Feb 27, 2021

Axios Deep Dives

Good afternoon. Led by Axios health care editor Sam Baker, here's a deep dive into the Biden administration's health care agenda as America emerges from the pandemic.

  • Smart Brevity™ count: 1,552 words ... 6 minutes.
1 big thing: The great debates

Illustration: Aïda Amer/Axios

For the first time since the AIDS crisis of the 1980s, public health is a massive national issue — and it’s likely going to stay that way for a long time.

Why it matters: Today's great health care debates are issues that usually don't get much attention. But recovering from the pandemic envelops every major part of President Biden’s agenda and will dictate his presidency's final marks.

Here are the biggest health care quandaries obsessing Washington's powerful.

Speed vs. strategy: The development and deployment of the COVID-19 vaccine happened with record-shattering speed, but there are still calls for inoculation to move faster.

  • These critics say states should have immediately thrown open vaccine eligibility to anyone who wanted one; that the Food and Drug Administration has set too high a bar for the vaccines’ clinical trials; and that second doses of the vaccine should be delayed so more people can get their first dose.
  • The other side: Some experts worry about undermining strategic planning designed to get the overall pandemic under control quickly and sustainably.
  • Delaying second doses hasn’t been studied, and the prioritization system for vaccines is there to ensure that limited supplies are used to protect the highest-risk people.

Reopening: The federal government doesn’t actually get to decide when or how schools reopen, but it’s already one of the biggest political flashpoints of the pandemic.

  • Experts generally agree that vaccinating teachers isn’t necessary to safely resume at least some in-person schooling — and that’s reflected in both the Biden administration’s guidance and the decision by most states not to prioritize teachers.
  • But teachers unions are pushing for vaccinations as a condition of going back to the classroom.

Us vs. them: The U.S. has bought up most of the world’s vaccine supply — more doses than we’ll actually be able to use.

  • A vaccine arms race among rich countries was to be expected, and of course Americans want first and foremost to quash the pandemic in the U.S.
  • But this is a global pandemic, and in an interconnected world, we won’t be fully done with the coronavirus anywhere unless and until we’re done with it everywhere.
  • How the U.S. goes about donating its excess doses will not just be an important piece of health policy, but foreign policy, too.
2. State of the shots
Expand chart
Data: Centers for Disease Control and Prevention; Map: Andrew Witherspoon/Axios
3. What comes next

Illustration: Aïda Amer/Axios

We're not there yet, but policymakers will ultimately also have to decide whether the U.S. will actually tackle some of the bigger, more structural weaknesses the pandemic has exposed.

Will we rebuild the public health infrastructure that was so clearly lacking in this pandemic?

  • Will we create a system for contact tracing, which would have helped control the pandemic earlier? Build a better stockpile of protective equipment? Learn the lessons about effective public health communication?
  • There won't be one grand, sweeping answer to those questions. They'll be answered over years, through policy trade-offs and budgeting decisions that will get harder as we get further away from the immediate crisis and as new crises emerge.
  • But if we don't make those investments, we'll be in a bad spot once again whenever the next pandemic rolls around.

And will we actually tackle racial disparities in health care?

  • People of color have long suffered worse outcomes than white Americans, from higher rates of maternal mortality to increased risk for certain cancers. COVID-19 followed the same pattern — and pushed the issue to a new position of national prominence in the process.
  • "This really can be a transformative time for the nation," said Nadine Gracia, the executive vice president at the advocacy group Trust for America's Health.
  • But those disparities in health outcomes are tied up with a whole host of other social and economic inequities, including nutrition, housing and transportation.
  • Solving this problem would require a thoughtful and sustained effort not just within the health care system, but across broad swaths of American life.
4. Where costs will rise
Data: OECD; Chart: Andrew Witherspoon/Axios

The pandemic has pushed the debate over health care costs to the back burner, but it won’t stay there for long. Those costs are simply too great.

By the numbers: The U.S. spent a total of $3.6 trillion on health care in 2019, for an average of over $11,000 per person per year — far more than any other industrialized country.

  • That’s the cost for a system that doesn’t deliver better outcomes than other countries and still leaves almost 30 million people uninsured.

How it works: The underlying cost of health care procedures is the biggest factor driving America’s spending.

  • As those prices go up, so do health insurance premiums. That burden mainly falls on employers. Covering a family of four through an employer-based plan — the biggest source of coverage in the U.S. — costs as much as buying a new car every year.
  • But employers have responded in turn by shifting more costs onto workers. The average deductible for employer-based plans has gotten over 200% bigger over the past decade, vastly outpacing wages.

