Biden’s First 100 Days for Healthcare: What was Accomplished and What’s Ahead

This Friday marks the Biden Administration’s 100th day in office. In the tradition of past President’s dating back to FDR in 1932, it’s marked as a milestone for those who have occupied the White House.

Joe Biden has an approval rating of 52% per ABC News/Washington Post polling–lower than any president at 100 days in office since 1945 except Gerald Ford at 48% in 1974 after pardoning Richard Nixon and Donald Trump at 42% in 2017. For the 14 presidents from Truman to Biden, the 100-day average is 66%. It’s understandable: the partisan divide in America is at an all-time high.

Voter feelings are mixed about this administration: it gets high marks for handling the pandemic and racism but lower marks on other issues including immigration and the economy. In its first 100 days, healthcare outside the pandemic has not been a major focus in its Center Left governing philosophy while climate change and social inequity have been elevated. Here’s a recap of healthcare system related achievements to date and those to come in the second 100 days:

MAJOR HEALTHCARE ACHIEVEMENTS IN THE FIRST 100 DAYS

• Covid-19 Vaccinations: The administration’s primary healthcare priority in its first 100 days has been the pandemic having taken 571,922 lives and infected 32 million in the U.S. since January 2020. Per Pew polling, 72% of U.S. adults say the Biden administration has done a good job managing the manufacture and distribution of COVID-19 vaccines. So far, 42% of the US population has received at least one dose of a Covid-19 vaccine and 28% are fully vaccinated. As of April 19, every state has opened vaccinations to all adults and schools are open, but vaccine hesitancy, the potential impact of new variants and the lingering impact of the pandemic on the economy are causes for concern going forward. As of last week, per the CDC, 8% of those scheduled for a second vaccine were no shows: that’s a big problem.

• Trump Policy Reversals/Delays/Reviews: A key focus of the first 100 days has been reversal of policies involving a wide range of Trump administration directives that limited access to healthcare. The Biden administration has reversed work requirements as a condition for Medicaid coverage. It added a special enrollment period for Healthcare.gov enrollment and beefed up the navigator budget (an 8X increase) to assist enrollees. It ended the global gag rule that barred international nonprofits from receiving U.S. funding if they provide abortion counseling and ordered a top to bottom review of safety in the vaccine manufacturing supply chain. It has suspended implementation of the CMS’ Center for Innovation’s alternative payment programs pending review of their impact on quality and Medicare savings and inclusion of equity and diversity measures.And notably, it has left in place rules requiring price transparency for drug manufacturers, hospitals and insurers and information blocking requirements included in Section 4004 of the 21st Century Cures Act (Cures Act) requiring compliance by providers, payers and vendors.

• Personnel: In the first 100 days, Veterans Affairs Secretary Denis McDonough, HHS Secretary Xavier Becerra, and Deputy HHS Secretary Andrea Palm were confirmed and important roles in agencies that shape healthcare regulatory Department of Justice (Merrick Garland, Attorney General, Securities and Exchange Commission (Chairman Gary Gensler) were also filled. But the confirmation of Chiquita Brooks-LaSure as Director of CMS is on hold as Republican Senators have pushed back against the administration’s limits on Section 1115 and Section 1332 Medicaid waivers popular in Red States. And nominees for key roles in the Food and Drug Administration, Veterans’ Health Administration and a vacancy on the Federal Trade Commission remain unfilled.

LOOKING AHEAD, WHAT TO WATCH IN THE NEXT 100 DAYS

The Biden administration’s healthcare focus in its second 100 days will shift from the pandemic to healthcare access, affordability and the economy. Two major events will frame the administration’s actions:

• SCOTUS: The Supreme Court heard arguments in California v. Texas November 10, 2020 brought by Republican attorneys general challenging the constitutionality of the individual mandate in the Affordable Care Act. Its decision will be announced on or before June 30 and set in motion a litany of federal and state actions involving insurance coverage requirements.

