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The Keckley Report

Health Policy in Campaign 2020: Comparisons, Contrasts and Reality

By August 17, 2020March 1st, 2023No Comments

Tonight begins the next phase of Campaign 2020 for the White House. Over the next four days, Democrats will stage their virtual 2020 National Convention culminating in the nomination of Joe Biden and running mate Kamala Harris as their ticket.

Next week, Republicans will nominate Donald Trump and Mike Pence as their nominees setting the stage for what promises to be a heated campaign in which contrasting policies about healthcare will be play a major role in who wins.

Setting aside partisan brinksmanship and political spin, the healthcare platforms for Donald Trump and Joe Biden offer a stark contrast:


Trump/Pence: ‘The healthcare system in the United States is fundamentally sound. It works well for the majority of Americans. It is hampered by archaic regulations that limit competition and lack of price transparency that would drive down costs for everyone. The Affordable Care Act is a flawed framework: it is government overreach. It should be repealed and replaced by a private system that rewards innovators, investors and job creators.’

Biden/Harris: ‘Healthcare is a universal right. The Affordable Care Act is a suitable foundation on which to improve access, quality and affordability and recover from the coronavirus pandemic. Expanding access to the health system for those who can’t afford it and restoring the public health system are its most urgent needs.’


Trump/Pence: The Trump administration’s health policies revolve around four strategies:

  • De-regulation of rules and barriers that add administrative costs, limit innovation, and discourage private sector participation in the system.

  • Expansion of state responsibilities in managing healthcare issues like the coronavirus in addition to scope of practice limitations for licensed professionals, medical liability, abortion, Medicaid eligibility, insurance plan solvency and more.

  • Increased transparency about prices, costs, outcomes, user experiences, profitability, business relationships and conflicts of interest across every sector with drug and hospital prices the primary focus. The administration sees price transparency for prescription drugs and “shoppable services” offered in hospitals as keys to lowering health costs for consumers.

  • Expansion of alternative payment models that replace fee-for-service/volume-based incentives for providers with value-based models that require them to assume financial risk for achievable savings due to unnecessary care. Note: the Center for Medicare and Medicaid Innovation ((CMMI) has tested more than 40 alternative payment approaches: only the Pioneer Accountable Care Organization and the Medicare Diabetes Prevention Program have been certified for expansion by the CMS actuary. According to the Healthcare Payment & Learning Network, 35.8% of total payments to providers are linked to “value” but savings have been lower than expected.

The Trump administration has advanced its policies through a series of Executive Orders (EO) and policy changes announced by the Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and Human Services (HHS), U.S. Department of Veterans Affairs (VA) and other government agencies. Notably, it has expanded the numbers of alternative payment models to 54 and EO’s that address expansion of telehealth, drug and hospital price transparency among others. It has also pursued dismantling of the Affordable Care Act through court challenges and successfully eliminated the ACA’s individual mandate as part its Tax Cut and Jobs Act (January, 2017).

Biden/Harris: The Biden/Harris health policies center on six strategies with most extending provisions in the Affordable Care Act:

  • Expanded access to health insurance coverage through Medicaid expansion, subsidies to purchase private insurance in the healthcare marketplaces and a new “Medicare-like public option” for eligible low-income Americans. In addition, the platform calls for lowering the eligibility age for Medicare coverage from 65 to 60. The goal: 97% coverage.

  • Affordability: No individual would be required to pay more than 8.5% of their income toward health insurance premiums.

  • Strengthening pandemic preparedness vis a vis free testing and vaccines, emergency funding for hospitals, nursing homes, state and local public health departments and replenishment of the national stockpile of PPE, masks, reagents et al.

  • Allowing Medicare to negotiate lower prices with drug manufacturers to lower drug costs.

  • Expansion of community health centers to increase access to primary care services among underserved populations including undocumented immigrants.

  • Aggressive enforcement of antitrust laws to prevent “costly consolidation and price increases” which is certain to be a major focus for its Department of Justice given Sen. Harris’ blocking actions as CA Attorney General

Both campaigns say they will end surprise medical bills, advance price transparency, expand access to mental health services and address drug addiction. Both envision expanded use of Health Reimbursement Accounts to allow premium payments for health insurance. And both promise increased testing for the coronavirus and protections against infectious disease pandemics.

In sum, the Biden/Harris agenda envisions a bigger role for the federal government in assuring equitable access and affordability; the Trump/Pence policies provide more latitude to states and private sector initiatives.


Trump/Pence: The administration anticipates federal government spending for healthcare will remain at current levels (3% annual increase) and annual GDP growth of 4% offsetting the need for additional spending. 

Biden/Harris: The Biden Health Plan would add $750 billion to current spending over the next 10 years. It would be funded by eliminating tax cuts and capital gains loopholes implemented by the Trump administration.

Neither campaign is likely to show its cards to voters around tricky issues risky for politicians seeking votes: drug importation, personal accountability for unhealthy lifestyle, the employer’s tax exemption for its employee health benefit expenses and others.


