This extraordinary March and April – marked by rising numbers of Covid-19 cases and fatalities, suffering for patients and families, courageous efforts by clinicians, restricted social interaction, business closings, massive unemployment – has battered our healthcare system and economy. Here are a few early thoughts on how the evolving pandemic has changed the outlook for health policy after the November elections:
Will voting go smoothly? Campaigning has been interrupted by delays in primaries, suspension of rallies and in-person campaigning, and reduced ability to raise funds. No one yet knows when or whether the danger of coronavirus infection will decline to the point where normal campaign activities can resume this season. Nor do we know whether there will be a rise in infections as social distancing restrictions are loosened and/or cold weather returns, and whether citizens will be deterred from going to polling stations on November 3. Efforts to switch to universal mail-in ballots face logistical, legal, and funding obstacles as well as partisan squabbling.
This was already promising to be a close contest for control of the White House and the Senate. Low turnout, changes in voting procedures, slow counts of ballots, and disinformation campaigns could feed questions about the election results and potentially legal action up to the Supreme Court. The result could reduce the credibility and authority of whoever takes office next January as President, in Congress, and in governorships.
Changes in key players: Clearly a Biden administration would bring new leadership for the Department of Health and Human Services, Food and Drug Administration (FDA), and other key health agencies. So could a second Trump term; there are widespread reports of bitter infighting among the administration’s health team, and some of the key leaders are unlikely to survive into a second term. In Congress, the agenda and priorities will be considerably different depending on whether Republicans or Democrats control committee chairs and the legislative calendar.
The blame game: Why was the U.S. so poorly prepared for the coronavirus pandemic? Expect a full investigation (or competing investigations), with plenty of finger pointing to go along with serious efforts to shore up our public health preparedness. The Department of Homeland Security was created in the wake of 9/11; will this crisis lead to a restructuring of health agencies?
Pressure on the FDA: The new Commissioner, Dr. Stephen Hahn, had a shaky introduction to most of the public as the FDA was roundly criticized for its early response to the pandemic. Clearly the FDA should have done better in approving testing kits, but now some of the resulting calls to “cut red tape” in approving drugs and vaccines threaten to weaken the FDA’s ability to ensure new agents are effective and safe. This pandemic revealed that many key decision makers only poorly understand the process for developing and approving new pharmaceuticals; there may be more support for populist ideas such as the bill, reintroduced by Sen. Ted Cruz (R-Texas), to automatically give reciprocal approval to any drug approved in another developed country, subject to review by Congress.
Drug pricing legislation: Even in the relief bills, there may be limits on the price of any new vaccine or drug for Covid-19. In 2021, expect to see stronger legislation to limit prescription prices, no matter which party controls the White House or Senate. Both parties want to show results on this issue – and will be even more anxious given new fiscal realities.
Addressing huge federal deficits: Last year the deficit was barely under $1 trillion, and it was projected to rise higher for fiscal year 2020. That was before the pandemic and the series of emergency rescue packages adding trillions of dollars in new spending. Yet the combination of the relief bills – on top of the higher spending on the social safety net and sharply reduced tax revenue that accompanies a profound recession – creates multi-trillion-dollar deficits and a debt burden that will hang over the federal government long after the pandemic passes. In 2021 and future years, especially when interest rates rise from current historically-low levels, either party will be forced to find ways to reduce those deficits. We should anticipate renewed interest in removing the deductibility of pharma marketing expenses.
State deficits, too: The pandemic also increases spending and reduces revenue for the states, and 49 (Vermont is the exception) are forbidden from running budget deficits. While the federal government may provide relief funds in the short term, for the longer term states will also need new revenue sources. Several have already looked at taxing digital advertising and/or direct-to-consumer advertising.
Data privacy legislation: Quietly and behind the scenes, leading Republican and Democratic Senators have been working in a fairly bipartisan way toward enacting new data privacy and security regulations at the federal level. The pandemic highlights new issues: For example, interest in using cellphone geolocation data to trace contacts of coronavirus patients illustrates an important public health value, the need to set rules at a federal level, and difficulties in preserving consumer privacy. This will add to the pressure for Congress to approve a new framework for data privacy regulation in 2021.
New focus on health insurance: The Supreme Court is slated to rule during its next term on whether the Affordable Care Act (ACA) is, as the Trump administration argues, unconstitutional. Yet the ACA was already becoming more popular over the past two years, and the idea of repealing it would seem untenable during and after this pandemic. A second Trump administration likely would be forced to come up with a legislative fix if the Supreme Court rules against the ACA. A Biden administration would push forward with a public option and might find sufficient support to take a Medicare for “More” approach.
It has been remarkable to watch how quickly attitudes have changed on the proper role of the federal government in protecting health and the economy. The implications will play out in new ways as we confront health policy and other issues after the 2021 elections.