2020 Election with Avalere: How Are Public Healthcare Programs Expanding?

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Tune into our sixth episode of the Avalere Health Essential Voice: 2020 Election series. In this segment, our experts discuss how we might see public healthcare programs expand under each candidate and what it might mean for future legislation.
Please note: This is an archived post. Some of the information and data discussed in this article may be out of date. It is preserved here for historical reference but should not be used as the basis for business decisions. Please see our main Insights section for more recent posts.
“As with so many domestic policy issues, healthcare is deeply personal, so I don't know that it's ever going to be solved. I don't think that we ever want it to be solved. This is an area of our economy and our lives that we’ll need to continue to evolve, and where politicians will always see an opportunity to make things better.” Elizabeth Carpenter


Chris Sloan , Principal, Policy

Chris Sloan advises a number of clients, including pharmaceutical manufacturers, health plans, providers, and patient groups on key policy issues facing the healthcare industry.

Elizabeth Carpenter , President

As president of Avalere Health, Elizabeth Carpenter is responsible for the firm’s consulting, sales, and operational functions.

This interview was originally published as a podcast. The audio is no longer available, but you can read the transcript below. For updates on our newly released content, visit our Insight Subscription page.

If you would like to watch the video version, please visit our video page.


Chris: Hello, and welcome to another episode of the Avalere Health Essential Voice podcast series focused on the 2020 election. In this series, we will be covering the current state of play in the 2020 election and the role of healthcare between now and November, and into the next administration. My name is Chris Sloan. I’m an Associate Principal on the policy team here at Avalere.

I’m joined today by Elizabeth Carpenter, who runs the advisory services group at Avalere. She’s an expert on health reform, and of relevance today, public program expansion.

Elizabeth, I want to start by taking a step back. We have drug pricing proposals from both candidates. We have public program expansion proposals from Vice President Biden. Medicare for all was the topic during the Democratic primaries. And we have a lot of poll results saying that voters care about healthcare more than anything else.

In your opinion, what is driving all this healthcare focus, both during the campaign and by voters?

Elizabeth: Well, first, thanks for having this conversation. We know that this is a topic that gets me excited, so I appreciate that.

Healthcare is a perennial issue on the campaign trail, so you must look at what is driving that interest from voters. Healthcare, fundamentally, is a kitchen table issue. It is an issue that is inextricably linked in this country to the economy and to your job. So, when voters feel nervous about their jobs and their economic future, they feel nervous about their healthcare. We saw this quite a bit in the 2008 campaign at the start of the crisis. Over the past few months, this has resurfaced.

In previous years, post-Affordable Care Act (ACA), we have seen less concern about monthly premium cost. As the economy deteriorates, so too do people’s feelings about whether they’re going to be able to afford those monthly costs.

One of the key issues driving healthcare in this election, prior to the pandemic, was out-of-pocket costs and unpredictability, which is, I figured out how to pay my monthly costs, but when I get a bill that I’m not expecting, I am not prepared. So as benefit design changes and people are exposed more directly to system costs, that’s become a big issue. It’s something that’s been driving the concern around drug costs and the conversation we have around balance billing or surprise medical bills.

The last thing I would say that is politically motivating is the elimination of a benefit. The Supreme Court case around the ACA was looming as part of this election, but certainly the death of Ruth Bader Ginsburg has turbocharged that concern. We have witnessed this in various healthcare debates before.

So those are some of the issues that are certainly top of mind for voters. Many of them have been exacerbated by the pandemic and other environmental factors, which is why we are where we are today, in terms of healthcare being so front and center in this race.

Chris: So, that was a lot. There are a lot of issues going on. Do you think the policy solutions in the Biden or Trump platform are getting at a lot of those issues? Will we see some of those things solved if their plans go forward?

Elizabeth: I think there’s a couple of things here. There’s the macro political stance, and certainly both candidates are vying to say, “We’re going to protect preexisting conditions.” Of course, that materializes differently depending on which candidate you’re talking about.

