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With the results of the presidential election and the race for control of the Senate still undecided, it's also not entirely clear what will happen to the many healthcare issues facing Congress, the president, and federal agencies. We asked experts to discuss the possibilities under a Trump administration or a Biden administration, and how a Democratic- or Republican-controlled Senate might play out.

The Affordable Care Act and Other Reforms

If President Trump wins re-election, what can Americans expect to see as far as healthcare reform? "Nothing," said Kavita Patel, MD, MPH, a nonresident fellow at the Brookings Institution, and a primary care physician. "I think he'll be betting the Supreme Court decision could invalidate the ACA [Affordable Care Act], and there's no reason to try to do anything in advance of that," she said referring to the , a case that centers around whether the law as a whole can stand now that the individual mandate penalty has been eliminated. Oral arguments in the Supreme Court case are expected on Nov. 10.

Asked about the possibility of a replacement plan were the ACA to be eliminated, Patel is suspect. "He hasn't been able to do that in the past 4 years, I have no faith he could do it now," she said.

Chris Pope, PhD, a senior fellow at the Manhattan Institute, also does not expect to see major healthcare reforms if Trump is re-elected. "I think on the Republican side, the appetite for touching healthcare again is very very low.... Assuming that [Republicans] somehow won the House again, I don't see where you get many Republicans who would want to touch healthcare again." Joseph Antos, PhD, a healthcare scholar at the American Enterprise Institute here, agrees that there will be very little movement on healthcare if Trump is re-elected but for different reasons. "Nancy Pelosi will still be Speaker of the House. Without the House, you really can't get significant legislation passed," Antos said.

With regard to Medicaid, many of the waiver invitations and work requirements were the ideas of Seema Verma, administrator of the Centers for Medicare & Medicaid Services, Antos said. "If Seema stays on, there's no question that she will continue to push in the directions that she's already pushed. If it's somebody new, then they may be less enthusiastic about it," Antos said.

Looking at the bigger picture, Pope said the Senate outcome matters more than who wins the presidency. "Instead of it being a Trump healthcare arrangement or a Biden healthcare arrangement, it really depends on who has the Senate majority, and who is that pivotal 51st senator or 50th senator," said Pope. Also, even "a 51-seat majority leaves a very different type of healthcare policy [vs] a 54-seat Senate majority or a 55-seat Senate majority," he noted.

If Biden wins the White House, said Antos, his first priority will be to respond to the pandemic and its associated economic crisis, and to pass a COVID relief bill, before turning to a "public option" health insurance reform. Despite Biden's "political problem" with so-called progressives who champion a single-payer system, "I think he's going to stay true to what he really believes in, which is ... to build off of the ACA," Antos said. "He wants to find a cheaper plan alternative within the exchange structure."

The focus on a COVID relief bill will buy Biden time to figure out the details of a public option "before he really has to push hard to get it to happen," Antos continued. "I could easily see that a public option could pass in the spring of 2022," he said, assuming an effective vaccine is in wide deployment and the pandemic is finally under relative control.

For his part, Pope anticipates that given the millions of people that are out of work and may have lost their healthcare, Biden would focus on expanding ACA subsidies and helping uninsured Americans in states that didn't expand Medicaid through a federal public option. But Pope sees that as ultimately failing.

"The idea that there's a free lunch out there" with a public option just isn't plausible, he said. Hospitals and doctors aren't going to give the same care for less money, just because a plan is stamped "public option"

"You only spend less if you give people less," Pope said.

Passing any significant plan to expand access to health insurance will be difficult without "sweeteners for industry," said Patel, irrespective of which party is in charge. Expanding coverage, whether through a public option or increasing access to ACA plans, would be expensive and likely lead to reimbursement cuts somewhere. So it will require some "creative negotiation" on both sides of the aisle, she said.

In the short term, Biden could take concerns about the California v. Texas lawsuit off the table. Pope said Biden could ask Congress to pass a law stipulating that the individual mandate is severable from the ACA. "Congress could easily do that ... and that would essentially make the lawsuit go away," he said.

As for the Medicaid program more broadly, "the Trump administration has spent their time in office trying to undermine and weaken the Medicaid program and think of new and different ways to prevent people from getting Medicaid coverage," said Joan Alker, a professor and the executive director and a co-founder of the Center for Children and Families at Georgetown University. "With a Biden administration we will see a strong fundamental commitment to the program and a welcome mat put out for children and families seeking Medicaid coverage and the welcome mat has very much been pulled back in the last few years," she said.

Some of the most important changes Biden could make would be personnel changes, said Patel. "We've really seen now how destructive people can be when you have the wrong leadership.... Having the right person at the CDC might be the most important change that could get made."

The COVID-19 Pandemic

Biden and Trump take very different approaches to the pandemic, said Robert Wachter, MD, of the University of California San Francisco. If Biden wins, "I think you'll see a pretty early and very strategic communication strategy," he said in a phone interview. "He'll have two months [before the inauguration] to position himself as a leader who'll have a new approach." That means "you'll see a naming of health leaders fairly quickly, a rollout of a strategy -- particularly on testing -- and a much more concerted strategy on public health maneuvers."

