As we consider what this election means for U.S. healthcare delivery, we expect that President-elect Joe Biden and Vice President-elect Harris will emphasize a stronger federal role in healthcare relative to the current administration. But with a divided Senate or Republican control, any type of dramatic policy change in healthcare will be challenging. We will continue to monitor key developments in our weekly Chartis Top Reads as more information is available.
In the piece below, we explore how the election outcome shapes three of the most pressing healthcare delivery challenges facing the nation and its healthcare providers. 
With Democrats controlling 48 seats and Republicans 50 seats, the January 5, 2021 runoff election for two Georgia Senate seats could result in a 50-50 split (in which case, Vice President-elect Kamala Harris would serve as a tie-breaking vote on legislation). Alternately, the runoff election will result in a Republican majority in the Senate with either 52 or 51 seats. In the House, while Democrats sustained a majority, Republicans have regained at least 8 seats, with results still coming in.
The nation is currently experiencing a major resurgence of COVID-19, with continued record-breaking numbers of cases. Not surprisingly, the incoming Biden Administration is already signaling that controlling the pandemic is its absolute first-order priority and that it plans to take a much more federally oriented approach to the pandemic response and the public health infrastructure. This approach stands in contrast to the current administration, which has deemphasized the federal role in the standard-setting, education, management, coordination, and regulation of a national COVID-19 programmatic strategy and approach. The current deference to state and local decision-making has resulted in significant variation in terms of how states are attempting to control the spread (Figure 1). And this variation has been amplified by an unfortunate politicization of the pandemic response — a political divide which shows no sign of abating post-election.
We expect the Biden Administration to push a strong federal assertion of influence to establish national standards and controls, along with a centralized management and coordination of public health infrastructure. Yet resistance to any type of federal ”mandates” will persist in many states and regions — particularly to any actions that are perceived to threaten the economy. And with either a divided or Republican-controlled Senate, we anticipate the Biden Administration will deploy more action through executive orders and other options that work around the Senate than if the Democrats had gained Senate control.
Still, a more structured and centrally driven response, even if tempered by resistance in the Senate or at the state level, will hopefully lead to a lowering of COVID-19 incidence rates more quickly. We might also expect accelerated direct and indirect federal funding into the healthcare delivery ecosystem and supporting public programs. Additionally, the news released around the Pfizer vaccine and the Moderna vaccine prompts some cause for optimism around the launch of a vaccination program — though many hurdles remain to get to the ultimate goal of managing COVID-19 comprehensively through systemic mass rapid-testing, broad-based deployment of proven effective treatments, and implementation of an ongoing widespread vaccination program.
On the economic front, as the holidays near, it is looking less likely that a divided Congress will pass a second stimulus bill. If not passed this year, getting a bill through will be one of President-elect Biden’s first priorities when in office — and the size and nature of that relief will be shaped by the Senate outcome or the ability to reach bipartisan alignment. The Biden Administration has communicated support for a generous package — with levers such as support for small businesses; extension of unemployment coverage; stimulus checks; student loan forgiveness; emergency paid sick leave; and elimination of financial barriers to healthcare access, especially for COVID testing and treatment. While the parameters of provider support are less clearly defined, we would expect the incoming administration to support relief particularly for rural areas, as well as to aid healthcare organizations in managing workforce pressures.
Figure 1: State Variability in Pandemic Response: Non-Essential Business Closures
Looking ahead, providers will find themselves at the forefront of leading the public response. Health systems should expect to exercise an even greater community leadership role in the COVID-19 response than has been asked of them so far. Provider roles are likely to include:
Finally, the dual systems of care that most health systems already have established should be able to manage the fluctuations in COVID-19 incidence, with suspension of elective services a last line of defense for systems that are capacity constrained, rather than a blanket action as experienced in the early weeks of the pandemic this spring. Continued organizational agility will be essential to both adeptly navigate the emerging treatment options evolving almost daily and flexibly adapt capacity in response to any rolling peaks in volume that may present. Organizational sustainability will require effective operating models to flex ICU capacity, decant low-acuity capacity, and maintain a level of service for ambulatory and elective access through surge periods. It also will require intentional incorporation of digital care modalities, including hospital-at-home and other virtual access options.
Both political parties have articulated support for issues impacting affordability of care among insured populations — such as drug pricing, price transparency, and surprise medical billing. Such issues may represent a domain where bipartisan alignment is potentially viable within a Biden Administration with a divided or Republican-led Senate. Yet the question will be whether the parties can get to this realm of a health policy agenda, given other competing priorities and myriad areas where there is less alignment.
