Where rheumatology care stands under Trump, Biden
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The 2020 presidential election is expected to dramatically alter the health care landscape, regardless of which candidate wins. Although every election is technically a “health care election,” this one is undeniably exceptional.
Not satisfied to merely be at the forefront of the 2020 general election, health care has instead repeatedly pushed itself to the top of the national conversation as a key voter issue. As a result, health care has become a centerpiece on each candidate’s ticket, sparring over the future of the Affordable Care Act, the most appropriate response to the COVID-19 crisis, and most recently, the contentious nomination of Judge Amy Coney Barrett to the Supreme Court, which has raised concerns about the future of abortion access.
There are stark differences between President Donald Trump and former Vice President Joe Biden on health care policy, ranging from the ACA, to COVID-19 to prescription drug prices, that would have meaningful impacts on all physicians, including rheumatologists. There are also some notable similarities: They have both publicly supported allowing patients to import drugs from Canada, for example.
The outcome of the election will have uniquely significant consequences for the state of rheumatology care, as the debate over ACA coverage for pre-existing conditions could impact millions of Americans living with autoimmune diseases. With this in mind, Healio Rheumatology explores some of the most pressing health care issues for rheumatologists, as well as their patients, and how Trump and Biden plan to address each.
COVID-19
Trump has responded to COVID-19 by publicly downplaying its severity and placing most of the responsibility for managing the pandemic on individual states. Early on in the administration’s response, Trump advocated strongly for the use of hydroxychloroquine to protect against the disease, despite a lack of research, sparking nationwide shortages for rheumatologists and their patients who require the drug for rheumatoid arthritis and lupus.
In addition, Trump has pulled the United States out of the WHO, pushed to reopen schools for in-person instruction and often contradicted federal health experts’ advice on mask wearing and social distancing, even after contracting the virus himself.
As of Oct. 14, there have been 216,872 deaths from COVID-19 in the United States, according to the Johns Hopkins dataset. On Oct. 15, the CDC projected there would likely be 3,400 to 7,100 new deaths reported during the week ending Nov. 7, for a possible total of 229,000 to 240,000 COVID-19 deaths by that date.
“There is no discussion under the Trump administration of a federal mask mandate,” Allan Gibofsky, MD, JD, FACP, FCLM, of the Weill Medical College of Cornell University and the Hospital for Special Surgery in New York, told Healio Rheumatology. “However, there is discussion of emergency legislation that will eliminate out-of-pocket costs for testing, prevention and vaccination, once developed. There is also discussion of fast-tracking and expanding access to a vaccine.”
Biden, in contrast, has noted that he would shift responsibility for COVID-19 management from the states to the federal government. The former vice president’s plan also supports expanded testing, eliminating out-of-pocket costs for treatment, increased production of personal protective equipment, rejoining the WHO and guidance on how to distribute vaccines to older and high-risk individuals once available.
“He also has a plan for — or at least has been quoted as discussing — a nationwide mask mandate, if so advised by scientists and experts, and has also discussed the possibility of the federal government, which would now be controlling the response, ordering a mandatory lockdown in areas that show high COVID rates,” Gibofsky said.
The Affordable Care Act and Medicaid
Trump has notably offered few details about his second-term health care agenda. His campaign’s website includes no plan or priorities — only a list of what it sees as first-term accomplishments.
Still, according to Gibofsky, who also holds a law degree from Fordham University, where he previously taught health care law, Trump’s words and actions paint a fairly clear picture of his intentions regarding the ACA.
“Under Trump’s plan, there would not be an ACA,” he said.
In addition to ending cost-sharing subsidy payments to insurers, and backing major cuts to Medicaid, Trump has supported several unsuccessful proposals from Congressional Republicans to repeal the ACA and replace it with weaker protections for patients with pre-existing conditions and reduced premium assistance. In addition, the president supports a lawsuit currently before the Supreme Court seeking to overturn the entirety of the ACA.
According to Meredith Freed, MPP, a policy analysist with the Kaiser Family Foundation, a Supreme Court decision striking down the ACA would have a “far-reaching impact” on providers and patients.
“If protections for people with pre-existing conditions are no longer in effect, there are 54 million people who have a pre-existing condition that would have been deniable in the pre-ACA individual market,” she said.
“Nearly 12 million people newly gained health insurance coverage under the Medicaid expansion through the ACA,” she added. “It is not entirely clear what would happen if the ACA is overturned, but many low-income people could lose a pathway to Medicaid coverage and would likely become uninsured.”
In addition, Trump has issued regulations allowing insurers to avoid certain consumer protection mandates in the ACA. This has led to the expanded use of short-term plans with lower premiums but exclusions for individuals with preexisting conditions and certain benefits.
Although Trump signed an executive order that would seek to protect people with pre-existing conditions, Freed said insurers could still deny coverage if those protections are invalidated by the Supreme Court.
