The Blue Wave didn’t happen. The outcome of Campaign 2020 is a nation deeply divided along racial, economic, and partisan lines. The healthcare industry and the policies that frame its roles and responsibilities are caught sharply in the crossfire.
Campaign 2020 attracted 145 million voters, the highest level of voter participation (63.3%) since 1900. Slightly more than 74 million voted for Vice President Biden and almost 71 million voted for President Trump—both historic highs. As of yesterday, the down-ballot results below reflect a nation where the Blue-Red divide is still its defining characteristic:
In the Senate, control boils down to two pending races in Georgia: Republicans lead 50-48 with the Georgia run-off January 5 a key determinant of the Biden legislative agenda.
In the U.S. House of Representatives, Democrats maintained control: with final results for 26 seats still pending, Dem’s lead 214-195 with a net gain of 5 for Republicans.
In the 11 contested Governors’ races, the GOP added one (Montana) and increased its lead to 27-23.
And in state legislatures, there were no major changes. The GOP picked up control in 3 legislative bodies but bipartisan governing in states is still an exception, not the rule. In 36 states, one party controls both legislative bodies and the Governor’s office: 21 are Republican and 15 are Democrat.
The 2020 vote is a turning point in American politics: voter intensity was high, media objectivity was questionable and reasoned debate hard to find. Pollsters followed their near-misses in 2016 with a strike-out this year. Boarded-up store fronts in NYC, DC, and major metro’s nationwide in anticipation of post-election civil unrest symbolize a nation on edge. Edison Research’ post-election exit survey of 15,990 voters offers a useful retrospective:
Personal circumstances impacted voting: Overall, voters are divided about the economy: 48% think it’s excellent or good vs. 50% who think it’s ‘not so good’ or poor. But 76% of Republican voters said it’s excellent or good vs. 17% of Democratic voters. And overall, only 45% of voters said they had not suffered financial hardship as a result of the pandemic and its impact on the economy.
Issues divide us: 82% of Biden voters cited the pandemic itself as the most important issue in determining their vote vs. 14% of Trump voters. Conversely, 82% of Trump voters said the economy was the most important issue on their minds vs. 17% of Biden voters. Likewise, views about the Affordable Care Act are divergent: 78% of Republicans think it should be overturned as the Supreme Court reviews its constitutionality vs. 80% of Democrats who favor keeping it.
Unifying the country is a priority: 96% said that bridging the country’s divides should be a priority for the next president. Among the roughly four in five voters who said this was very important, most cast ballots for Mr. Biden.
For the next 58 days, all eyes will be in Georgia. More than $100 million will be spent to convince Georgia voters to elect Senators whose votes in the 117th Congress will be key to the Biden legislative agenda.
In the lame duck period, the Trump administration will conduct unfinished business: a COVID-19 relief package, administrative actions to loosen regulations and reviews of Medicaid Section 1115 waivers in 44 states, among others. At the same time, the Biden transition team will announce its Cabinet, activate its COVID-19 task force under the leadership of former U.S. Surgeon General Vivek Murthy and former FDA Commissioner David Kessler and finalize its 100-day plan commencing January 20.
Wall Street will be watching closely, having seen U.S. stocks’ strong recovery: last week, the S&P 500 gained 7.3% posting its second-best performance for any presidential election week on record. The Dow Jones Industrial Average advanced 6.9% for the week and the Nasdaq Composite rallied 9%. All three reached their strongest week of gains since April. Pfizer’s announcement today of its Phase 3 trial results will also buoy investor confidence: volunteers who took the two injections three weeks apart experienced more than 90% fewer cases of symptomatic Covid-19 than those who received a placebo beating expectations that the vaccine might be only be 60% or 70% effective.
The lame duck between a Presidential election and inauguration day this year is far more consequential in healthcare. Here’s why:
Healthcare will be Prominent in the Georgia Senate Campaigns
Tomorrow, the Supreme Court will hear arguments in California v. Texas and rule next year on the fate of the Affordable Care Act. But for the next 58 days, Georgia voters will face a barrage of campaign ads that frame the 2010 law as a choice between socialized medicine or a lifeline for those who lack access to the health system. My assumption is that SCOTUS will determine the individual mandate severable from the rest of the law, thus pre-empting cessation of coverage for the 30 million who gained insurance coverage vis a vis Medicaid expansion in 39 states and the marketplaces. The Georgia Senate runoff will likely be a referendum on health insurance access: Georgia is among 11 states that did not expand its Medicaid program, and 518,000 in the state lack insurance coverage. On October 15, 2020, CMS approved an 1115 waiver (“Georgia Pathways to Coverage’) that expands Medicaid coverage to 100% FPL with enrollment conditioned on compliance with work and premium requirements but CMS denied the state’s request for enhanced ACA funding match. Access to health insurance is a hot issue in Georgia.
The Coronavirus Pandemic is Spiking
Daily positive cases have increased to all-time highs of 130,000 and 1000 deaths. Hospitals ICUs in 6 states are full and diversion procedures are being implemented. As winter approaches, public health officials predict deaths may reach 400,000 by the end of the year, up from 237,000 today. Public anxiety is palpable and the economic impact devastating to businesses and households. In Georgia, 8,194 have died as a result of the Covid-19 virus and 32,468 have been hospitalized. And as of yesterday, the 2-week positive test rate (PCR) rate increased to 7.1% from 6.9%.
The Biden health policy agenda will be significantly impacted by these Senate races in Georgia. During the Biden campaign, Medicare for All, a public option, expanded subsidies for those uninsured and lowering the age for Medicare eligibility to 60 were key elements. A Republican majority in the Senate would likely temper major changes. In the interim lame duck session, the Biden team’s attention will be on its coronavirus plan and appointments to lead the HHS, CMS, FDA, CDC and other government agencies.
In my view, the lame duck session also affords the Biden administration an opportunity to advance policies that are popular with voters and a bipartisan consensus achievable i.e. price transparency for hospitals, drugs and insurers; simplification of alternative payment models (APMs) to reward providers for cost-effective care and increased funding and federal coordination of public health for starters.
Voters care about the healthcare system but there’s no consensus about how it should be operated, regulated, or funded. For the next 58 days in Georgia, it will be vilified for its affordability and corporatization and lauded for the heroics of its frontline providers. That’s predictable. Healthcare is a fair game for both, especially this year.
Regardless of the outcome of the Georgia Senate races, the need for consensus about the U.S. health system’s future among voters is its highest priority. That will require the system’s key stakeholders—hospitals, physicians, drug and device manufacturers and health insurers—to take a fresh look at how we operate collectively.
We’re not there.
“The Landscape of Medicaid Demonstration Waivers Ahead of the 2020 Election” Kaiser Family Foundation October 30, 2020; Kaiser Family Foundation
John Cassidy “The First Question for Democrats to Answer About the Election: What Happened?” New Yorker November 7, 2020; The New Yorker
“National Exit Polls: How Different Groups Voted” November 3rd, 2020; New York Times
Whaley et al “Changes in Health Services Use Among Commercially Insured US Populations During the COVID-19 Pandemic”; November 5th, 2020; JAMA Network