One such domain where there is markedly more contention is the role that the federal government should play in addressing access to care for low-income and other vulnerable populations. Providers will continue to see their payor mix deteriorate as the pandemic drives a loss of commercial insurance coverage nationally. Even individuals who maintain commercial insurance coverage are more likely to end up under-insured, as more individuals opt for lower premium, high-deductible options and are increasingly challenged to afford their portion of healthcare costs. Medicaid enrollment increased 6.1 percent nationally over the initial COVID-19 period of February through July and is projected to increase 8.2 percent in FY2021.  Meanwhile, declining state tax revenues will pressure state budgets to handle such increased demand for Medicaid coverage. Every state across the union will face a growing Medicaid burden with increasingly limited resources.
We anticipate that the Biden Administration will support the use of federal policy, regulatory, and budgetary levers to increase insurance coverage and access, particularly for low-income populations. We will also likely see less approval of state Medicaid waivers that are perceived to place barriers to access, such as work requirements. Still, how each state manages the burden of uninsurance and underinsurance will vary significantly based upon who is in office at the state level. The Supreme Court of the United States’ forthcoming ruling in California v. Texas will also be watched closely; fully striking down the Affordable Care Act would, of course, have significant consequences for states that expanded Medicaid with federal funding availed by this law. While oral arguments look promising to the issue of severability, we will not have certainty of this outcome until the ruling expected in June.
If the ACA is upheld, we anticipate that the Biden Administration will build incrementally on this existing policy and support its implementation in tactical ways that the Trump Administration has not (e.g., by funding advertising and outreach during open enrollment). Yet with a Republican-controlled or divided Senate, the pathway for President-elect Biden to drive a more aggressive health policy agenda as signaled by his ”Bidencare” references during the campaign (e.g., creation of a public option, Medicare eligibility changes) seems less likely. In any case, the initial four priorities emerging in his initial plan — COVID-19, the economy, climate change, and racial equity — may leave limited room for a broader conversation around healthcare affordability, at least in the year ahead.
Across the country, for the many health systems experiencing a deteriorating payor mix, caring for financially challenged communities and individuals will require strategic approaches to, and partnerships within, the health and social safety net. This may span a range of endeavors — from working with FQHCs to collaborating with safety net providers on care management and distribution to addressing compounding factors, such as food insecurity and unstable housing.
Myriad factors have led to heightened awareness of pervasive health and healthcare disparities extant across the U.S. healthcare delivery landscape. Two of the most recent, COVID-19’s disproportionate impact on people of color (see Figure 2) and the multiple high-profile events exemplifying structural racism — including the tragic killings of George Floyd, Breonna Taylor, and Ahmaud Arbery — have prompted an unprecedented level of focus on the inequities in care and access experienced by people of color. Multiple healthcare organizations, health systems, professional health associations, and health publications have declared racism to be a public health crisis. While racial health inequities are by no means a new issue, the level of attention on the intersection of race and health disparities has increased notably in the past several months.
Figure 2: COVID-19 Mortality Rates by Race/Ethnicity, as of November 20, 2020
The election outcome most certainly shapes the way in which the government will frame and focus attention, funding, and policies with relevance for health and other racial disparities. We expect that the Biden Administration will bring greater focus on and attention to the role of systemic racism in contributing to health disparities in our communities — at a minimum through its COVID-19 approach and commitment to provide federal healthcare funding support. Beyond that, Democrats have outlined a comprehensive plan around racial equality that spans issues ranging from healthcare access to housing and education and from the economy to policing and criminal justice. Racial equity is also one of four priority pillars in President-elect Biden’s “Build Back Better” plan. The question remaining will likely be more around prioritization and focus within this potential list, as well as the specific levers available, given the Senate composition.
Unfortunately, the complexity of factors driving racial health disparities will not be easily addressed from Washington or policy and regulatory intervention alone. It will require strong and visible local community leadership, commitment, and resources. The goal is too large, the challenge too great, and the drivers too embedded for any single organization to meaningfully advance against them. It will require the collective efforts of all players across the healthcare landscape — and those within the social fabric of our communities who are dealing with the contributing social determinants of health — to work in a coordinated manner against a common set of objectives.
Health system leadership will be essential to these efforts. No other entities will be able to bring to bear the scope, resources, or reach necessary to facilitate such efforts. We anticipate that Democratic leadership in the White House will bring increased direct and indirect supports to local efforts addressing health disparities. But organizations should not expect such supports to take the place of the imperative for local leadership.
The coming months will bring final results of the Senate and House, more information on COVID-19 vaccination and treatment options, and better visibility as to how the country is able to manage through this most devastating period of the pandemic. In any event, the challenges for health providers will be significant — as will the strategic, programmatic, clinical, operational, and financial implications. As the path forward becomes known, we look forward to sharing a more in-depth analysis in our Chartis State of the Union 2021.
1 The following discussion reflects Chartis analysis of a range of primary and secondary sources.
2 https://www.kff.org/coronavirus-covid-19/issue-brief/analysis-of-recent-national-trends-in-medicaid-and-chip-enrollment/; https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-spending-growth-fy-2020-2021/
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