I think the truth is, Chris, as with many policy proposals on the campaign trail, they’re designed to resonate politically. Take, for example, a Medicare expansion or the ability to buy into Medicare over age 60. You have to ask whether Medicare is more affordable than what we have on the market today in terms of monthly costs. Is the benefit design better than what we have on the market? Then there’s the notion that maybe a Medicare expansion in and of itself doesn’t address some of the things that we just talked about, and it becomes a bigger question of what other sort of wrap-around reforms are included as part of a proposal.

I know you didn’t think you were going to get away with this conversation without talking about this. When you look at the uninsured in this country and focus on how they’re broken up, what do you see? You see people who are undocumented, and while that’s unfortunate, I think we probably could all agree that the political will is unlikely to exist to address that population in the near term. You also see a lot of people who are already eligible for subsidized coverage, whether that’s Medicaid or exchanges, and in some cases, employer-sponsored coverage. You have people who fall into the gap of states that haven’t expanded Medicaid. What I’m getting at is that you have to ask, if you really want to move the needle on the uninsured, where do you want to focus?

I would suggest that when the rubber meets the road, we’re going to be hearing a lot more about how to incentivize states who have not expanded Medicaid to expand. How do you titrate the subsidies structure to really maximize the people who are participating in those subsidized ACA markets? How do you look at insurance coverage and benefit design and say, okay, if somebody is eligible for subsidized coverage today, why aren’t they getting it? Is there something about what health insurance is or is not providing that’s not making the market attractive or the trade-off appropriate? And then finally, what are we doing to invest in outreach and enrollment efforts?

So, I think those are topics that aren’t quite as exciting from a political perspective, but when we think about how to move the needle on the uninsured and protect Americans from higher out-of-pocket costs, those are some of the issues that will come up.

You spent the past decade or so modeling these various types of policy proposals. I’d be interested to know from your perspective and what you see in the numbers what moves the needle in terms of people choosing to buy insurance or reducing the number of uninsured people that we have?

Chris: First, I have to get over the sudden wave of depression that hit me that I’ve been doing this almost for a decade, so I’m just going to work through that.

Elizabeth: Sorry, I guess I aged you a little.

Chris: It is never a challenge capturing, or bringing into a form of coverage, people who are sick or who need healthcare. You expand coverage, those people flood in. We saw that with the exchanges, we saw that with Medicaid. It is harder convincing people who don’t think they need coverage or don’t need as generous coverage. If you’re 23 the odds that you’re going to have a terrible set of medical events are low. So, I think a lot of the people eligible for a thing and not taking it up comes down to cost, not just from premiums, but cost sharing.

Then they’re weighing whatever remaining cost there is versus their understanding of their healthcare needs. Oftentimes, that balance doesn’t work out in the favor of buying health insurance. So, I think there’s opportunities for education. Sometimes people are just wrong about that and need to know the risks. But also, tailoring some of these solutions to the people who are not purchasing coverage because there’s less incentive to buy coverage is going to help with a lot of that uptake. We look at that in the employer market and in the individual market. Those are the places we’re thinking we’ll see some coverage gains that are beyond just expanding coverage. It’s also cost and access and education and those things.

So, you mentioned Medicare expansion and some of the other policy proposals. There’s a very long tradition of Americans supporting healthcare policies in concept, but when you explain the policy, support drops. We see this in Medicare for All. Policy support tends to be above 50%. Then they are informed that a full Medicare for All means you lose your current health insurance and support drops.

Looking ahead, if we have a President Biden and Democrats take the Senate, what do you think the odds are that we see a big coverage expansion, like a Medicare expansion or an enhancement of the ACA or a public option? Are those realistic going into the next four years if Democrats sweep?

Elizabeth: That’s a complicated question, but we’ll start with a few things. One, the simplicity of the message on the campaign trail is obviously not the specificity that you ultimately need to see in public policy. So regardless of what any candidate may say in a stump speech, we all know that there’s real work to be done if that person becomes President, or if Congress were to actually make some changes or try to advance legislation. There are real policy decisions that need to be made. Historically, that moves the platitudes that are discussed on the campaign trail to something more specific, and by nature, the details of what is in that policy begin to change.

This question of whether a potential President Biden will prioritize healthcare is a fundamental one for me. If we had had this conversation in January or February, and you asked me what I would do if I was a political advisor to a future Democratic president, I would have said, I would lay down on the train tracks before I let him or her send a piece of healthcare coverage legislation to Capitol Hill.