For the healthcare industry, this is the most consequential race in modern history. Campaign promises aside, two issues will shape how health policies change in the next four years:

  • Coronavirus Impact on the American Psyche: The pandemic has had a chilling impact on the economy (below) and lasting impact on the American psyche. One in four young adults has considered suicide in the last year, 30 workers have lost jobs, and more than half of our households have unpaid medical bills. Surveys show confidence in our elected officials and media have plummeted while trust in the health system has hit a 27-year high. Hope for a vaccine via Project Warp Speed next year buoys optimism, but the death rate (170,000) lends to despair that’s pervasive and potentially long-lasting. Americans are anxious about the future: that will carry over to their views about policy changes in the health system.  

  • Economic Recovery: The addition of $2.8 trillion in FY2020 deficit spending (which includes $2.4 trillion in coronavirus relief funds) has added to our already bloated federal debt ($26.5 trillion) exceeding our total GDP ($19.41 trillion in 2Q 2020) by 31%.  For much of the 20th century, our total debt to GDP hovered at 40%; from 2000 to 2016, it almost doubled to 80% and is likely to settle at 100-110% in the next term of the President we elect. That means efforts to reduce federal spending for healthcare, including Medicare Advantage and Medicare Fee for Service, will be among many that get attention. And given Sen. Harris’ previous opinions against Prime Healthcare in CA and a growing body of evidence showing hospital consolidation has not resulted in lower costs, it’s certain fresh attention will be given to provider deals.

So, each campaign will advance its vision about the future of the health system and each will avoid saying too much. The reality is this: regardless of the resident in the White House, fundamental changes in how the health system is structured and funded will be on the table. And how each candidate advances their ideas about its performance and needed changes will be key to what voters decide.



Donald Trump Presidential Campaign 2020;

Joe Biden 2020 Presidential Campaign;

Rasmussen et al” Precision Public Health as a Key Tool in the COVID-19 Response” JAMA. August 12, 2020;

US Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report;

Megan Brenan “Amid Pandemic, Confidence in Key U.S. Institutions Surges” Gallup August 12, 2020

Furukawa et al “Consolidation Of Providers Into Health Systems Increased Substantially, 2016–18” Health Affairs August 2020;

Wolfson et al “Food as a Critical Social Determinant of Health Among Older Adults During the Coronavirus Disease 2019 (COVID-19) Pandemic” JAMA Health Forum July 31, 2020

Megan Brenan “Amid Pandemic, Confidence in Key U.S. Institutions Surges” Gallup August 12, 2020


U.S. Ranks 31 out of 36 Countries for Covid-19 Response

FPA’s COVID-19 Global Response Index covers an initial set of 36 countries, including G20 nations as well as other developing and middle-income countries based on global data tracked from December 31, 2019 through August 1, 2020:

The U.S. ranks 31st out of 36 countries in its assessment of government responses to COVID-19–below developed countries like New Zealand and Denmark, and below nations with fewer resources like Ghana, Kenya, and South Africa

“The Covid-19 Global Response Index

Right to Repair Legislation Introduced

The legislation introduced last week by Senator Ron Wyden (D-Ore) and Rep. Yvette Clark (D-NY) expedites access to repairs for equipment used in treating Covid-19 patients sometimes delayed by manufacturers. Titled, “Critical Medical Infrastructure Right-To-Repair Act of 2020”, the bill seeks temporary relief during the pandemic emergency from provisions of the copyright and patent laws which could be used to limit rights to service access information. If adopted, the legislation would allow incidental copies of service materials made during maintenance or repair of “critical medical infrastructure”.

“First federal ‘right to repair’ legislation filed in US to help hospitals through pandemic” Healthcare Business News August 06, 2020;

Parental View about School Re-Opening Influenced by Employment, Income Status

According to this survey of 730 parents of school-aged children by the Seattle Children’s Hospital researchers conducted June 2-June 5, 2020:

  • In estimates weighted to US population norms, 31% of participants indicated they would probably or definitely keep their child home this fall vs. 49% who indicated that they would probably or definitely send their child to school this fall.

  • Factors associated with planning to keep children home included lower income (38% with incomes <$50 000 vs 21% with incomes $100 000-$150 000 per year); employment status difference, (40% unemployed vs 26% employed); and having a flexible job (33% with flexible jobs vs 19% with inflexible jobs).

Kroschus et al “Plans of US Parents Regarding School Attendance for Their Children in the Fall of 2020A National Survey” JAMA Pediatrics August 14, 2020;

Obesity Raises Covid-19 Mortality Risk

Background: 42.4% of the U.S. adult population is obese and 9.2% are severely obese. To assess the correlation between obesity and Covid-19 exposure, Kaiser Permanente Southern California members diagnosed with COVID-19 from 13 February to 2 May 2020:

Patients with BMIs of 40 to 44 kg/m2 and greater than 45 kg/m2 had relative risks of 2.68 and 4.18 compared to patients with a BMI of 18.5 to 24 kg/m. This risk is most striking among those aged 60 years or younger and men. However, Increased risk for death associated with Black or Latino race/ethnicity or other sociodemographic characteristics was not detected.

