Dec 8, 2023 - Health

The era of major U.S. health reform is over

Illustration of the American flag as an EKG monitor

Illustration: Sarah Grillo/Axios

The era of massive overhauls of the health care system appears to be over — at least for now.

Why it matters: Health care is shaping up to be a prominent 2024 campaign issue, but today's political environment has all but extinguished hopes for sweeping changes to the system.

  • At the same time, health care is getting tougher to afford and access, testing Americans' tolerance for incremental reforms.
  • "I think at some point there will be [systemic] demand for more," said Lanhee Chen, a fellow at the Hoover Institution and a former GOP campaign strategist. "The question is whether our political system can accommodate that systemic demand."

Driving the news: The Biden administration on Thursday announced a new framework that opens the door for the government to use march-in rights to seize the patents of certain pricey drugs developed with the help of taxpayer dollars.

  • Notably, the administration isn't flexing the power yet, but it gives President Biden another way to put health care front and center in 2024.

Yes, but: Although progressives have long pressed the government to use march-in rights to lower drug prices, it ultimately — at best — may reduce the prices of a handful of prescription drugs.

  • That's illustrative of a larger dynamic. Political constraints force lawmakers to rely on regulatory action and whatever legislative changes they can muster enough votes for, even as health care remains a major voter concern.
  • Biden's first term featured the enactment of Democrats' long-held goal of allowing Medicare to negotiate prescription drug prices, although resistance from moderates led to a relatively modest version of the policy becoming law.
  • Biden also led the charge for temporarily enhancing Affordable Care Act subsidies, which will expire after 2025 if they're not renewed, and other measures that will help contain seniors' drug costs.
  • But most — if not all — of Biden's second-term agenda would likely build on existing policies, not create major new ones.
  • "The political environment does not allow for huge policy shifts," said Democratic strategist Chris Jennings. "You can either deal with that by doing nothing or by taking an important step forward, and as much as you possibly can get, and laying the groundwork for larger progress when the opportunity arises."

The big picture: Both parties have seemingly accepted that a more targeted approach is more realistic for now. Republican lawmakers aren't talking about repealing the ACA. Democrats aren't talking about Medicare for All.

  • "The practical amongst us certainly have decided to focus on what I would consider more micro approaches" that could still be impactful, Chen said.

State of play: Trump's renewed calls to replace the ACA recently elevated health care as a major campaign issue.

  • Democrats have relished the opportunity to talk about how a second Trump term would endanger the health care law, which has been a winning political issue for Democrats since Republicans' failed attempt to repeal and replace it in 2017.
  • The Biden campaign will begin rolling out a package of health care measures that he'd push in a second term, CNN reports, setting up a contrast with GOP policies.
  • The measures include expanding some of the drug pricing provisions Democrats passed in the Inflation Reduction Act and making enhanced ACA subsidies permanent.

Reality check: Republican lawmakers aren't thrilled about rehashing the ACA repeal fight. Similarly, most of what Biden is calling for didn't make it into Democrats' major domestic policy legislation after months of infighting.

  • But there is plenty a president can do through executive action, though that can be unwound by a successor.
  • Joe Grogan, the former director of Trump's Domestic Policy Council, said the former president's health care goals are likely more targeted than headlines suggest.
  • "The Biden admin and many in the media are saying he wants to have the repeal and replace fight again. He doesn't. He wants to address real health care problems that Americans are facing, and any objective look at the ACA reveals real problems with access and affordability," Grogan said.
  • "I think he would be interested in some targeted legislative things, some administrative things and expanding options for people and making health care more affordable," he added. "Cost is the big issue in health care, and copays, deductibles, and premiums really hit Americans hard."

Strategists in both parties argue that the more limited ideas under discussion would still be impactful.

  • "In terms of policy design, they're not whoppers," Jennings said. "But we should not downplay the significance of finishing the job — so wherever you live, Americans would have access to affordable health coverage. To me, that's meaningful; it's the long-unfilled commitment of Democrats."
Go deeper