Biden strongly rejected calls for “Medicare for all” throughout the Democratic Party primary and instead campaigned on bolstering existing protections in the ACA. He has proposed increasing premium assistance, decreasing the age for Medicare eligibility to 60 years and increasing Medicaid funding for states during the COVID-related economic crisis. In addition, he has promised to reverse Trump’s policies that have loosened ACA rules.
Biden also supports establishing a “public option,” a Medicare-like plan for those who cannot afford private insurance or live in a state without expanded Medicaid eligibility. However, Gibofsky said the plan lacks some essential details.
“What and how the public option would cost out is something that remains vague, and whether the intent is an option or a first step toward the elimination of private insurance also remains vague,” Gibofsky said.
“One of the things we’ve seen, and one of the things people have to keep in mind, is that there is a big difference between having insurance and having access,” he added. “People may have insurance but be unable to get access to their provider, or to a provider who accepts the plan they are currently insured with. The best example of that of course is Medicaid, where not all providers accept it — indeed, many providers specifically do not accept Medicaid patients. So, having insurance doesn’t guarantee access, and it is unclear to what extent public options would be expanding access.”
Prescription drug prices
Throughout his first term, Trump has repeatedly promised to reduce prescription drug prices, but, according to Freed, has so far produced “negligible” results.
Although the president has signed several executive orders aimed at lowering costs for consumers, most have not been implemented, including an order to test a “most favored nation” pricing model for certain high-cost Medicare Part B and Part D drugs as well as an order that would ban prescription drug rebates in Medicare Part D.
Trump also signed an executive order that would require Federally Qualified Health Centers that participate in the 340B program to make insulin and EpiPens available at 340B prices. The administration later proposed a rule relating to this executive order, but it cannot go into effect until it has been finalized. In addition, under a voluntary Medicare Innovation Center model, participating Part D plans can offer coverage of insulin for a monthly copayment of no more than $35 beginning in 2021.
The executive order closest to implementation is one that would allow certain prescription drugs to be imported from Canada. Still, Freed said there remain several unanswered questions regarding the policy.
“Unless there is a legal challenge, the rule will become effective at the end of November,” said Freed. “However, in the final rule, the Trump administration did not provide an estimate of the expected savings from any importation plan. Therefore, it is unclear how much consumers will save on their prescription drugs if a state or other entity ultimately gets approval to implement its own importation program. Furthermore, the timeline of how quickly a state could get approval and be able to implement an importation program is also unclear, so it could still be quite some time before patients see any savings.”
Biden also supports allowing patients to import drugs from Canada. He has also proposed caps to out-of-pocket drug costs in Medicare and eliminating tax breaks for drug advertising expenses.
However, the centerpiece of Biden’s prescription drug plan is a rule allowing the federal government to negotiate drug prices for Medicare and other public and private purchases, with prices capped at those paid in other comparable countries. The plan would also create a board that could examine the value of new drugs and recommend a price, similar to the model used in Germany.
Although such price caps could lower costs, Gibofsky cautioned that “it remains to be seen how they would reduce innovation.”
“I am by no means an apologist for the drug industry, and I think negotiation is a good thing, but negotiation where there are no other options — or that could lead to options that are less desirable — would be problematic,” he said. “It is one thing to say, ‘If you don’t give us this price, we won’t buy your drug,’ but people still need biologics. We see some of that now, with third-party payers and insurance companies. If they don’t get the price they want for a biologic, they won’t put that biologic on their formulary. They will simply require use of another biologic. So, a lot of this is already in process in our current system.”
Congressional consideration
It should be noted that much of both Biden’s and Trump’s priorities would require cooperation from Congress, which, depending on the outcome of the election in November, is far from a given for either candidate.
And although executive actions are an option, they are no less protected from legal challenge than regular laws.
“If there is a Democratic president and a Democratic Congress, then the Democratic Party will be able to get its priorities passed, assuming they don’t need a two-thirds majority in the Senate,” Gibofsky said. “Regardless of who is in the White House, if there is a Democratic House and a Republican Senate, as is the case now, it means that the likelihood for a Democratic president to get anything through is lower, except by executive action. However, the extent to which these things can be done by executive action remains to be seen, because just like legislation itself, it is always subject to judicial review.”
“I suppose that a president could wave their pen and say, ‘Effective tomorrow, the cost of drugs will be cut by 50%’,” he added. “However, I am not sure how that would be implemented if there were a split in the houses between Republicans and Democrats.”
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Allan Gibofsky can be contacted at the Hospital for Special Surgery, 525 E. 71st St., 7th Floor, New York, NY 10021; gibofskya@hss.edu.
Meredith Freed can be contacted at the Kaiser Family Foundation, 1330 G St. NW, Washington, DC, 20005; clee@kff.org.
Johns Hopkins COVID-19 dataset. Accessed Oct. 14, 2020.
CDC forecast of COVID-19 deaths. Accessed Oct. 15, 2020.
Joe Biden campaign website.
Donald Trump campaign website.
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