Kathleen Sebelius Reflects on the ACA, Potential for Biden Health Reforms

As 2021 promises to be a formative year for health care policy in the United States—what with the coronavirus disease 2019 (COVID-19) pandemic and new Democratic majorities in Congress—former HHS secretary Kathleen Sebelius and Sachin Jain, MD, MBA, CEO of SCAN Group and Health Plan, took time Tuesday to reflect on the advent of the Affordable Care Act (ACA) and examine the Biden administration’s opportunity to enact influential policy.

The two sat down for a conversation at the 2021 AcademyHealth National Health Policy Conference during a session entitled “What’s Next for the ACA and Health Reform.”

Sebelius, now CEO of Sebelius Resources LLC, was instrumental in the passing and implementation of the ACA under former President Barack Obama. Between 2009 and 2011, Jain also worked in the Obama administration and was the first deputy director for policy and programs at the Center for Medicare and Medicaid Innovation (CMMI), created as part of the ACA.

At the time of her April 2009 appointment, the country was in the midst of the H1N1 flu outbreak, marking the first pandemic in the nation in 70 years. As the United States devised a national vaccination campaign to deal with the outbreak then, “some of what we’re going through right now seems very familiar,” Sebelius said.

In addition, as a major health bill had not been passed in the country since 1965 with the enactment of Medicare and Medicaid, Sebelius felt the desire in Congress to enact new health legislation had been pent up over the years and was encouraged under the new president.

“He [Obama] was a believer and said over and over again, you can't fix the economy unless you fix health care and believed that, and that was really our mission,” Sebelius said.

Looking back, the former secretary said she would not have fought so hard to gain Republican support of the bill by adding amendments only to ultimately have the bill pass without any Republican votes. “If we knew we would not have Republican votes we could have moved a lot faster and had a different version of the Affordable Care Act at the outset, because we would not have tried to incorporate so broadly ideas that we thought might bring votes with them. But unfortunately, we got the ideas and not the votes,” she said.

Referring to how the politics played out, the ACA, “was really, essentially a very pro-private sector health care bill that ultimately got painted as something very different,” Jain said.

Apart from the expansion of coverage, the experts highlighted other, lesser-known factors enacted by the legislation that have had lasting impacts on the nation’s health care, most notably including the creation of CMMI. As the government had never previously created a research and development center to test protocol in the health care space “the most impactful change…which will live on well beyond the insurance reforms, is the creation of the Innovation Center,” Sebelius said. “For the first time, you really had administrative authority that could change the way the system worked.”

Describing CMMI as a “$10 billion self-funding pool,” Sebelius feels the center will drive massive changes as government programs continue to grow.

Touching on the challenging road ahead for President Biden’s HHS secretary nominee, California Attorney General Xavier Becerra, Sebelius endorsed the nominee’s previous defense the ACA in his home state and lauded his previous work with immigrant children, family issues, and underserved populations. “I think he is really well equipped to come into that job with a lot of experience, a lot of expertise, and knows where the administrative levers are to roll back some of the really dangerous precedent that's been put in place by the Trump administration.”

The bigger challenge, says Sebelius, will be whether the Biden administration pauses to build a bipartisan coalition or take advantage of the Senate and House majorities to quickly enact reforms. “I'm hoping they really put the gas down,” said Sebelius, “because there's an opportunity, not only to put the framework of the ACA back together, but there's a lot in this COVID-19 [relief] package that would actually enhance the affordability of health insurance. For a lot of people who qualify, it still is not affordable.”

Capping out-of-pocket costs, removing barriers to Medicaid enrollment, and more robust subsidies could all aid in improving uninsured rates that spiked as a result of the pandemic, she added. With newly proposed programs aimed at increasing health equity and public health more broadly, Sebelius hopes Biden-era policies will make it so “people will have less contact, hopefully, with the clinical side of health care and more contact with communities where they can live, and eat, and work, and breathe in, and live in a healthier fashion for longer lives.”