Biden’s State of the Union: Bold Promises on Public Health
On March 1st, President Biden delivered his first State of the Union Address to both chambers of Congress and the American people at large. Amid a slew of foreign and domestic policy proclamations, particular attention should be afforded to the statements and commitments made about addressing the COVID-19 pandemic and public health, more broadly. Championing the landmark legislation that was the American Rescue Plan, the President laid out how the legislation’s programming reduced food pantry lines, increased employment, and how expansion of the Affordable Care Act’s subsidies resulted in lower insurance premiums for many Americans. In addressing the COVID-19 pandemic, Biden also recognized a sobering outcome that will shake the nation: within the next few weeks, the United States’ official COVID death toll will surpass one million people. Though the President misstated the moment in that those empty seats at dinner tables will be more than a million; on average each COVID death has impacted 9 other people, including orphaning children across the country. Biden then shifted the address, citing the Centers for Disease Control and Prevention’s recent announcement of adjust masking guidelines and metrics of risk, trying to signal a much-needed political win in the fight against COVID. However, immediately following these statements, the President also focused on providing the country with another round of free at-home COVID-19 tests and implementing a tactic already well-known in the HIV space: test-to-treat, with added bonus of the program following the COVID vaccine model and having no out-of-pocket expense for patients.
The program ideals outlined in the days that followed found some confusion, need for clarity, and even some professional association bickering. Public health professionals who have long advocated for more robust responses to the pandemic took to news outlets to vent their frustrations and the American Medical Association drew derision on social media for their statement discouraging pharmacists prescription and provision of COVID antivirals. Pharmacists have long been a target for HIV advocates, especially in terms of increasing pre-exposure prophylaxis (PrEP) access and decreasing test to treat initiation delays. Wouldn’t it be nice if this COVID program provided a model outside of vaccination in which pharmacists could also serve a more robust role in facilitating seamless treatment and prevention? The meaningful hiccups the administration and advocates should keep a close eye on in this regard is the labor shortage of pharmacists, closing of more rural locations for chain pharmacies, and any developments around anti-competitive practices of pharmacy benefit managers (PBMs) associated with pharmacies. Consequences of these will extend beyond immediate COVID programming and ideal HIV programming.
The President also made statements referring to medication costs and price controls and needing to make sure more Americans could afford their care. However, details were lacking and if any recent effort is indicative, singularly focusing on manufacturer list prices won’t address patient costs or get much anywhere. Buyer beware, some proposals in the apparently sunk Build Back better legislation would also cut provider compensation in public payer programs, a dire consequence as the nation struggles with health care staffing shortages. Those shortages should be noted in detail because the American Rescue Plan provided funding meant to supplement the financial demands of staffing a pandemic and there’s good reason to suspect administrators, rather than providers, enjoyed the fruits of that labor. Further, most Americans experience their out-of-pocket costs of care due to the benefit design of their insurer (and PBM), not the manufacturer list price. Indeed, the Biden Administration appears to eb as insurer friendly as the Obama admin. To impact the costs facing patients more meaningfully at the pharmacy counter and other burdens in accessing medication, the Biden administration should focus more on developing patient protections via the regulatory process, limiting the aggressive utilization management (or deny-first coverage) policies, increasing formulary restrictions, and discriminatory plan design. Some of the tools for doing so already exist, but the federal government has yet to curb the tactics of payers in avoiding their responsibilities under the ACA’s medical-loss-ratio rules or ensure payers are not inappropriately applying cost-sharing for qualifying preventative medications and services.
The President also became the first to mention “harm reduction” in a State of the Union Address. Urging Congress to pass the Mainstreaming Addiction Treatment Act (MAT Act), President Biden is seeking to fulfill his commitments to address the opioid epidemic and move toward modernizing domestic drug policy. In a sign of acknowledgment of the scope and size of substance use epidemic in the country, Biden endorsed recovery programs and recognized the more than 23 million people struggling with addiction in the country. Immediately following the MAT Act mention, the President moved on to address of a lesser defined but equally important need in encouraging commitment to a robust set of policy ideals aimed at meeting the mental health needs of the country.
All these good things can easily be outweighed by what wasn’t mentioned. President Biden did not mention any interest in extending another round of stimulus payments, despite the program resulting in one of the largest reductions in poverty in US history. And while there was focus on rebuilding the nation’s health care staffing, no mention was afforded to rebuilding the nation’s public health infrastructure. Meanwhile, we’ve known for quite some time poverty as a notable association with HIV and decreasing poverty also decreases HIV risks and prevalence, data remains in the decline with regard to HIV and STI screenings, Hepatitis C rates are still on the rise, and inconsistencies in PrEP usage during the height of initial COVID waves likely foretells a more diverse at-risk community. Even the government’s own HIV.gov webpage dedicated to the State of the Union fails to mention any HIV or HCV specific programming efforts associated with the address.