Regarding making mask-wearing mandatory: "Does the president or the CDC have the authority to make everybody in the country wear a mask? Probably not -- it's more using the bully pulpit to make the case that there should be universal masking and maybe even make the case that there should be more consistency in terms of local and regional policies regarding what's open and what's not open," Wachter said.

Increasing contact tracing depends on the state of the epidemic, he added. "If things are going as off the rails as they are now, then contact tracing is probably not all that applicable -- there's just too many cases for contact tracing to be super useful." On the other hand, "I think you're going to see a push for more testing -- more insistence on getting kits out into communities and more guidance from the CDC on who should be tested and when."

And if Trump wins? "You can expect more of the same -- which is chaos," said Wachter. "He's as predictable as my clock; he doesn't want to confront a hard problem." States will continue to be left to their own devices if there's a second Trump administration, he added.

Care for Older Americans

"If Biden wins the election, he is under pressure to expand Medicare (or a rough equivalent) to a somewhat larger slice of the near-elderly population," Thomas Miller, JD, resident fellow at the American Enterprise Institute, said in an email. "In the final analysis, this is easier to do as a somewhat-Medicare-like public option for those either 60-65 or perhaps 55-65, on a quasi-optional basis. In this manner, a Medicare expansion would not as directly threaten to eat away at some of the current Medicare coverage for the over-65, and it would not directly change the scoring of the over-65 Medicare budget and Part A Trust Fund projections. It also would allow the below-65 'new' Medicare coverage to differ somewhat from conventional Medicare."

In terms of expanding the Medicare population, "Without an overwhelming blowout win in the presidential race (closer to 60% than below a 55% share of the popular vote, accompanied by more than 55 Senate Democrats), Biden won't have the margins to move toward a 'Medicare for a Lot More' option for the rest of the below-65 population," Miller continued. "Pandemic and continued economic recovery needs will overwhelm a major move in federal health policy mega-expansion."

As for Medicare Advantage, it "has grown too large, and popular, to be placed back in political jeopardy," he added. "However, Medicare participation requirements could be leveraged to essentially try to mandate participation by insurers and providers in any new expansions of below-65 post-ACA public coverage options (the partial public options expansion that will be attempted)."

Biden's proposal to lower the age of Medicare eligibility to give adults ages 60-64 an option to get more affordable health insurance "would be a pretty big deal for older adults who have trouble finding affordable coverage," said Tricia Neuman, ScD, executive director of the Kaiser Family Foundation's Program on Medicare Policy. "It could also lead to savings for employers and state Medicaid programs."

Patel predicted that Biden would make good on his promise to lower the age of Medicare to 60, create a Medicare "buy-in," or establish a separate public option, Patel said. "Those three choices will shape what the 2021 landscape looks like in terms of healthcare," she noted. Patel said she also anticipates a "slate of executive orders" on day one of a Biden presidency reinstating Title X family services planning and "putting back into place everything that got decimated" under Trump.

One trend that's likely to continue under a Biden administration is the shift towards value-based care, Patel said. "I don't see Biden coming in and undoing value- based models that the Trump administration started," she said, such as the Kidney Care Initiative and the 'Primary Care First' payment model.

If President Trump is re-elected, on the other hand, "expect some deal-making proposed to change the mix of givebacks in prescription drug pricing between insurers and drug manufacturers," said Miller. "More permanent telemedicine reforms could be institutionalized in Medicare before trying to expand them to the rest of the health care sector. Luckily, Medicare would not run out of money any sooner than the rest of the U.S. government and economy does!"

Drug Pricing

Healthcare consultant Marsha Simon, PhD, said in an email that if Biden wins, she expected him to "rein in the more outrageous behavior of the drug companies. For example, several companies are denying 340B discounts to some safety net providers, which should result in the loss of access to the Medicaid market, but the Trump administration has done nothing." On the other hand, "whether Biden achieves reforms to drug pricing policy ... turns on Democrats also taking the Senate majority since [Republican leader] Mitch McConnell refuses to take up the " containing modest drug price reforms.

"Historically, Joe Biden has not been a champion of restraining drug prices -- reflecting both the role of drug manufacturers as important employers in Delaware and, after the Obama administration, his apparent greater interest in novel drug development to treat cancer than in access to these expensive new drugs," she added.

If Trump is re-elected, Simon expects him to "continue his approach to reining in drug prices -- proposing genuine reform such as European Union reference pricing, for example -- while implementing marginal policies such as the Medicare insulin demonstration that will have only a marginal impact on access to affordable drugs for a few seniors with insulin-dependent diabetes enrolled in certain Medicare drug plans."

Kaiser's Neuman noted, "While Trump and Biden have both talked about drug prices, a big difference between them is that Biden supports the proposal to let the [Health and Human Services] Secretary negotiate prices," adding that one of Trump's other promises -- a $200 discount drug card for seniors -- has not yet materialized.

Miller predicted that "more action (albeit more symbolic than real) is likely in the drug pricing arena, related in part of Medicare, due to the latter program's overall purchasing leverage. At least some entry into federal government price negotiations with drug sellers will begin, though far from what's been promised. Further gap-filling in cost sharing (lower catastrophic coverage ceilings) and pricing restrictions on sole source suppliers will be initiated."

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