A fraught season for health care

With the election less than a week away, various health care issues — among them, the pandemic and the Affordable Care Act (ACA) — are high on voters’ minds. The Gazette spoke with Benjamin Sommers, a health care economist at the Harvard T.H. Chan School of Public Health, about the changes that may loom after the balloting. Sommers, the Huntley Quelch Professor of Health Care Economics, noted that in addition to uncertainties involving the executive and legislative branches, the U.S. Supreme Court would soon be hearing a challenge to the ACA. Sommers shared his thoughts on where we are and where we may be headed.

Q&A

Benjamin Sommers

GAZETTE: As a health care economist, what do you think of the national debate on health care this election cycle?

SOMMERS: COVID has increased everyone’s focus on health issues and the health care system. I think some of the debate is still mired in the muck of the past decades’ debate over the Affordable Care Act, with the same talking points of “repeal it and replace it with something better,” even though there hasn’t been a substantive proposal to replace the Affordable Care Act since repeal efforts failed in Congress a few years ago. There’s some genuine momentum on the left, and if Democrats retake the White House and Congress we would see some substantial proposals to enhance and expand the reach of the Affordable Care Act with a public option and more generous subsidies. But we’re still in the ACA era. Even with COVID, the fundamental health care debate is over a law that was passed 10 years ago. The terms of that debate have changed: The mandate is gone. That was the least popular part of the law, but the law is still largely functioning without it. We continue to have this very polarized debate, even as public opinion has gradually moved toward greater support of the law.

GAZETTE: Are you surprised that the ACA has survived as well as it did without the mandate? My understanding was that the mandate was needed to pay for some of the things people like, like coverage for preexisting conditions.

SOMMERS: The mandate wasn’t so much a revenue generator — the taxes and other fees were what funded the insurance expansion — but it was thought to be a key feature that made the insurance pool stable. The concern was that if you required insurers to cover everybody — even with preexisting conditions — and they couldn’t charge higher prices based on health status, premiums would go through the roof, and no one would be able to get coverage. But the very large subsidies — these big tax credits to buy insurance — kept that from happening by bringing healthy people into the marketplaces. Some people were receiving thousands of dollars from the government to cover most of the costs of health care. And it turns out that carrot had a bigger impact than the mandate’s stick. So even after the mandate was eliminated, there weren’t dramatic changes in enrollment. Some of the early research that I was part of in 2014 through 2016 found that the mandate wasn’t really driving people’s decisions. It was much more about the subsidies. Based on that work, I don’t find the change over the past year surprising. The subsidies are still there, and people want coverage if it’s affordable. Most people don’t sign up for coverage because they have to. It’s because they want health insurance.

GAZETTE: On the political front, is support or opposition to the Affordable Care Act the main difference between the two parties, and how important is the fate of the ACA to the future of health care in the U.S.?

SOMMERS: One of the interesting changes over the past decade is that both parties now say they want to protect people with preexisting conditions. When the Affordable Care Act was passed, there was no consensus around that, and it was the act that forced the change to how insurers could approach people who had health problems. The Democrats pushed that through, but on the Republican side I think it’s been largely a rhetorical rather than a true policy change, because while we see President Trump and others arguing that they do want to protect preexisting conditions, the policies they’re advocating don’t actually do that. Their proposals have much more limited protections for people with preexisting health problems. So if the ACA were repealed, either by legislation or the Supreme Court, the Republicans and President Trump are going to have to put forward a different proposal than anything we’ve seen from them if they’re really going to protect preexisting conditions as the current law does.

GAZETTE: If the ACA is struck down, is it possible for insurers to cover preexisting conditions without major systemic change, like the ACA attempted?