Tartof et al “Obesity and Mortality Among Patients Diagnosed With COVID-19: Results From an Integrated Health Care Organization” Annals of Internal Medicine August 12, 2020

Nursing Home Star Ratings, Covid Protections Relate More to Staffing Levels than Quality Measures or Inspections

27% of deaths in the U.S. due to coronavirus disease 2019 (COVID-19) have occurred among residents of nursing homes (NHs). Researchers analyzed data from 4254 NHs in 8 states across 3 domains—health inspections, quality measures, and nurse staffing—and their Star Ratings in CMS Nursing Home Compare for the period of January 1, 2020, and June 30, 2020. Key findings:

  • NHs with high ratings on nurse staffing were less likely to have more than 30 COVID-19 cases vs facilities with 11 to 30 and vs facilities with 10 or fewer cases than were low-performing NHs.

  • There was no significant association between high- vs low-performing NHs in the health inspections or quality measures domains with COVID-19 cases.

Figuroa et al “Association of Nursing Home Ratings on Health Inspections, Quality of Care, and Nurse Staffing With COVID-19 Cases “JAMA. August 10, 2020;


Gallup: Confidence in U.S. Medical System Near All Time High

According to Gallup’s latest poll (June 8-July 24) on confidence in U.S. institutions, healthcare and public schools have seen noticeable increases, while others have dropped. Highlights:

  • Confidence in the medical system is at 51% its highest since 1993 (34%) when it began tracking of the system.

  • Small business (75%), the military (72%) and the U.S. medical system (51%) are the only institutions garnering majority-level confidence in 2020. By contrast, confidence in Congress (13%), TV news (18%) and big business (19%) were at all-time lows.

Megan Brenan “Amid Pandemic, Confidence in Key U.S. Institutions Surges” Gallup August 12, 2020

Global Capitation for Primary Care Associated with Higher Quality Care for Seniors

Primary care physicians reimbursed via global capitation perform better on quality metrics than those in a fee-for-service model according to an analysis of 5 million patient records by UnitedHealth Group.

  • 80% of patients treated in the value-based arrangements were screened for breast cancer, compared to 74% of those in fee-for-service.

  • More than 80% in global capitation were screened for colorectal cancer while 74% of fee-for-service patients were screened.

“Achieving Better Care for Seniors by Aligning Incentives with Quality of Care” UnitedHealth August 11, 2020;

Specialist-Primary Care Pay Gap Narrows to 61%

Researchers studied inflation-adjusted change in physician compensation from 2008 to 2017 using the voluntary physician compensation survey conducted by the Medical Group Management Association (MGMA). Highlights:

  • From 2008 to 2017, specialist compensation increased by a weighted mean of 0.6% (1.2%) per year, from $378 600 to $399 300.

  • Primary care compensation increased by 1.6% (2.2%) per year, from $214 100 to $247 300. The specialist premium declined during this period, from $164 500 in 2008 to $152 000 in 2017, or from 77% to 61%.

Hsiang et al “Trends in Compensation for Primary Care and Specialist Physicians After Implementation of the Affordable Care Act” JAMA Netw Open. 2020;3(7):e2011981;

CMS Proposes New Payment Model for Rural Health

Last Tuesday, CMS announced a new payment model to provide up-front investments and capitated payments to healthcare organizations in rural areas. The Community Health and Rural Transformation Model (CHART) includes two options for participation: the community transformation track and the ACO transformation track:

  • CMS will select up to 15 lead organizations for the community transformation track who will receive $5 million upfront and capitated payments. CMS will select up to 15 rural communities to participate in the community transformation track in early 2021, and the first performance period will begin in July 2022.

  • CMS will select up to 20 rural-focused CHART ACOs that will receive an upfront payment of $200,000 plus $36/beneficiary as part of joining the 5-year Medicare Shared Savings Program. CHART ACO’s will receive a per beneficiary per month payment of a minimum of $8 for up to two years.

CHART Model August 11, 2020

NIH Encouraging Precision Nutrition

Like precision medicine, precision nutrition aims to understand the health effects of the complex interplay among genetics, microbiome, antibiotic and probiotic use, metabolism, food environment, and physical activity, as well as economic, social, and other behavioral characteristics. The National Institutes of Health (NIH) is promoting the field of precision nutrition vis a vis its 2020-2030 Strategic Plan for NIH Nutrition Research which addresses reducing the burden of disease throughout life and across generations; interactions of nutrition with other potentially modifiable exposures such as the microbiome; and how to use this holistic knowledge to develop and implement actionable recommendations.

Griffin Rodgers, Frances Collins “Precision Nutrition—the Answer to “What to Eat to Stay Healthy” JAMA. August 7, 2020;

NY Opioid Trial to be Live-Streamed

Last Wednesday, a New York state judge said he would allow “meaningful public access” to upcoming hearings in the state attorney general’s suit alleging that opioid companies fueled the addiction epidemic, after opioid companies protested against livestreaming. Note: Although states and local governments have filed thousands of cases blaming drug companies for the opioid crisis, only one case has gone to trial. That trial saw Oklahoma’s attorney general win a $465 million judgment against Johnson & Johnson, which it is appealing.
Emily Field “Opioid Hearings In NY AG’s Suit Will Be Made Public” Law360 August 12, 2020;