The bottom line: Every year, health care gobbles up more of the federal budget, states’ budgets, employers’ costs and families’ income.

Go deeper: The health care debate we ought to be having

5. Where the money goes
Data: Peterson Center, KFF; Chart: Sara Wise/Axios

Cutting health care costs has always been politically dangerous, and the industry’s biggest targets will emerge from the pandemic with even a stronger hand in Washington.

Hospitals take up the biggest share of U.S. spending, at over $1 trillion per year before the pandemic.

  • Congress has shoveled money to hospitals to help offset the losses they took when elective procedures were canceled, but those losses, combined with the very real human toll borne by health care workers over the course of the pandemic … would you want to be the senator who stands up and says it’s time to take on hospitals?
  • “If you get straight A’s, it might be the time to ask your parents for a new iPhone. This is the time not to be shy. You’re kind of the golden children, but it’s not going to last,” one health care lobbyist recently told Stat.

Pharmaceutical companies don’t have the same affection from the general public as hospitals, but they’re exceptionally good at the inside game in Congress.

  • The drug industry almost always wins — it struck a deal to avoid any real cost controls from the Affordable Care Act and then emerged fully unscathed from the Trump administration, too.
  • There was no bipartisan agreement on cutting drug prices even before the industry delivered multiple life-saving vaccines in record time. And though the public paid for those products through Operation Warp Speed, the shots will be free to the people who get them.
6. How we're insured
Data: Kaiser Family Foundation; Note: Data is from 2019; Chart: Andrew Witherspoon/Axios
7. Five Biden picks to know

Illustration: Sarah Grillo/Axios

President Biden’s health care team is a diverse group with one big thing in common: a whole lot of experience in Washington.

  • Why it matters: Most of the action on health policy over the next four years will likely come from the executive branch, not Congress.

Jeff Zients, Biden’s pandemic response coordinator, may not be an epidemiologist, but he has a track record of wrangling complex processes into line, most notably when President Obama brought him in to clean up the mess of the HealthCare.gov launch.

Chiquita Brooks-LaSure, Biden’s nominee to lead the Centers for Medicare & Medicaid Services, where a lot of the meatiest federal health policy gets made, spent years on Capitol Hill before joining the Obama administration to work on Affordable Care Act implementation.

  • Liz Fowler and Andrea Palm, two other veterans of the ACA implementation effort, also have reportedly been tapped for senior roles in the Health and Human Services Department.

Xavier Becerra, Biden’s nominee for HHS secretary, is in some ways an outlier, with no particular background in health policy, management or regulatory work. But he has ample political experience, after serving for over 20 years in the House and as California’s attorney general.

What’s next: Biden hasn’t yet announced his pick to lead the FDA — a big job, as vaccines continue to roll out and as the agency regroups from former President Trump's accusations that it slow-walked coronavirus vaccines to hurt him politically.

8. 1 boom thing: Virtual care

Illustration: Annelise Capossela/Axios

Telemedicine finally met its moment over the past year, and it’s one of the few parts of pandemic life that anyone wants to keep.

Details: Virtual doctors visits skyrocketed last spring, finally unleashing a tool that experts have been heralding for years.

  • That expansion was helped along by a raft of payment and policy changes, led by Medicare, that made it easier for more providers to see their patients virtually.

Between the lines: Telemedicine can’t do everything — a whole lot of care simply has to be delivered in person — but it can do a lot.

  • Virtual doctors visits can act as a safe and efficient initial screening to determine whether patients need in-person care. That’s especially promising in rural areas.
  • Many doctors visits that are just conversations — including mental health care, managing chronic conditions and checking in over a long course of treatment — can easily move online.

What they're saying: There’s very little bipartisan agreement on anything in health care, but lawmakers from both parties want Medicare to retain some of its short-term policy changes so that telemedicine stays big even after the pandemic.

“In the midst of a crisis, we often make big leaps forward in innovation, and we need to make sure that doesn't go away as we work our way through this crisis. That is very much the case in telehealth."
Sen. Tina Smith (D-Minn.)
“The addition of telehealth and tele-mental-health has been fantastic — something that, yeah, was being used, has exploded in use. ... I do think telehealth has been a huge game changer.”
Sen. Bill Cassidy (R-La.)

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