• Economic Stimulus: The Administration has proposed spending at least $2 trillion to boost the economy paid for by higher corporate taxes on businesses (the rate would increase to 28% from 21%) and higher federal income taxes for high-income households (a marginal income tax rate of 39.6% and capital gains rate of 43.4%–down from 23.8% today for households with income above $1 million). Congressional action on the American Jobs Act (aka infrastructure plan) is pending but the partisan stalemate in the Senate suggests it will pass with the Vice President Harris’ tie breaking vote the difference. Also of note, the infrastructure bill does include significant funding for home and community-based care but essentially nothing for hospitals and physicians.

With this background and Campaign 2022 around the corner, is unlikely the Biden’s administration’s healthcare actions in the next 100 days will be dramatic. While appointments to key leadership posts are completed, the three areas likely to get attention are these:

• Clarity from the CMS Center for Innovation on Alternative Payment Models (APMs): Liz Fowler, the new director of the CMS Center for Innovation has pledged that APMs will continue but changes will be made to address benchmarking methodology flaws, patient/enrollee experiences and equity and diversity considerations and savings derived in patient/enrollee populations served.

• Scrutiny of Competition and Consolidation in Healthcare: A focus of attention of the Biden administration’s health policy is consolidation and unfair competition. House and Senate Subcommittees, the Consumer Financial Protection Bureau and Federal Trade Commission will begin investigations and host hearings about the impact of consolidation on competition and affordability in healthcare with the legal principle of “consumer welfare” a central focus. As an element of this attention, the role played by private equity and SPACs will be scrutinized. Market conditions for private investment in healthcare are favorable. Funds raised in IPO and SPAC transactions hit $250 billion through April 20, the same amount raised in all of 2020, according to data from Dealogic. Today, at least 60 of the 300+ SPACs are focused on healthcare acquisitions targeting medical groups, outpatient providers, insurers, and business solutions. Concern that these deals might prompt junk-bond risks and long-term sustainability issues will get attention from regulators.

• Resolution of Telehealth Reimbursement & Integration: Studies have shown telehealth and virtual care popular with patients and most physicians, but data has also shown access limited for under-served populations and utilization and associated costs have increased where widely used. Providers and insurers want the federal government to expand telehealth use but the basis for reimbursement and optimal integration in care management for certain patient populations are a focus of discord.

Not getting attention in the next 100 days are major reforms like lowering the age of Medicare eligibility, a public option or Medicare for All: they’re risky to incumbents hoping to win in Campaign 2022. So, the next 100 days will be staging for longer-term reforms of more consequence.

MY TAKE

President Biden will speak to a Joint Session of Congress this Wednesday: his campaign theme “Build Back Better” will no doubt be prominent. But lurking in the Chamber will be its toxic partisanship and the specter of Campaign 2022 where Democrats and Republicans are split 50-50 in the Senate and Democrats hold a slim 218-212 margin in the House.

Healthcare policy in the next 100 days will be marked by heightened attention to the issues of access, affordability and competition but major changes in regulatory oversight are unlikely. Like FDR who advanced his Social Security legislation and National Labor Relations Act AFTER his first mid-term, the Biden administration is likely to hold its major healthcare reforms until 2023 and beyond.

Paul

RESOURCES

“Biden Nears 100-Day Mark with Strong Approval, Positive Rating for Vaccine Rollout”; April 15,2021; Pew Research

Weiner et al “In-Person and Telehealth Ambulatory Contacts and Costs in a Large US Insured Cohort Before and During the COVID-19 Pandemic”; March 23, 2021; JAMA Network

“New Head of CMS Innovation Center Prioritizes Fairness in Healthcare”; April 21, 2021; MedPage Today

Galston, William, “At 100 days, where does President Biden stand with the public?”; April 22, 2021; Brookings

“Biden’s 100 days: Low-end approval, yet strong marks on pandemic response: POLL”; April 24,2021; ABC News

Joyce Frieden “Senate Committee Splits on Nominee to Head CMS”; April 22, 2021; MedPage Today

“SPAC Surge Pumps Up Junk-Bond Market”; April 23,2021; Wall Street Journal

“New CMMI director says value-based care models at crossroads”; April 20, 2021; Fierce Healthcare

