While ideological divides on U.S. health care policy remain wide, the next Congress and administration will face several key issues that, regardless of the November election outcomes, will require bipartisan collaboration to address. In addition, there will be several potential opportunities for bipartisan agreement to further advance the health of the American public. Here we examine the current political divides and opportunities for action in the coming years.
Existing Partisan Fault Lines
Congressional Democrats, the Obama Administration, and the 2016 Democratic National Committee platform are unified in their support for preserving and building on the Affordable Care Act (ACA). President Obama and other supporters of the ACA tout the law’s progress in reducing the uninsured rate, improving quality of care, and reducing per-enrollee health care spending across private payers, Medicaid, and Medicare. To further reduce the uninsured rate, Democratic presidential candidate Hillary Clinton proposes expanding Medicaid for low-income Americans in the 19 states that have not done so under the ACA, allowing individuals aged 55-64 to buy into Medicare, and creating a new public insurance option to be sold alongside private plans in the Health Insurance Marketplace.
The GOP Health Care Reform Task Force and the 2016 Republican National Committee (RNC) platform seek to repeal and replace the ACA in ways that would restore and expand authority to states and provide more options for consumers, for example by promoting Health Savings Accounts and Health Reimbursement Accounts for the purchase of insurance, allowing insurance sales across state lines, and converting Medicaid to a block grant or per-capita allotment to enhance state flexibility in program administration. Other proposals would promote private-sector, free-market solutions including Medicare “premium support” with an exchange for Medicare plans to compete with one another. GOP presidential candidate Donald Trump has vowed to repeal and replace the ACA, a principle also included in the Health Care Reform Task Force and the RNC Platform. However, the Senate is not likely to have the 60 votes needed to pass a wholesale repeal.
Opportunities for Bipartisanship
Absent repeal, there may be opportunities for bipartisan changes to the ACA. Dozens have already been enacted, and there is bipartisan interest in others, for example, streamlining employer reporting requirements under the ACA, and removing restrictions on small businesses offering employees Health Reimbursement Accounts to cover health insurance premiums and out-of-pocket medical expenses.
Beyond the ACA, we see three main areas of opportunities for bipartisanship for the next Congress and administration. These areas involve programs ingrained in the current health care system and due for reauthorization or funding extension, areas with existing bipartisan support and momentum in the current Congress, and areas with potential bipartisan common ground for which leadership by the two branches of government could yield tangible benefits. Table 1 illustrates the progress of specific bills pending in the 114th Congress highlighted in this article as having bipartisan momentum or potential.
What Congress Needs To Do
We expect debate to begin early in the new Congress around extending funding for the Children’s Health Insurance Program (CHIP), which expires September 30, 2017. States will urge action early, needing certainty to pass their budgets, which begin for most on July 1, 2017. Major considerations include how long to extend funding and what, if any, programmatic changes should be made.
Other bipartisan policies may move along with a CHIP bill. These include extensions of community health center funding and expiring Medicare provisions — for example extending payment increases to certain rural or low-volume providers.
Another issue up for consideration is the Veterans’ Administration Choice Program established in 2014 to reduce health care wait times for veterans. The need to address these items raises questions about how to pay for a legislative package that could cost tens of billions of dollars, and where legislation is moving, there will be pressure and the desire by some to attach other legislation such as pending bills related to hospital services. While challenging, these dynamics may create an environment for bipartisan deal-making.
Another major anticipated item of business is the reauthorization of prescription drug and medical device user fee bills, which expire September 30, 2017. This follows year-long negotiations among the biopharmaceutical industry and the Food and Drug Administration (FDA) on what fees companies will pay in exchange for faster drug reviews and other commitments. The FDA and manufacturers have recently reached agreements on draft Prescription Drug, Medical Device, and Generic Drug User Fee Act Reauthorization (PDUFA, MDUFA, GDUFA) proposals, which, when finalized, will go to Congress to inform the legislative process.
Existing Bipartisan Efforts with Momentum
The 114th Congress has fostered significant bipartisan collaboration on the House’s 21st Century Cures Act and Senate HELP Committee’s 19 medical innovation bills to accelerate development and approval of safe and effective drugs and medical devices, and increase electronic information sharing and interoperability of electronic health records. While final action on these bills is still possible in the remaining weeks of the 114th Congress, bipartisan deals must still be struck on issues including funding for the National Institutes of Health (NIH). Whatever does not pass this fall could provide a foundation for deliberation in the new Congress.
Members on both sides of the aisle have supported legislation to improve oversight and outcomes of federal mental health programs and tackle the nation’s opioid addiction crisis. The Comprehensive Addiction and Recovery Act (CARA) was enacted in July and partially funded ($37 million of $181 million authorized) in the recently enacted short-term funding bill. Additional CARA funding may be considered as part of a subsequent spending bill during the final weeks of this congressional session. While there is tremendous bipartisan momentum behind advancing mental health legislation this year, House and Senate versions must still come together, and policymakers must resolve issues of funding levels and gun-related amendments before it can cross the finish line.
