Politics. One of the underappreciated realities of politics is that it is mostly a math exercise. A first-time officeholder reflects nothing more than the opinion of a majority of people that showed up to vote that day. From there, the job of the newly elected is to do more addition than subtraction on that base. Those that don’t understand the math, risk very short political careers.
Expanding a political base is especially urgent when a portion of it is violent and dim-witted enough to take selfies while vandalizing one of the most beautiful and important public structures in the world. That imperative is made more so when the rest, who perhaps recognize some good policies, won’t admit it.
It is an eternal truth of American politics that you do not get to pick your voters. Once elected you do have the opportunity and the power to direct passionate opinion toward constructive common cause, to mute the effects of factionalism as James Madison might say. Sometimes, you are called upon to reject those that seek to harm others. All those things require skilled leadership, a command of the issues, and a public personality that is at least tolerable for most people.
Harshly will history judge the last few months. An admission that the president got the election math wrong; that base consolidation, especially at a high social cost; was an error; and that it was time to move on to other things; would probably have preserved most of the more laudable policies from the last four years, not to mention the careers of those who worked for him.
Unlike trade and tax policies, health care will probably be an exception. Most of the meaningful changes were brought about through regulation, or more accurately, deregulation and are more closely associated with Secretary Alex Azar and CMS Administrator Seema Verma whose reputations, to this point anyway, seem to be holding up. As we have noted before, the drug price policy known as Most Favored Nation, already on the ropes legally, may end up in the trash heap, as could the rebate rule.
What is unknowable is the extent to which moderate Republicans will seek to distance themselves from their party and embrace a more progressive stance on legislative priorities like a public option. The 74 million votes Donald Trump secured by urging his fans, people who rarely show up on voter target lists, out of America’s electoral woodwork would seem to suggest “no.”
But hey, we still have 11 days left. Unfortunately, anything could happen.
Policy. The COVID-19 pandemic will keep the Trump health policy apparatus in place through the end of the term as the vaccine roll-out continues to be plagued by distribution issues, some of them self-inflicted.
A little over half the states have administered 30-40% of their supplies. California and Florida are lagging with 25% and 29% respectively. The challenges for states are myriad. Health care workers are in short supply to administer the vaccine due to COVID-19 outbreaks across the U.S., school closures and burnout. The lack of clarity on subsequent deliveries from the federal government has complicated state and county level decision-making while slavish adherence to ACIP guidance has left little room for improvisation in the field.
Labor shortages have made it imperative that health systems exercise care when administering the vaccine to staff as the reaction could result in sick days a stressed hospital can ill-afford. Some states have adjusted. In Tennessee, medically trained National Guard have been called in to support the effort and the state has been able to use 42% of its supply. Gov. Gavin Newsom has instructed vaccine administrators to move on to other eligible populations rather than waste doses that should be matched to a health care worker.
On the other hand, Gov. Andrew Cuomo’s response was to demand fines assessed to providers that did not use all their allotted supply which predictably resulted in complaints from Mayor Bill DeBlasio who wishes to follow Newsom’s model. (Cuomo amended his policy today, making it more consistent with Newsom’s)
The federal government continues to hold on to a significant stockpile of vaccine (~28 million) to be used for the required second dose. Joe Biden has pledged to release it which may help with decision making but could also complicate the dosing regime if manufacturing slows as it did in the summer/fall.
Vaccinating 50 or 100 million people is a vast undertaking, especially in a country as large and rural as the U.S. Seven million doses in three weeks is not exactly a failure and things are sure to pick up as the eligible populations expand and manufacturing continues to ramp. A release of the stockpile will only add to the acceleration later in the month.
The open question is how many vaccinations does it take for Governors who have imposed significant restrictions on their populations to let things return to some version of normal?
Power. The fallout from President Trump’s power struggle with the pharmaceutical industry continues. On Friday, CMS approved TennCare III, a Medicaid waiver that allows Tennessee to manage its program under a fixed spending cap, taking risk for overspending and receiving the benefit of any savings realized. Included in the waiver is the ability to close TennCare’s formulary to new drugs and limit those covered to one per therapeutic class.
Recall that Massachusetts requested and was denied authority to adopt a closed formulary in its Medicaid program early in the Trump administration. Closed formularies are the pharmaceutical industry’s bête noir and Seema Verma determined it made little political sense to pick that fight.
Of course, that was before negotiations on drug price policy collapsed July, the industry determined Joe Biden should be the next president as soon as possible, and the Trump administration issued the Most Favored Nation rule.
The administration got a second chance with their 11th hour approval of TennCare III. The closed formulary allows TennCare to delay coverage of new drugs that obtain fast-track approval at the FDA. Such delay is designed to gather more data on effectiveness. TennCare officials have pointed to the mandatory coverage of Sovaldi when more time and research revealed that Harvoni worked best on patients that had not been previously treated.
Lawsuits are already being threatened but a closed formulary is going to be attractive to a lot of states. In addition to the obvious negotiating leverage, a closed formulary offers real potential for value-based arrangements which heretofore have had difficulty getting off the ground.
Call with questions.
Emily Evans
Managing Director – Health Policy
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