CORONAVIRUS NEWS

Studies: Healthcare Workforce, Especially Nurses Hard Hit by Pandemic

Based on a survey of 2298 adults conducted February 11-March 7, 2021: 1327 of healthcare workers and 971 non healthcare workers. Findings:

• 4 in 10 health-care workers have not been vaccinated

• 5 of 10 say they are burned out

• 6 in 10 say stress from the pandemic has harmed their mental health

• 3 in 10 health-care workers consider leaving the profession

Related: In this cohort study using data from 2007 to 2018 that included 2374 nurses, 857 physicians, and 156,141 individuals in the general population (age, ≥30 years), the suicide incidence rates per 100 000 in 2017-2018 among women were 17.1 for nurses, 10.1 for physicians, and 8.6 for the general population, and the suicide incidence rates per 100 000 in 2017-2018 among men were 31.1 for nurses, 31.5 for physicians, and 32.6 for the general population. The suicide risk compared with the general population was significantly increased for nurses but not for physicians.

“Washington Post-KFF frontline health-care workers survey Feb. 11-March 7, 2021”; April 22, 2021; Washington Post

Davis et al “Association of US Nurse and Physician Occupation with Risk of Suicide”; April 14, 2021; JAMA Network

Study: Death Rates for Surgery Patients with Covid-19 Double Non

UC Davis researchers matched the 5,470 COVID-19 patients with the same number of patients who underwent surgery that tested negative for the coronavirus for the period from April-November, 2020. The inpatient mortality rate among surgical patients with COVID-19 was 14.8%, compared to 7.1% among noninfected surgical patients, findings showed. The number of hospital-acquired conditions and patient safety indicators were also higher among the cohort of infected patients.

Haffner et al “Postoperative In-Hospital Morbidity and Mortality of Patients With COVID-19 Infection Compared With Patients Without COVID-19 Infection”; April 12, 2021; JAMA Network

Study: Telehealth Use Increases Utilization; Problematic in Underserved Populations

In this cohort study of 36,568 010 working age US individuals continuously enrolled in private health plans, claims data for March to June in 2019 and 2020 analyzed by Blue Health Intelligence, researchers found:

• Ambulatory contacts decreased by 18% between the 2019 and 2020 March to June periods while telehealth use increased from 0.3% of contacts in 2019 to 23.6% of all contacts in 2020.

• Persons living in areas with limited social resources were less likely to use telehealth (most vs least socially advantaged neighborhoods, 27.4% vs 19.9% usage rates).

• Costs per person were nearly $900 more for individuals who had at least one telehealth visit ($2,214.10 vs. $1,337.78) due in part to the fact that people with at least one telehealth visit were older and had greater preexisting disease burden than those with in-person visits only.

Related: Comparing downstream care utilization data from a large, commercial payer for the period 2016–19, University of Michigan researchers found that patients with initial visits for acute respiratory infection were more likely to obtain follow-up care within 7 days after direct-to-consumer telemedicine visits (10.3%) than after in-person visits (5.9%). In both settings approximately 90% of patients did not obtain additional care. The telemedicine cohort had fewer (0.5% versus 0.6%) emergency department visits—a small but statistically significant difference—but more subsequent office, urgent care, and telemedicine visits.

Weiner et al “In-Person and Telehealth Ambulatory Contacts and Costs in a Large US Insured Cohort Before and During the COVID-19 Pandemic“; March 23. 2021; JAMA Network

Li et al “Direct-To-Consumer Telemedicine Visits for Acute Respiratory Infections Linked to More Downstream Visits”; April 2021; Health Affairs

CMS: Marketplace Enrollment Up 5%, Navigator Funding up 800% for 2022

Last Thursday, the Centers for Medicare and Medicaid Services (CMS) released the final Marketplace open enrollment report for 2021:

• Enrollment across all 50 states and DC increased 5% during the 2021 open enrollment period to 12.0 million consumers: 8.3 million consumers enrolled through the 36 states that use HealthCare.gov, and about 3.8 million consumers enrolled through the 15 states that operate their own Marketplaces.

