Assessing health care challenges for next U.S. president
October 2, 2024 – How can health care in the U.S. be more accessible, more affordable, and more equitable during the next presidential administration?
Those were the topics addressed by a dozen experts who spoke at a Sept. 27 symposium at Harvard T.H. Chan School of Public Health hosted by the School’s Department of Health Policy and Management and the New England Journal of Medicine (NEJM).
Eric Rubin, NEJM editor-in-chief and adjunct professor of immunology and infectious diseases at Harvard Chan School, and Jane Kim, the School’s dean for academic affairs, gave opening remarks at the event, held in Snyder Auditorium.
In previous years, Rubin explained, NEJM used to commission each presidential campaign to write articles spelling out their health care policies prior to the election. “It turns out those statements got less and less interesting over time,” he said. “So we thought, what if we turned to real experts instead to tell us about what we should expect and what we should hope for.”
In her opening remarks, Kim listed a number of pressing issues, including the challenges of insurance coverage, the barriers still preventing millions from accessing the care they need, the rising cost of health care, and persistent health disparities.
Robert Blendon spelled out the stark differences between Republicans and Democrats according to surveys he’s helped conduct as director of the Harvard Opinion Research Program. “Let me make this simple for you,” said Blendon, Richard L. Menschel Professor of Public Health and Professor of Health Policy and Political Analysis, Emeritus at Harvard Chan School. “Democrats think we have to spend more after the election on every major problem this country is suffering, and even when we are spending enough, we need to invest more on equity. For Republicans, government spending is the reason we have such high inflation, and we have to cut back on government spending.”
Outside of that simple calculus, there are some nuances, he said. While mostly opposed to higher spending, Republicans do support more health care funding for veterans and for Medicare. “Medicare is incredibly popular with both parties,” Blendon said—though Republicans are more supportive of coverage offered through Medicare Advantage (a type of Medicare plan provided by private companies), and Democrats are more supportive of imposing stricter price controls to limit costs for insurees. Also, he noted, while Democrats are supportive of abortion access in most scenarios and Republicans mostly oppose it, both parties are united in supporting in vitro fertilization (IVF) treatments.
In a panel on accessibility, Sherry Glied, dean of New York University’s school of public service, started with the good news—health insurance coverage has increased to record levels, with only 8% of Americans now uninsured. In addition, changes in tax credit subsidies since the American Rescue Plan and the Inflation Reduction Act have increased enrollment in state health insurance exchanges. The bad news, however, is that those subsidies are set to expire next year and will take $335 billion to renew—leaving a choice for the next president and Congress that could continue to increase health care access or erode it.
Ben Sommers, Huntley Quelch Professor of Health Care Economics at Harvard Chan School, discussed one of the challenges regarding Medicaid—the drop-off in enrollment numbers following the end of a federal policy that safeguarded coverage for millions by requiring states to maintain enrollment for most enrollees during the pandemic. State and federal policies, he said, could help people retain coverage by allowing continuous periods of eligibility, or extending the amount of time children are eligible to stay in the program even if their families’ income changes. He also addressed one of the sticking points surrounding health care accessibility—that 10 states, mostly in the South, have not expanded Medicaid coverage as permitted under the Affordable Care Act. Though expansion remains popular among citizens, it is often opposed by conservative governors and legislators, he said. State referenda and additional federal incentives have succeeded in expanding Medicaid in a handful of states, Sommers said, but are unlikely to prevail in many more. He noted that a recent Georgia plan to expand Medicaid in exchange for higher work requirements could be a possible way forward for other states.
In a panel addressing affordability, J. Michael McWilliams, a health care policy professor at Harvard Medical School, noted that although federal subsidies have made health care more affordable for individuals, rising spending in the health system as a whole may mean that the subsidies can’t keep pace, making them less helpful. Another problem, he said, is Medicare Advantage. Those plans are aimed at reducing costs by cutting unnecessary care and better managing spending. But the plans are also costing the government and taxpayers more than traditional Medicare, and there are concerns that private insurers are pocketing earnings without trying to improve affordability. McWilliams said he thinks that stronger regulation must be put in place to ensure that Medicare Advantage plans pass any savings along to subscribers.
Addressing the affordability of prescription drugs, Stacie Dusetzina, a health policy professor at Vanderbilt, outlined improvements under the Biden-Harris administration: Medicare is now able to negotiate prices for some prescription drugs, and there are caps of $35 for insulin and $2,000 for out-of-pocket prescription drug costs annually. Given Donald Trump’s track record on prescription drug prices, another Trump presidency is likely to roll back recent cost-cutting efforts, she said, while a Harris presidency would likely expand them. Dusetzina warned, however, about potential unintended consequences of Harris’s stated plan to extend existing price caps to private insurance plans. “That’s not necessarily going to help people the way you think it should,” she said. “You end up shielding consumers from price, but they are still paying for it through higher premiums or low wage growth.”
In a panel on health equity, Ohio State University health law professor Ruqaiijah Yearby pointed to the importance of examining how structural determinants of health create health inequities, including structural racism embedded in federal policies. That effort, however, could be complicated by the recent Supreme Court ruling in the Chevron case, which shifts more power to judges to overrule decisions by federal agencies. “We need to pay attention to who we elect, because they are going to decide what judges we appoint,” Yearby said.
Harvard Chan School’s Marcella Alsan, professor in the Department of Health Policy and Management, spoke about the role of interest groups in shaping public policy. She pointed out that one of the biggest players in shaping our current system of private health insurance after World War II was the American Medical Association (AMA), leading to many of the problems we see today with access, affordability, and equity. No matter who is elected to the presidency or to Congress, she said, it’s important to be vigilant about these often unseen players who can influence health policy. After all, she noted, four of the top 10 federal lobbyists by spending come from the health care industry [Blue Cross Blue Shield, the AMA, the American Hospital Association, and the pharmaceutical industry]. It’s crucial, she said, to pay attention to who the special interests are and who they’re beholden to.
Photos: Kent Dayton
