What’s Next in Health Policy After the First 100 Days of the Biden Presidency?

With President Joe Biden marking his 100th day in office at the end of the month, a health policy strategist sat down for a conversation—conducted over Zoom, of course—to discuss the new administration’s achievements and challenges at a session at the Academy of Managed Care Pharmacy 2021 meeting (AMCP).

Ceci Connolly, president and CEO of the Alliance of Community Health Plans, interviewed Chris Jennings, who worked for both Presidents Obama and Clinton as well as elsewhere in Washington, DC.

The two turned to the first major move by the administration, the American Rescue Plan (ARP), which is also the first major investment in the Affordable Care Act since the landmark law was passed in 2010.

Are these immediate quick fixes or is there potential for long-term impact, Connolly asked. Both, Jennings responded, noting the provisions regarding vaccine distribution and uptake, as well as the ones related to making health insurance policies purchased through the exchanges more affordable.

The bill made it through Congress through the reconciliation process, which means the measures are set to expire at the end of 2022—unless they are made permanent.

The measure covers premiums for those with incomes 100% to 150% of the poverty level and allows more individuals to qualify for subsidies, up to those with incomes over 400% of the federal poverty level. That affects the subsidy cliff, where currently income cutoffs (as low as $51,040 for a 60-year-old) mean that a monthly insurance premium doubles.

Jennings said Congress will be pressured to make these changes permanent.

“I don't see how you can have a 2-year policy where you provide that type of assistance, that people become used to those types of coverage policies, and then don't continue them on, so there'll be enormous pressure to make those permanent,” he said.

The ARP also includes incentives for states that have not yet expanded Medicaid to do so; even states that decide not to do that may face pressure regardless.

Reflecting on the crisis that has gripped the country and the world for nearly a year and a half, Jennings noted the faults and gaps that COVID-19 exposed, such as a lack of access to affordable care and health inequities, a health care system struggling to respond, and the new president's aggressive response.

“Because that's where the public is—the public doesn't want to go through this again,” he said. “There really is a theme of, it is our responsibility as a country to ensure that we are never so vulnerable as we were this time around for this type of crisis.”

In addition, despite the fact that the issues raised by the pandemic have been known to those inside the health care and health policy space for years, all sides of the health care system have not done a good job of addressing these challenges.

“We've failed on almost every single frame, whether we're talking about transportation or nutrition or housing or income or education,” he said, which made the health of the population vulnerable to the effects of COVID-19.

Asked what the role of industry is, Jennings said it starts with the health care industry becoming more sensitive to the individual needs of patients.

“It's well documented that we treat different patient populations differently within the health care system when we deliver health care. It's well documented that the health care system, in terms of how we cover people, almost explicitly says, ‘It's not my problem,’” when confronted with patients who come from poverty-stricken communities, he said.

Given that Biden did not endorse the idea of Medicare for All in the campaign, preferring instead to strengthen the ACA, Connolly asked, “What are the next steps that we are likely to see from a Biden White House and Congress in that that same vein of health reform, access, affordability, quality?”

Frame it as “cost, coverage, and complexity,” Jennings replied. “The public still is very frustrated with the complexity of our health care system, their out-of-pocket costs.”

Ultimately, he said, “the elephant in the room” has to be addressed—the cost of health care and the cost of prescription drugs. Containing cost would allow for investment in other health care areas, whether it is Medicaid, expanded ACA subsidies, or integrating value-based care with primary care, he said.

In another area of cost, Connolly asked Jennings for his opinion on a legislative priority of AMCP, the passage of a preapproval information exchange (PIE), which seeks to streamline 2 steps in the drug approval process into one. Under the idea, as a developer submits its product to the FDA for review, payers and health plans could begin a simultaneous evaluation of clinical trial and economic information in order to calculate demand and budgetary impacts.

“I would say it makes a lot of sense,” said Jennings. For a payer, if a drug comes out that was not expected, at a high cost, it becomes very difficult to manage and increases premiums. However, he noted, “It is one tool. It is not the tool.”

Paying for specialty drugs, which represent a growing share of drug spending for a relatively small slice of the population, is going to become a much larger challenge, Jennings said.

“I don't think we as a country are prepared for some of the pricing that is about to come around the corner here on some of these products,” he said. While increasing access to biosimilars and ending patent abuse would help, he also said policy makers need to be prepared to deal with pricing that at some point becomes abusive.