• Despite overall enrollment gains, the percentage of new enrollees declined: For 2021, 21 % of consumers—about 2.5 million people—were new enrollees. This is a decrease, of about 300,000 people, relative to 2020 when new enrollees accounted for 25% of all enrollees.

• Most Marketplace enrollees, 79%, were returning consumers. Many of these returning customers—46 % of all enrollees, or about 5.5 million enrollees—actively reenrolled in coverage by assessing their options and shopping for a plan. The remaining 3.9 million consumers (33 percent of all enrollees) were automatically reenrolled in coverage for 2021.

• Of the 8.3 million individuals enrolled through HealthCare.gov, more than 7.2 million (88 percent) qualified for advance premium tax credits (APTCs). APTCs covered 85 percent of consumers’ gross monthly premium, leaving an average net premium of $92 per month.

Katie Keith “Marketplace Enrollment Tops 12 Million For 2021; Largest-Ever Funding for Navigators”; April 22, 2021; Health Affairs

Drug Spending up 5% in 2020

Per a new report by the American Society of Health-System Pharmacists:

• U.S. total drug spending rose by 5% in 2020 to $535.3 billion, but drug spending at hospitals declined by the same percentage.

• The biggest increases were home healthcare (13%), mail-order prescriptions (9%) and clinics (8 %).Drug spending at hospitals decreased by 5%, as patients delaying care amid the pandemic correlated with decreased drug utilization in hospitals.

“National trends in prescription drug expenditures and projections for 2021”; April 21, 2021; American Journal of Health-System Pharmacy

Report: Out of Pocket Costs

Background: In 2019, 26% of Americans postponed needed care, and 21% skipped a recommended medical test or treatment because of cost. The average deductible in 2019 for people with employer-sponsored insurance was $1,655. Over a decade, the percentage of covered workers facing an annual deductible of more than $1,000 increased from 22% in 2009 to 55% in 2019, and the percentage of those facing an annual out-of-pocket maximum of more than $3,000 increased from 31% to 62%.

Researchers analyzed claims data for the commercially insured population in 2017. Highlights:

• 40% of the patients incurred half of their annual out-of-pocket spending with just one encounter.

• 26% of the patients incurred 90% of their annual out-of-pocket spending with just one or two encounters.

• 26% of the patients incurred at least $400 in out-of-pocket spending in just one month during the calendar year.

• An estimated 11% of enrollees had no health care encounters, 6% of enrollees had at least one encounter but no cost sharing, and the remaining 83% were responsible for a portion of their health care costs. For them, the average annual cost sharing was $954.

• Among people with low demand for health services (defined as those with total annual health care spending at or below the median), 34% incurred no cost sharing during the year (23% had no health care encounters, and 11% used care that was fully paid for by their insurance plan), and an additional 44% reached half of their annual out-of-pocket spending in a single day.

• Among people with high demand for health services (defined as those with total annual health care spending above the median), 32% reached half of their annual out-of-pocket spending in a single day, and 13% incurred 90 percent of that spending within thirty days.

Chen et al “Annual Out-Of-Pocket Spending Clusters Within Short Time Intervals: Implications for Health Care Affordability”; February 2021; Health Affairs

LendingTree: Majority of U.S. Households Have Medical Debt

LendingTree surveyed 1550 U.S. adults in February. Highlights:

• 37% owe medical debt, and 23% have had medical debt in the past. Most consumers with medical debt owe between $5,000 and $9,999.

• Drivers of medical debt are often unpredictable: emergency room visits (39%), doctor or specialist visits (28%), surgery (26%), childbirth (22%) and dental care (20%).

• 19% say their medical debt is preventing them from buying a home and 68% have lost sleep worrying about it.

• 33% of those who paid off medical bills used savings, but nearly a quarter used credit cards and 10% took out a medical loan.

“60% of Americans Have Been in Debt Due to Medical Bills”; March 15th, 2021; Lending Tree