Politics. Almost no one reads political convention platforms. If the prose style isn't enough to repel, then the dog-eared ideas whose usefulness was last in evidence 15-20 years ago should be enough.
The draft Democratic platform released ahead of the convention, which is scheduled to begin tomorrow, does not disappoint. Driven mostly by what is expected rather than by what is needed means it is hard to find many significant differences between the party's 2020 draft and the 2016 adopted, especially as it relates to health care.
The 2020 draft continues the call for a public option, a reduction in drug prices, support for long-term care services, security for reproductive rights, funding of substance abuse treatment and investments in science and research. The 2020 platform does add new language in support of policies that address gender, race and geographical health disparities and protection of the health care workforce.
What makes the 2020 platform worth a read is finding the small shifts in policy hammered out in some coronavirus-era version of a backroom between the many tentative alliances within the party. Take the public option, for example. Unlike the 2016 plan, the draft platform, adopting the policy of the Biden-Sanders Unity Task Force, calls for a public option offered on the ACA exchanges and administered directly by CMS, not a private insurer. The public option, according to the 2020 platform would be available by default to anyone living in a non-expansion state who would otherwise be eligible for Medicaid.
Another shift can be found in the drug price policy. In 2016, after a lot of internal debate - Hilary Clinton was perceived as a friend of Pharma - control of drug prices rested on Medicare negotiation and improved competition. In 2020, the negotiation language has been retained but extended to all types of coverage and price increases would be capped by inflation.
These small and very likely, unrealistic, policy changes mark a shift to the left that is belied by the candidates themselves. The records of Joe Biden and Kamala Harris would not be mistaken for those of a left-wing firebrand like Bernie Sanders.
The importance of these leftward shifts lies more in understanding how power - if not position - are shifting within the party, the implications for which are not likely to be felt until 2024 or beyond.
Policy. Meanwhile, the Trump administration has its own form of radicalism going. Medicare Rule-A-Rama now underway at a Federal Register near you, has produced new policies for physicians, hospital outpatient departments and ambulatory surgery centers.
The new policies for physicians include the proposed extensions of telehealth coverage and reimbursement established during the response to the COVID public health emergency, as well as those for other technology supported physician-patient interactions like Remote Physiological Monitoring and Communication Technology-based Services.
The new policies for hospital outpatient departments include an end to the "Inpatient Only List" which dictates the procedures that must be performed in a hospital on an inpatient basis, because, presumably the lawyers at CMS have a better sense of that sort of thing than your own doctor.
In a radical departure from history and tradition, CMS is going to presume each physician will select the site of service that is most appropriate for the patient. Doctors, being who they are, will be slow to make changes and will likely look to specialist societies for guidance which will develop over time.
As a complement to that policy, CMS is also proposing new standards for adding procedures to the Covered Procedure List for Ambulatory Surgery Centers. Historically, CMS has taken up consideration of procedures after a recommendation from an advisory panel. In the future, the regulators are proposing to democratize the process and allow procedures to be nominated for addition to the Covered Procedure List from the public.
After their recent court victory, CMS has also proposed another reduction in reimbursement for 340B drugs; from ASP-23% to ASP-28%. The 340B program is credited with health system acquisition of physician practices, especially in the areas of rheumatology, oncology and ophthalmology. The change in 340B reimbursement may put in reverse all those acquisitions or, at a minimum, limit valuations.
Finally, CMS is changing the standard for "direct supervision" of non-physician practitioners by physicians. Under current "direct supervision" rules, a physician must be physically present in the same building as the NPP. CMS is relaxing those rules to allow virtual presence via two-way audio and video.
This change means a physician can supervise NPPs on the other side of town or state and lends scale to practices in a way we have not seen before.
These changes add up to a significant erosion of the regulatory structures that have prevented consumer choice, competition and with the possible accompaniments of lower cost and increased productivity.
Pretty radical.
Power. Conventions are nigh. Incumbency may not win the day in November. The challenger has been banging around Washington for half a century.
From that you can draw but one conclusion: the “campaigns” of aspiring political appointees are going to make beach volleyball tryouts look like a mothers’ club tea.
This election cycle, potential health care appointees for the FDA Commissioner, CDC Director, Secretary of HHS and CMS Administrator have a unique soapbox from which to declare their party bona fides and allegiance to the nominee: Virus Twitter.
The politicization of the response to COVID-19 – by literally everyone – means cabinet wannabes can offer up advice, criticism and Monday morning quarterbacking from the safety of their Ivy League appointment, Washington think tank or private equity firm.
Heaven knows, the White House has given them a lot of material with which to work.
Leading campaigner is former Obama CMS Acting Administrator Andy Slavitt who is rumored to have been measuring for drapes when Donald Trump took away the tape measure in November 2016.
Slavitt has been outspoken in his criticism of the Trump response to the COVID-19 outbreak and has frequently veered into the ridiculous, like when he suggested in late June that summer harvests cease to accommodate another prolonged and more substantial lockdown.
We suspect he is gunning for HHS Secretary but would probably settle for his old job back.
Dr. Tom Frieden, former CDC Director has used Twitter more effectively to promote public health. A veteran of the once legendary New York City Health Department, Frieden has the credentials to support his criticisms.
Now working on global health issues, Frieden could probably also be persuaded to take his old job back too.
Scott Gottlieb, who has deftly cultivated good relationships on both sides of the aisle has been less pointed in his criticisms of the Trump administration’s COVID response. He has been ever present on Virus Twitter as well as CNBC, offering prognostications on COVID-19’s impact, vaccine development, among other things.
When Gottlieb departed the FDA he indicated that he would like to return. He does not have the party cred of Andy Slavitt but his bipartisan appeal may mean it doesn’t matter.
Missing from Twitter, virus or otherwise, is Chris Jennings. Jennings co-authored the Biden-Sanders Unity Task Force section on health care and was rumored to be slotted for a senior health care position had there been a Clinton White House.
His quietude means but one thing to me: he is a serious candidate for HHS Secretary or other very senior health care post in a Biden White House.
Emily Evans
Managing Director – Health Policy