SOMMERS: States tried this before the Affordable Care Act. They said that insurers had to cover everybody and couldn’t charge different prices based on health status, but they did it without the large subsidies that make the ACA function. As feared, premiums did go way up, only sick people signed up, and the market collapsed. That was what people said might happen to the ACA without the mandate, but that hasn’t occurred because of these generous subsidies. But if you take away the ACA subsidies, which is what would happen if the Supreme Court overturns the whole law, there’s really no way to sustain protection of existing conditions. Any alternative plan might be called something else but would essentially have to take similar form: If they’re not going to use a mandate, they would have to use large subsidies like the ACA does. If you want private insurance to cover people, regardless of preexisting conditions, you have to put in place the regulations that require them to do that and the money that makes it affordable for people to buy that insurance. There is, of course, an entirely different approach, which is to say, “Forget trying to do this through private insurance. Let the government cover everybody.” That’s a Medicare-for-All approach, but that is not what we’re hearing from opponents of the ACA, which means that is not what President Trump and his supporters are advocating.

GAZETTE: I’ve heard that if Republicans had been in charge of reforming U.S. health care, a market-based solution like the ACA might be what they would come up with, since it incorporates principles Republicans favor, like providing incentives and then letting the free market find the solution. Is something like the ACA necessary to provide universal coverage if we’re not going for a wholly government-run, Medicare-for-All approach?

SOMMERS: The ACA is one of many approaches you could take to try to expand health insurance, but if you look at the roots of the ideas that led to it, Massachusetts’ health reform, for instance, and some of the ideas around mandates and subsidies in private coverage from the 1990s, they did originate in Republican circles and in conservative think tanks. This was viewed as the conservative or market-based approach — with regulations — to getting people insured through private sources rather than through the government. Now, when Republicans had unified control over the past two decades, they have not put forward any substantial expansion of health insurance. It just wasn’t a priority. So I think both of those statements are true: The ACA took a more market-oriented, moderate, or even conservative approach to expanding health insurance than proposals like Medicare for All. But I’m not sure that it would have happened if it hadn’t been Democrats pushing it forward. Now, the spectrum of ways to expand health insurance run the gamut from using private insurance to providing it directly through the government. Right now we have a combination of approaches. We have the Medicaid expansion. We have Medicare, which provides universal coverage for people 65 and over. And we’re seeing proposals from the Biden campaign that don’t move all the way to government provision for everyone but would increase the footprint of government involvement, by lowering the Medicare age to 60 from 65, by creating a new automatic enrollment in a public option for low-income people who are in states that haven’t expanded Medicaid, and by putting a Medicare buy-in or public option — in all the marketplaces across the country. That would shift more people into government plans but wouldn’t eliminate coverage for the majority of people getting insurance through the private sector.

GAZETTE: So he’d be using the government to fill the gaps, essentially?

SOMMERS: To fill the gaps and to also do some transitioning: taking folks who were between 60 and 65 and giving them Medicare as an automatic option. That isn’t just filling in gaps; that’s also replacing private coverage for a small share of the population. But his proposals are nowhere near as sweeping as Bernie Sanders’ Medicare for All or most of the other versions of a single-payer program.

GAZETTE: Should the ACA survive the Supreme Court challenge and if Biden does become the next president, would his plan move the country closer to universal coverage than it was even at the height of the ACA’s enrollment?

SOMMERS: Any significant legislation is going to depend on having control of Congress. There’s no likelihood that a Republican Senate would advance any of the ideas that Biden has proposed on health care. If the Democrats have full control of the House and Senate and Biden is the president, I think we will see some version of these proposals make its way into law. I don’t know if all of the features will make it — once it’s in Congress, it’ll get changed. But I think it’s safe to say it is a priority. The other thing is that this isn’t all about legislation because the White House, through executive action and oversight, has a lot of flexibility and discretion to affect the way the Affordable Care Act is implemented. We’ve seen the changes the Trump administration has made without legislation, like cutting the length of enrollment periods, doing less outreach, allowing for more short-term, skimpy insurance plans. That has all likely contributed to the fact that we now have a higher uninsured rate than in 2016 and that the coverage gains from the Affordable Care Act have eroded over the past four years. Even without changing the composition in Congress, a Biden White House could put back more funding for outreach, could extend the open enrollment period, and do a lot of messaging around getting more people signed up for insurance.

GAZETTE: We’ve talked a lot about insurance in discussing health care. What has been left out of the political debate on health care?