While there’s much to celebrate about the President’s COVID goals, advocates should be cautious about projecting those goals onto other public health efforts. Afterall, COVID proved we could provide more up to date reporting than the 2 year delays we typically see in HIV and HCV surveillance, but we haven’t. COVID-related telemedicine expansion was welcomed by patients across the nation but Congress is poised to claw back those gains. For many of us, while the state of the union is improving coming out of the Omicron wave of the COVID-19 pandemic, much work remains. Including reminding this administration that it is empowered to protect patients, access to and affordability of care, an obligation to invest in public health programs beyond COVID and has committed to advancing efforts to End the HIV Epidemic.
Coverages & Pitfalls: Pandemic-Related Health Care Expansion
On September 17th, the Centers for Medicare and Medicaid Services (CMS) announced its first complete rule on health care marketplaces (federal and state – HealthCare.gov and SBEs), certain expectations of insurers participating in the health care marketplace, and a slate of other issues. This final rule serves as a regulatory tool amid a raft of information the federal government has provided regarding health insurance coverage during the pandemic.
Portions of the rule were fairly well expected (extending the annual open enrollment period from the slimmed down 45 days the previous administration imposed and revamping the “navigators” program), while other portions sought to more narrowly address – read “stop” or “reverse” – changes from the previous administration (specifically those introduced in 2018 and others introduced on January 19, 2021). The rule also aims to address some pressing concerns from legislators and health care access advocates about affordability of insurance as the economic future of the country remains unstable with the COVID-19 pandemic still wreaking havoc on much of the country.
One September 14th and 15th, the Census Bureau and the Department of Health and Human Services (HHS), respectively, issued data related to insurance coverage among residents of the United States in 2020 and 2021. The Census data diverged slightly from the HHS data in that the Census data did not show an increase in the number of people enrolled in Medicaid from 2018 to 2020, whereas previously released CMS data had shown a substantial increase (15.6% or about 10.5 million people) in Medicaid and Children’s Health Insurance Program (CHIP) enrollment from February 2020 through March 2021. A report from the Urban Institute cites potential for the remainder of 2021 to net an additional 17 million people enrolled into the safety net health insurance programs. All of this coincides with the Census data showing the uninsured rate was near static from 2018 to 2020 (8.6% compared to 8.5%).
This is a pretty remarkable comparison, given the pandemic’s effects on the country’s economy. The Census does cite a reported drop in employment related coverage during 2020, with the highest rate of employer sponsored coverage drop occurring among those employed less than full-time. Indeed, the data shows the largest drop in employer sponsored coverage occurred for those at the lowest end of the compensation scale.
Part of why tying together the employment data of the Census and the Medicaid and CHIP enrollment growth data together is to better understand the severe risks to vulnerable people and families as the seeks to wrap up the public health emergency declarations (likely sometime next year). While the administration’s payment rule highlights efforts to keep afloat lower- and middle-income families afloat and insured, the same can’t be said of the lowest-income earners. While the Biden Administration has extended the period for states to return to enrollment recertifications for Medicaid, federal matching funds (a boosted benefit to states during the pandemic) are expected to end on a similar timeframe, giving states some added financial motivation to move through disenrolling current recipients quickly, rather than in a staggered fashion.
While we outlined steps state Medicaid programs and safety net providers could take at the wrap up of the PHE in a blog earlier this month, the Biden Administration must seek even more moves than currently planned, to ensure “back to normal” doesn’t amount to “back to broke” for low-income families across the country.
Biden Administration’s Healthcare Future is One of Promise & Peril
Last month, the Biden Administration issued a press release outlining a look toward the future of American health care policy. Priorities in the presser include ever elusive efforts around prescription drug pricing and items with steep price tags like expanding Medicare coverage to include dental, hearing, and vision benefits, a federal Medicaid look-alike program to fill the coverage gaps in non-expansion states, and extending Affordable Care Act (ACA) subsidies enhancements instituted under the American Rescue Plan (ARP) in March. Many of these efforts are tied to the upcoming $3.5 trillion reconciliation package.
