high, and promised that Americans would pay prices similar to what other countries pay overseas (Ironically, many of these countries have prices that are negotiated by the federal government, something the Trump administration and Republicans have refused to do).
While the Trump administration has been incredibly vocal on this issue, most of what has been proposed has not been enacted, either due to a delay in issuing federal regulations, challenge in the courts, or waiting to be implemented.
Early on, his administration signed S. 2553, the Know the Lowest Price Act of 2018, which was a huge win for pharmacists. The law prohibited “gag clauses” that prevented pharmacists from telling patients that they could pay less for prescription medications if they opted to pay for them out of pocket instead of going through their prescription insurance. This was certainly a victory for the profession, as this was something we had been advocating for as a way to promote transparency for patients.
President Trump also signed the Bipartisan Budget Act of 2018, which helped close the Medicare Part D coverage gap, or “donut hole” faster than what had been laid out in the ACA. The President has also focused on reducing costs for Part D beneficiaries by capping insulin copays for some beneficiaries, though this is expected to take effect in 2021. And finally, this summer, President Trump signed executive orders allowing for the importation of prescription drugs. The FDA issued guidance last month on what this proposal would look like. The rule has caused a bit of controversy regarding safety standards and whether the importation of the smaller Canadian drug market, would be enough to significantly impact prices in the American market.
President Trump has also proposed other policy changes that we think would be the basis of a plan in a second term. Specifically, he has called for limiting prices for certain medications to those charged in other countries.He has also called for capping out-of-pocket drug costs for Part D beneficiaries, and has ordered $200 copay cards to be sent to seniors to help them limit out-of-pocket costs. This move is currently being challenged, with many government officials saying that doing so this close to an election would not be legal.
President Trump has also sought to promote transparency when it comes to letting consumers know how much medications will cost. He has proposed requiring drug companies to disclose list prices in TV advertisements, though this proposal is currently being blocked in a federal court. He has also taken up an issue that the pharmacy profession has rallied behind, which is banning rebates paid to PBMs, starting with Medicare.
Former Vice President Biden
Former Vice President Joe Biden has also focused much of his platform on reducing prescription drug costs, though his proposals would empower the government to be actively involved in these steps. His plan would create new government rules in order to set the price of prescription medications.
Specifically, Biden has called for letting the federal government directly negotiate drug prices for Medicare and other federal purchasers. This would put the US on par with many other countries that also negotiate prices with pharmaceutical companies. Biden would create an independent review board to help set the price of new drugs, based on the price of the medication in other countries. This is incredibly similar to President Trump’s proposal, although it would allow the Independent Review Board to take in additional factors to set the negotiated price. Biden and Trump also agree on other ways to reduce drug costs such as capping out-of-pocket costs in Medicare Part D and allowing the importation of prescription medications, provided certain safety guardrails are in place.
Biden also wants to focus on reining in how fast drug prices can be increased each year, limiting price increases for all brand, biotech, and high cost generic drugs to the rate of inflation as a condition for these medications to be included in Medicare and the Public Option. Since the federal government is a significant payor for prescription medications, this could mitigate some of the egregious causes of price hikes that we had seen in years past like with Epipen and Daraprim. Finally, Biden’s proposal calls for removing tax breaks that pharmaceutical companies currently receive for money spent in advertising.
What’s At Stake
We hear it every four years, but this election will be one of the most consequential elections of our lifetimes. In the middle of a raging pandemic that has killed over 225,000 people in this country alone, both candidates have drastically different views on how they would manage the next phase.
This year’s ballot is more than just two candidates or two political parties. It’s more than just policy differences. This year’s ballot is about what the future of health care will look like in this country. It’s about whether or not we believe that health care is a fundamental right for all people. It’s about whether we want to ensure that when you get sick, you will be taken care of, without having to worry about how you will pay for it. It’s about ensuring that our patients don’t go bankrupt trying to afford a treatment or medication that will save their lives. It’s ensuring that women continue to have access to the reproductive care that they need without being discriminated against and being forced to pay higher costs. It’s ensuring that regardless of your age, race, gender, sexual orientation, or previous health status that you have the ability to get the kind of care you need, when you need it.
What’s at stake is what health care means to all of us as a nation.
The election is right around the corner. Make sure you vote.
For more information on how to vote click here.
For more information on the differences between the candidates see the links below: