Health policy nerds pinning their hopes on a Joe Biden win Tuesday night or Wednesday morning are very likely to be disappointed.
There seems to be this false hope, delusion maybe that come 2021, the pointed head economists and policy wonks who have been hiding out at the Center for American Progress will be reinstalled in their rightful place as the centrists definers of American health care policy. It will be so easy. We can all pick up where we left off that unfortunate November night in 2016.
Except we won't.
As JT Taylor, Daryl Jones and I discussed last week, Joe Biden will find himself between a leftward leaning House and a quite moderate, notwithstanding Elizabeth Warren and Bernie Sanders, U.S. Senate. The more ambitious policy objectives of House members like Medicare-for-All and price controls on drug prices are likely to be stopped cold in the Senate. Similarly, the modest health policy efforts Joe Biden has articulated on the campaign trail are going to be bitterly contested by leftward leaning House members.
It would be easy to see a future for health policy that involves very few major legislative initiatives. After all, America seems to be moving on from its obsession with health care, a function no doubt of the rising influence of healthier, younger generation. The realities of politics make that outcome unlikely.
Speaker Nancy Pelosi has spent the last two years keeping her caucus together by assuring them a long game means a Democrat in the White House which, in turn gives greater hope to their agenda. A victory, however limited in scope or duration must be had or the risk to the party's discipline will be real.
As we have discussed before and below, Medicare drug prices and Medicare Advantage seem like possible release valves, giving the left flank a win while staying out of the soup on things like Medicare-for-All.
How far House Democrats can go depends not just on the Senate outcome but also a number of moderate suburban district races in which Pelosi has been involved this cycle.
If the end result is two moderate but Democrat-controlled houses, liberal firebrands like Sanders and Ocasio-Cortez will (re)learn an important lesson of politics: long term promises are worthless.
From the left's perspective, there is no place more suited for an early battle with centrists than Medicare Advantage. Since the Affordable Care Act, Medicare Advantage plans have grown in popularity and, under President Trump, have been a primary vehicle for reforms such as expansion of telemedicine services.
For good reason, most insurers and their investors have greeted Joe Biden's plan for a public option and/or and expansion of Medicare eligibility as an opportunity to grow membership.
Joe Biden's left flank will have none of that.
It has been a curiosity for years that Sen. Bernie Sanders could assail privatization of certain government functions while ignoring the growing numbers of MA enrollees. For much of that time, Medicare Advantage was not much of a threat. It took 10 years for penetration of eligible population to grow from 25% to 35%, at least according to published numbers.
Last week, CMS updated its enrollment data and corrected some record keeping. According to the readme file, "An issue has been identified for the eligibles number, where the number of beneficiaries was double counted for beneficiaries with multiple addresses. The issue has been corrected for the October monthly report."
It would appear that penetration is approaching 45% and may get close to 50% during this year's Open Enrollment Period. No surprise then that in the last few months Sanders and others have made it clear that any expansion of Medicare eligibility or adoption of a public option will be done via direct insurance similar to the Veterans Affairs and Indian Health Service.
Meanwhile, questions are being raised about the efficacy and costs of Medicare Advantage. As one senior administration official put it, "we are looking at all our subsidies, including Medicare Advantage." The raison d'etre of MA is its ability to manage care better than fee-for-service by deploying all the ordnance in the value-based armory.
Recently Matthew Holt broke down a Humana report and pointed to very little progress since 1997. Around the same time, Brad Smith, Director of CMMI and Seema Verma called for a course correction for the Innovation Center citing little savings from VBP demonstration programs.
The set-up for the next phase of health policy battles has some wanting to limit MA plan growth if there is an expansion of eligibility, whether that be through a public option or a change in qualifying age for Medicare, and others wanting to demand more from MA plans in terms of outcomes or cost.
I am sure there is a compromise in there somewhere but either way, it probably won't make us bullish on these MCOs for some time.
Given Bernie Sanders' experience with the Democratic establishment in 2016, his support - arguable his tireless support - for Joe Biden comes as a bit of a surprise. He isn't even actually a Democrat though he has always caucused with them during his long tenure as a Senator.
Sanders is also not generally known as a team player, preferring to stick close to the principles on which the people of Vermont voted when they elected him. Admirable, of course, but rarely a characteristic that yeilds a long list of legislative accomplishments especially in a divided government.
Yet, there he is campaigning virtually, filling up Twitter feeds and making a daily and hourly argument that Joe Biden should be the next president of the United States. Cynics will say his support is designed to secure a spot in a Biden cabinet. There has been talk of Sanders as the next Secretary of Labor.
The non-cynics and political realists see a more durable result. In the event the race is close - and some battleground races suggest it might be - Sanders, together with Alexandria Ocasio-Cortez, may share responsibility for a Biden victory. Such influence has implications for the Biden administration's legislative agenda especially as it relates to the Sanders' priorities of health care, labor, taxes and the environment. It also has great significance for 2024.
Almost no one in Washington thinks Biden will run for a second term. Rather, he will likely spend part of the next four years supporting the emergence of a field that can take up his mantle.
Sanders' field work in 2020 will make sure his priorities are part of that agenda.