President Biden renewed his call in support of the Democrats effort to negotiate Medicare prescription drug costs, enshrined in H.R. 3. Drug pricing reform has been an exceptional challenge despite relatively popular support among the voting public, in particular among seniors. The pharmseutical industry has long touted drug prices set by manufacturers do not represent the largest barriers to care and mandating lower drug costs would harm innovation and development of new products. Indeed, for most Americans, some form of insurance payer, public or private, is the arbiter of end-user costs by way of cost-sharing (co-pays and co-insurance payments). To even get to that point, consumers need to be able to afford monthly premiums which can range from no-cost to the enrollee to hundreds of dollars for those without access to Medicaid or federal subsidies. The argument from the drug-making industry giants is for Congress to focus efforts that more directly impact consumers’ own costs, not health care industry’s costs. Pharmaceutical manufacturers further argue mandated price negotiation proposals would harm the industry’s ability to invest the development of new products. To this end, the Congressional Budget Office (CBO) recently released a report giving some credence to this claim. The CBO’s report found immediate drug development would hardly be impacted as those medications currently “in the pipeline” would largely be safe, but a near 10% reduction in new drugs over the next 30 years. While new drug development has largely been focused on “personalized” medicine – or more specific treatments for things like cancer – implementing mRNA technology into vaccines is indeed a matter of innovation (having moved from theoretical to shots-in-arms less than a year ago). With a pandemic still bearing down on the globe, linking the need between development and combating future public health threats should be anticipated.
The administration’s effort to leverage Medicare isn’t limited to drug pricing. Another tectonic plate-sized move would seek to expand “basic” Medicare to include dental, hearing, and vision coverage. Congressional Democrats, while generally open to the idea, are already struggling with timing of such an expansion, angering Senator Bernie Sanders (I-VT) by suggesting a delay until 2028. While any patient with any ailments related to their oral health, hearing, and vision will readily tell you these are critical and necessary coverages, even some of the most common of needs, the private health care insurance industry generally requires adult consumers to get these benefits as add-ons and the annual benefit cap is dangerously low (with dental coverage rarely offering more than $500 in benefit and vision coverage capping at one set of frames, both with networks so narrow as to be near meaningless for patients with transportation challenges). While the ACA expanded a mandatory coverage for children to include dental and vision benefits in-line with private adult coverage caps, the legislation did nothing to mandate similar coverages for adults and did not require private payers to make access to these types of care more meaningful (expanded networks and larger program benefits to more accurately match costs of respective care).
The other two massive proposals the Biden Administration is seeking support for, more directly impact American health care consumers than any other effort from the administration: maintaining expanded marketplace subsidies and a federal look-a-like for people living in the 12 states that have not yet expanded Medicaid under the ACA’s Medicaid expansion provisions. The administration has decent data to back this idea, as the Centers for Disease Control and Prevention released a report showing a drop in the uninsured rate from 2019 to 2020 by 1.9 million people, largely attributed by pandemic-oriented programs requiring states to maintain their Medicaid rolls. The administration and Congressional Democrats are expected to argue subsequently passed legislation allowing for expanded subsidies and maintained Medicaid rolls improved access to and affordability of care for vulnerable Americans during the pandemic. As the nation rides through another surge of illness, hospitalizations, and death from the same pandemic “now isn’t the time to stop”, or some argument along those lines, will likely be the rhetoric driving these initiatives.
Speaking of the pandemic, President Biden outlined his administration’s next steps in combating COVID-19 on Thursday, September 9th. The six-pronged approach, entitled “Path out of the Pandemic”, includes leveraging funding to support mitigation measures in schools (including back-filling salaries for those affected by anti-mask mandates and improving urging the Food and Drug Administration [FDA] to authorize vaccines for children under the age of 12), directing the Occupational Safety and Health Administration (OSHA) to issue a rule mandating vaccines or routinized testing for employers with more than 100 employees (affecting about 80 million employees) and mandating federally funded health care provider entities to require vaccination of all staff, pushing for booster shots despite the World Health Organization’s call for a moratorium until greater global equity in access can be attained, supporting small businesses through previously used loan schemes, and an effort to expand qualified health care personnel to distribute COVID-19 related care amid a surge threatening the nation’s hospitals ability to provide even basic care. Notably missing from this proposal are infrastructure supports for schools to improve ventilation, individual financial support (extension of pandemic unemployment programs or another round of direct stimulus payments), longer-term disability systems to support “long-COVID” patients and any yet-unknown post-viral syndromes, and housing support – which is desperately needed as the administration’s eviction moratorium has fallen victim to ideological legal fights, states having been slow to distribute rental assistance funds, and landlords are reportedly refusing rental assistance dollars in favor of eviction. While the plan outlines specific “economic recovery”, a great deal is left to be desired to ensure families and individuals succeed in the ongoing pandemic. Focusing on business success has thus far proven a limited benefit to families and more needs to be done to directly benefit patients and families navigating an uncertain future.
President Biden did not address global vaccine equity in his speech, later saying a plan would come “later”. The problem, of course, is in a viral pandemic, variant development has furthered risks to wealthy countries with robust vaccine access and threatened the economic future of the globe.