Another area of promise is the Senate Finance Committee’s Chronic Care Working Group which is working to finalize legislation to bring before the committee. Bipartisan proposals focused on, for example, advancing team-based care and empowering individuals and caregivers in care delivery were put forward by the Working Group in 2015 for public feedback. Programs to support home-based primary care and policies to provide and coordinate non-clinical services with clinical services through Medicare Advantage and accountable care organizations have been proposed through bipartisan, bicameral legislation.
Related to chronic care reform, there has been support for advancing the use of technology that enables clinicians to deliver care to patients virtually, such as telehealth. Bipartisan, bicameral legislation seeks to expand use of telehealth and remote patient monitoring services, for example by lifting certain regulatory restrictions for its use by qualifying participants in alternative payment models (APMs) and Medicare Advantage. This would build upon existing efforts by the Centers for Medicare and Medicaid Services, including under the Medicare Access and CHIP Reauthorization Act, to encourage the use of telehealth through APMs.
Areas with Potential Bipartisan Common Ground
The Bipartisan Policy Center’s Delivery System Reform Initiative, Prevention Task Force, and Advancing Medical Innovation Initiative, among other projects, have previously offered specific recommendations to improve the health of Americans and the effectiveness of the health care system. These recommendations provide the basis for identifying several areas with potential bipartisan common ground for the next Congress and administration which are detailed below.
Coordination of Care and Long-term Services and Supports
The high cost of patients with multiple chronic conditions and complex social needs has increased policymakers’ focus on ways to target interventions and improve care coordination for these patients. Recent research has suggested that targeted interventions, including better care coordination and integration of traditional health services and long-term services and supports (LTSS) for patients dually eligible for Medicare and Medicaid, can reduce hospital admissions and emergency department visits, while increasing the availability of LTSS, such as home and community-based care. This evidence, when viewed through the lens of recent efforts to find consensus on long-term care financing, may prompt broader discussions about the link between targeted care management, integration of services for high-need patients, and expanded access to LTSS.
Simultaneously supporting the innovation and affordability of pharmaceutical drugs is a critical issue for the health care system as 16.7 percent of personal health care expenditures were attributed to pharmaceutical medicines (retail and non-retail) in 2015. A small percentage of prescription drugs resulting in a rising share of total pharmaceutical costs may intensify the pressure to focus on value-based payment strategies. While substantive policy action in this area would require much more bipartisan collaboration and agreement than we have seen to-date, some policymakers have begun to explore ways to promote competition and access to lower-cost generic drugs as evidenced by recently introduced bipartisan legislation.
Medical Liability Reform
The medical liability system costs the U.S. health care system approximately $55.6 billion annually. With both parties increasingly embracing paying for value in health care, there is a recognition that defensive medicine, care provided less based on evidence and more to guard against future lawsuits, could make it more difficult to achieve provider accountability for reduced total costs of care. While political hurdles for passage of legislation in this area may be high, proposals from both sides of the aisle have touted policies such as safe harbors for clinicians following evidence-based practices and tort processes outside the traditional court system as potential ways to reduce pressure on practitioners to prescribe unnecessary tests and procedures.
Value-Based Insurance Design
While much of the attention on increasing health care value has focused on provider incentives, it has been argued that consumer incentives should be aligned to maximize health system transformation. Though progress has been made through executive branch actions, restrictions in Medicare Advantage to vary patient cost-sharing based on value have been noted by both parties. Barriers also remain for fee-for-service Medicare and alternative payment models such as accountable care organizations. The move away from one-size-fits-all cost-sharing structures to ones that vary based on value and quality of services and providers is consistent with the bipartisan direction of paying for value under BPC’s delivery system reform recommendations and the Medicare Access and CHIP Reauthorization Act of 2015.
Prevention & Public Health Infrastructure
Partisanship over the ACA’s Prevention & Public Health Fund has at times made it difficult to focus on prevention solutions, with one notable exception being opioid abuse. At the same time, however, tobacco use and obesity are two of the leading risk factors contributing to potentially preventable deaths in the United States. Bipartisan solutions to support communities addressing these issues could further prevent chronic diseases such as diabetes, cardiovascular disease, and cancer. Opportunities also exist to reinforce national public health and emergency preparedness infrastructures. Specifically, bipartisan efforts to improve the nation’s water infrastructure and create an emergency fund for public health crises are underway and could progress in 2017.
The 115th Congress and the new administration will inherit a full slate of issues that require leadership. Given competing demands, health policy may not receive the same high level of attention it has in recent years. Affordable Care Act partisanship will not dissipate even with a Democratic president particularly given the House GOP challenge to cost-sharing subsidies moving through the court system. While a Democratic administration might increase opportunities for changes to the ACA, it is unclear how much bipartisan congressional support will exist. With a Republican president, movement toward repealing the law will only grow but will remain a procedural challenge in the U.S. Senate.
Nevertheless, regardless of the election outcome, there will be opportunities for bipartisanship to address health care issues. They may be more incremental in nature and differ depending on the make-up of the Congress and administration. Whether the political will exists to reach across the aisle and work together remains to be seen. If so, bipartisanship may very well contribute to having a positive impact on the nation’s health.