We’re all students of history, we don’t have to go back that far to see President Clinton and President Obama and President Trump in terms of how much political capital they spent in the early days. The reality is, in our environment, there is a very short window for a new president to get domestic policy moving in Washington, DC.

Now, enter COVID and the game has changed. Healthcare has become a big issue on the campaign trail and is on voters’ minds. We are once again in a situation where, if Vice President Biden wins, healthcare is going to be a big reason. So, what does he do about it? How does his administration prioritize the somewhat long list of things that he might have on his mind?

The next question is, what is the balance of power in Congress? What are the rules? Specifically, what is the makeup in the Senate, and does a potential Democratic Senate get rid of the filibuster? That legislative process places some inherent limitations on what any President could do.

Now, if that filibuster went away and you had a majority, you could coalesce a group around moving some of these policies, but I think the reality is that almost all policies that become law or get serious traction have to move a little bit to the center of where the discussion is on the campaign trail.

Chris: I think that’s an underrated point. There’s a lot being promised legislatively in this campaign, particularly on the Biden side, and there’s only going to be so much time to do it. There is also going to be this COVID thing that’s still sucking up oxygen.

Elizabeth: …and infrastructure and climate change and taxes. The list is quite long.

Chris: It’s long broadly, but it’s also just long within healthcare. There’s a lot to chew on heading into next year if Democrats sweep.

Last question for you on this, flashing ahead past this current presidential election. We had the ACA in 2010, and it was a big part of the 2012 elections. It was a big part of the repeal and replace discussion in President Trump’s first term and what was happening in Congress. We’ve been doing this for a long time. Now it’s a big part of 2020.

Looking ahead to the 2024 presidential election, if we can be the first people talking about that, do you think this will still be an issue? Will we still see healthcare popping up at the top of voters’ preferences and as a big part of both candidates’ campaigns? Or is there a chance this gets solved? COVID disappearing reduces the emphasis. What are you predicting in terms of how salient this issue is in American politics in four years?

Elizabeth: As with so many domestic policy issues, healthcare is deeply personal, so I don’t know that it’s ever going to be solved. I don’t think that we ever want it to be solved. This is an area of our economy and our lives that we’ll need to continue to evolve, and where politicians will always see an opportunity to make things better.

With that said, and I do want to close with a little optimism because I know there isn’t much of that sometimes, but I do see an exciting opportunity. If Vice President Biden were to win and there was the political will in Congress to tackle some of these coverage issues, there is opportunity for industry to come forward with proactive positive solutions that help real people and move the needle on the uninsured. I don’t think you need to disrupt the whole system to do it. Now is the time to start to figure that out.

This is part of what you like doing so much, asking, what levers can you pull? How much do you improve people’s lives and for what costs, and how might you pay for it? Those are complicated questions, but to some degree, the groundwork laid by the ACA creates this opportunity. To the degree that the discussion moves from a political campaign discussion to one of public policy, I feel good about what some of the options might be, and the ability for people to come together to move something forward.

Chris: Very much agreed. When there are these policy discussions and vague campaign platforms, figuring out what the levers are, what they do, what they move, and how many people a subsidy can bring into coverage, is key. Obviously, we, as well many other people, do a lot of that, and it’s going to potentially be a big focus next year.

Elizabeth: And things have changed since we had this discussion in a real way. Certainly, things have changed since the 08-09 period, but things have changed since the repeal and replace discussion. Not just that underlying baseline associated with the economic impact of COVID, but we have a better sense of who’s buying, who’s not buying, and what their incomes are and where they live. Those are all helpful data points to be able to design targeted public policy.

Chris: We’ve had 10 years of healthcare reform and we’ve seen what’s worked and what hasn’t, and hopefully, whatever the next healthcare reform is, we’ll build off of some of the lessons that we learned this round to drive people into insurance.

So, that’s everything. Thank you, Elizabeth, and thank you all for tuning into Avalere Health Essential Voice. Please stay tuned for more episodes in our 2020 election series. If you want to learn more, please visit us at avalere.com/2020-election.


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