To top off all of this policy-making news, Judge Reed O’Connor is taking another swing at dismantling some of the most popular provisions of the ACA. Well, rather, yet another plaintiff has come to the sympathetic judge’s court in an effort to gut the legislation’s preventative care provisions by both “morality” and “process” arguments in Kelley v. Becerra. The suit takes exception to a requirement that insurers must cover particular preventative care as prescribed by three entities within the government (the Health Resources Services Administration – HRSA, the Advisory Committee on Immunization Practices – ACIP, and the Preventative Services Takes Force – PSTF), which require coverage of contraceptives and pre-exposure prophylaxis (PrEP) with no-cost sharing to the patient, among a myriad of other things – including certain vaccine coverage. By now, between O’Connor’s rabid disregard for the rights of lesbian, gay, bisexual, and transgender Americans and obsessive effort to dismantle the ACA at every chance he can – both to his own humiliation after the Supreme Court finally go their hands on his rulings – Reed O’Connor may finally have his moment to claim a victory – I mean – the plaintiffs in Kelley may well succeed due to the Supreme Court’s most recent makeover.
As elected officials are gearing up for their midterm campaigns, how these next few months play out will be pretty critical in setting the frame for public policy “successes” and “failures”. Journalists would do well to tap into the expertise of patient advocates in contextualizing the real-world application of these policies, both during and after budget-making lights the path to our future – for better or worse.
Checking-In: 100 Days of the Biden Administration
Advocates in public health and addressing HIV, viral hepatitis, and substance use disorder will affirmatively tell anyone the race to win these fights is a marathon, not a sprint. Globally, despite the devastation, COVID-19 is likely to be much the same with most experts anticipating COVID-19 to become endemic for a variety of reasons. And while every administration takes extraordinary efforts to brand their term with lofty promises of what “starts” in the first 100 days of a presidency, the Biden administration is making some tentative progress in some of those named goals.
Maintaining the brand that arguably helped him win the 2020 general election, Biden’s press team has focused on the sympathetic messaging while delivering policy appeals. One remarkable example likely to please disability and care giver advocates is Biden’s commitment to include an expansion of community and home-based services and better pay, benefits, and the right to unionize in the American Jobs Plan. Indeed, Biden’s infrastructure plan goes far outside of more traditional notions of “infrastructure” and seeks to initiate or expand several initiatives directly addressing to the gaps COVID-19 has highlighted with idea that infrastructure is the economic ecosystem supporting the country, regardless of industry. All of this is on the back of Biden’s American Rescue Plan, which expanded subsidies established by the Affordable Care Act and moves like recently announced renewed funding for Marketplace Navigators for 2022, extension of a universal school lunch program, and expansion of syringe services funding, among others.
The administration detailed further in the President’s Discretionary Budget Request for Fiscal Year 2022, priorities in further spending, namely requesting additional funding for the Ending the HIV Epidemic, reforms to the criminal justice system related to racial inequities and substance use treatment for incarcerated persons, addressing the opioid epidemic with – as some advocates have called – a “reformist” mindset rather than a penalty mindset. While these efforts are a solid move in the right direction and arguably a good down payment on Biden’s campaign promises, they do fall short of some of the funding goals advocates have long sought. And that’s just the beginning of the problems in finding the money to meet those lofty goals. For example, the United States is facing a new height to the overdose crisis and advocates have long argued to meaningfully tackle this epidemic funding needs to answer to the tune of $125 billion. Even if the president were to get his wish list funding of $10.7 billion in addition to the $4 billion provided for in the ARP, this still falls incredibly short of that advocate driven funding goal.
Much of the Biden administration’s priorities are likely to find similar fates and advocates should be prepared to both take their wins and lick their wounds. COVID-19’s havoc isn’t the only thing standing in the way of progress. With the exceptionally narrow divide in the House and Senate, the man seemingly wielding the power of majority leader, Senator Joe Manchin’s dedication to maintaining the filibuster, Democrats have an uphill battle in helping their party deliver on the promises sold to the country. Whether the issue is Nancy Pelosi’s (D-CA) desire to maintain ACA subsidy expansion or an entirely opaque drug pricing policy overhaul or expanding the age eligibility of Medicare, Democrats have promised to go big and if they don’t, they can very likely look forward to “going home”, either in the midterms or 2024.
Meanwhile, COVID-19 has very likely pared back minimal gains made in the South with regard to fighting the HIV epidemic in the United States, HIV and STI health care workers are burning out at extraordinary rates due to having to pull double duty for the last year, studies are finally digging into the hepatitis and HIV related health disparities among transgender people, and every other issue of health equity prior to pandemic has lost ground. Biden’s Health Equity Taskforce should absolutely take into consideration the nuances of emerging data on these existing disparities and advocates should seize this moment and pathway provided by engaging the taskforce on addressing these issues. After all, we’ve argued all along COVID-19 is merely thriving in these long neglected communities and it’s not unique for COVID-19 manifest disparate impacts among marginalized peoples, every other epidemic has.
It’s a marathon, not a sprint.