“We have let our partisan lenses shape decision-making as opposed to making a more evidence-based assessment of the risks and tradeoffs of the different choices. There’s no reason that a pandemic-response map should look like an election map.”

SOMMERS: Some really important changes going on in response to the pandemic are not getting a lot of attention in the campaign but are really critical for what health care is going to look like over the coming 12 months, and really the coming years. For instance, there’s been a huge shift toward telehealth during the pandemic. We’ve seen both the infrastructure for telehealth and the demand for it from patients surging. Some of that will go back down once the pandemic is behind us or at much lower rates of infection. But there are going to be some people and some providers who find real advantages in telehealth. There are strong arguments that a better telehealth system is critical to promoting access to care in rural areas, especially for specialty care that may not be within a reasonable drive. And there are additional benefits for patients who are frail and homebound. I would also hope that after the pandemic, the country more seriously invests in public health infrastructure. It has become very clear that local and state public health departments, contact tracing, vaccination capacity are all factors that are really more critical than our ability to care for patients in the ICU in terms of the total impact of the pandemic. These are all areas that we have underinvested in for a long time, and I am cautiously optimistic that their importance has been brought home to the general public as well as policymakers.

GAZETTE: The president has been taking a lot of criticism for his handling of the COVID-19 pandemic. But looking ahead, how different do you see the future course being with different national leadership? Are we at this point locked into a specific track?

SOMMERS: I don’t think so. There’s still a lot of room for a new president or President Trump — if he’s reelected and has a change of perspective — to enact a more comprehensive federal plan. There really isn’t clear guidance being given from the White House as to how state and local leaders ought to proceed. You could very easily imagine that a new White House would say on day one, “We’re going to appoint a panel that’s going to make broad recommendations about when schools should be open, when businesses and restaurants should be open, when nonessential businesses should be open.” Now, does the federal government have the authority to enforce all of that? No, a lot of it will still fall to the states in our federalist system. But that lack of clear guidance has been a real vacuum. You end up with a map that shows, for instance, schools open in areas with high rates of spread but where public opinion is generally positive toward the president. Meanwhile, places where the president is unpopular, even if their rates are lower, are more likely to have their schools closed. That doesn’t make sense from a public health perspective. COVID decisions shouldn’t be based on the partisanship of the population. So we don’t really have our act together in terms of how these decisions are being made. More scientifically oriented and clear messaging from the White House would go a long way toward consistency in how we make these tough decisions.

GAZETTE: That’s interesting. So, on both sides, there are errors related to how you feel politically.

SOMMERS: That’s my read of the evidence on schools. We have let our partisan lenses shape decision-making as opposed to making a more evidence-based assessment of the risks and tradeoffs of the different choices. There’s no reason that a pandemic-response map should look like an election map. It ought to be driven by what’s going on with the disease and what’s going on in terms of the capacity to mitigate the risk of spread. Where is the capacity in place for remote learning and where isn’t it? Where can schools be updated to appropriate ventilation standards and where do investments need to be made? We’re missing that sort of systematic national evaluation and investment and I think a new administration — or the Trump administration if reelected — ought to prioritize that.

GAZETTE: It seems that a lot of officials, and in particular the president, are counting on a vaccine to end the pandemic. Can the pandemic end without a vaccine?

SOMMERS: Through human history, many pandemics have ended without vaccines. But I think there will be a vaccine. I think we will, over time, have multiple effective vaccines. The question is how effective will it be? Will it be highly effective — more than 90 percent protection? Will this be a moderately effective vaccine, with 50 to 60 percent protection? We don’t know. We also don’t know what percentage of the public will get a vaccine, both from the perspective of their willingness — we know there’s increasing skepticism in public opinion polls — and because of implementation. How quickly can we get a vaccine to the people who want it once one has been approved? So the short answer is the pandemic will end. Whether it will end by going away completely or become endemic and more like the flu in that every year we see a rise in cases but not nearly to the level of damage that it’s caused over the past year, it’s hard to say. And I don’t think anybody knows.

GAZETTE: Systemic or unconscious racism in the health care system hasn’t been a big part of the political debate, but the health care system has been mentioned as part of the nation’s recent awakening on systemic racism. How big a problem do you see that being, and do you have a sense of how to tackle it?

SOMMERS: I think structural inequality, in terms of racism, discrimination against immigrants, and inequality based on income are critical problems in the health care system. The U.S. health care system has always been plagued by different levels of access to care and quality of care depending on what group you are in. That is a huge source of structural inequality in health care. If you look at the map of which states have expanded Medicaid, the states that have yet to expand have large African American and Hispanic uninsured populations: Texas, Florida, the Deep South. That’s part of a long history in our country of policies with adverse and discriminatory effects against racial and ethnic minorities. That’s been true in health care, too. Hospitals were not integrated until the 1960s and that required federal intervention. So, absolutely, this is a key feature of our health care system. There’s also the role that implicit bias plays in our micro-interactions. There’s a large literature in medical research that shows providers treat patients differently based on factors including race, gender, sexual orientation, and income, and these forms of implicit bias have real harms. Patients are less likely to get diagnosed or treated appropriately when they’re in one of these marginalized groups. There’s no quick fix for this. Some of this has to do with how we train our clinicians and doctors and nurses. Some of this has to do with how we make broad policy decisions. It all starts with recognizing the roles that structural inequality and racism play. If we don’t recognize there’s a problem, we have no hope of fixing it.

GAZETTE: How would you advise Republicans if they retain the White House and the Senate? What would you say to do first, in terms of health care?

SOMMERS: A lot is going to hinge on what happens at the Supreme Court. I think if you read between the lines of what Republican legislators have been saying, they are worried about the ACA ruling. If the court does strike down the whole law, suddenly the Republicans would be in control of fixing this enormous disruption to the system. They have been calling for the ACA to be repealed for a decade and failed to do so when they had their best chance in 2017 because the moderate wing of the party — governors of states that have expanded Medicaid and a handful of senators — said, “This is too damaging. We don’t have a replacement; we can’t pull the plug.” The Supreme Court could force their hand and say, “Well, we just pulled the plug. Whether you have a replacement or not, the ball’s in your court.” There almost certainly would have to be some sort of legislative response if the Republicans control Congress and the White House.

GAZETTE: So, be careful what you wish for?

SOMMERS: Right. If there’s divided government, the outlook is worse, in terms of a response to the Supreme Court. In that case, I worry we’d see a lot of the blame game and nothing would get passed. If either party is in full control and the Supreme Court struck down the whole ACA, we would see some sort of legislation emerge. If the Supreme Court doesn’t overturn the law, what should Republicans do? My sense is that health care wouldn’t be a high priority, and I think most of them would be happy to turn the page on ACA repeal and not revisit it. Every time they have tried, they have failed, and the law gets more popular. On more practical issues, you might see some focus on prescription drug costs. President Trump has been talking about that for a while, and I think there’s bipartisan interest in seeing drug prices come down. As to the long-term response to the pandemic, I think some we would see, again, support for increased use of telehealth. That’s a very popular position among rural legislators, both Democratic and Republican. But under Republican leadership, we almost certainly won’t see any broad expansion of health insurance.

GAZETTE: Same question for Democrats. What would you advise them to do first?

SOMMERS: I think the easy answer is to undo some of the more harmful policies that have been implemented by the administration. I would go back to making it easier for people to enroll in the Affordable Care Act marketplaces. And I would go back to doing a better job of advertising and informing people about their coverage options. I would get rid of some of the policies in Medicaid that have made it harder for people to enroll, like work requirements. Those can be done pretty quickly through executive orders. In terms of legislation, I think a potential Biden administration has indicated that they’re not going to go for a sweeping change of the system and instead are going to build on existing law. If that’s the framework they want to use, I think more generous subsidies, particularly for middle-income families, would help. I think the deductibles for many people in the marketplaces are bigger than they can afford, and drug prices for everybody — whether in ACA plans or their employer plans — is a real issue. Some movement there, including the possibility of Medicare drug price negotiation, will be on the table as ways to improve affordability and access.