Why it matters to business that 2024 isn’t a healthcare election

Modern Healthcare – Monday, October 28, 2024
By Michael McAuliff

The point of campaign rhetoric is to convince people to vote for one side or the other, catering to hopes those words will turn into policy. The ads and news clips blaring at voters are impossible to avoid. But what happens when a vital issue is all but missing from the debate?

That’s a question stakeholders in the healthcare industry need to at least consider this election season when immigration, inflation, crime, abortion and the fate of democracy are the dominant themes on the hustings.

Healthcare is not exactly absent from the 2024 campaign, but it has been relegated to a supporting role. That lack of prominence could have implications for the healthcare sector when Congress starts legislating shortly after Election Day, and next year alongside Vice President Kamala Harris, the Democratic presidential nominee, or former President Donald Trump, the Republican candidate.

There is an enormous roster of lingering healthcare priorities and bipartisan bills sitting in Congress that are important to the industry and could be fodder for campaigns.

But they surface only in passing or not at all. Issues such as forestalling physician and Medicaid disproportionate share hospital payment cuts at the end of the year, or tightening rules on prior authorizations, or regulating pharmacy benefit managers, or strengthening cybersecurity simply get little air time.
At least some of them will have to be addressed, regardless who wins the White House and what parties control the House and Senate.

Exactly what the healthcare attention deficit will mean in late fall when the 118th Congress returns for a lame duck session and next year under a new Congress is difficult to parse. Depending on the topic and the circumstances, a policy that may be more technical and has not been featured in the campaigns could benefit from a lower political heat factor.

At the same time, a lack of attention on the trail could translate into a lack of urgency in the backrooms of Capitol Hill, especially for items with significant costs.

Still, in trying to game out these scenarios, experts warn any effects of campaign messaging have to be considered in the more important context of who actually wins, and what things the government has little choice but to face because of looming deadlines.

Politics, then policy

Democratic or Republican control in Washington will have the largest influence, and Congress will be dealing with healthcare no matter who wins or what their campaigns promised, said Debra Curtis, a consultant at McDermott+ who worked as Democratic aide on Capitol Hill for decades.

“I wouldn’t over-read from healthcare not being a major issue in the electoral politics of today into how healthcare plays in the future, because as a major federal expenditure, it’s part of any conversation,” Curtis said. As examples in 2025 alone, the tax cuts Trump enacted in 2017 are due to expire, the debt limit must be raised, and enhanced health insurance exchange subsidies are going to run out.

Those issues are more partisan and do show up in campaign pitches, although in the case of the Affordable Care Act of 2010, it’s less about subsidies expiring and more about Harris and the Democrats arguing that Trump would undermine and kill the law.

Trump has been unclear on that front, suggesting infamously only that he has “concepts of a plan” for healthcare, which prompted a flurry of attacks from the Harris campaign. Trump the GOP-led Congress tried and failed to undo the ACA in 2017. During the campaign, Sen. JD Vance (Ohio), the Republican vice presidential nominee, has floated policies that would weaken the law’s protections for people with preexisting conditions.

Heather Meade, who leads the healthcare practice at the lobbying firm Washington Council Ernst & Young, agreed healthcare issues will emerge regardless of scant campaign talk because of the pending deadlines. The expiration of Medicare telehealth authorities is another priority, she said.

“Healthcare is still going to be an issue, and there’s still going to be a lot of action in healthcare that won’t be driven by a particular issue that we’re hearing about in the campaign,” said Meade, who has lobbied for healthcare interests including the American Benefits Council, the Purchaser Business Group on Health and the American Academy of Physician Associates.

What does it mean, though, if the healthcare issues at stake in Congress are not being debated by the candidates? One consequence is important matters can more easily become fodder for broader negotiations in Congress.

Cutting deals

For instance, if Republicans would like to extend the Trump tax cuts, even if they control all of government, it comes with a hefty price tag, Meade said. And while the GOP may downplay that cost, it still makes it harder to spend for other things they might like to do, such as extending the telehealth rules or improving home-based care, even with Democratic support.

Some of the big issues that stakeholders care about also happen to save the government money.

So even if PBMs are not in a campaign catchphrase, or “site-neutral payments” get a blank stare from voters, bills targeting such items reduce spending and trim the deficit. Lawmakers who aim to advance PBM legislation or bills limiting what hospitals charge for outpatient visits can do so by cutting deals to offset costs elsewhere.

“Providers need to be paying particular attention to places where they might be on the menu as a potential pay-for, for all of these things that both candidates are interested in doing,” Meade said.

The lack of intense campaign scrutiny can make such wheeling and dealing easier, said David Sirota, a journalist and former adviser to Sen. Bernie Sanders (I-Vt.), who chairs the Senate Health, Education, Labor and Pensions Committee during this Congress and ran for president in 2016 and 2020.

Bills pass either because an issue becomes so elevated in campaigns that lawmakers are forced to follow through — as happened with president-to-be Barack Obama after 2008 and as Sanders hoped would happen with Medicare for All — or because legislators are able to cobble together an alliance of colleagues and interest groups such as medical societies and pharmaceutical companies, Sirota said.

The first is not happening this year, but the latter is, and the lack of political rhetoric can be helpful in passing more technical measures.

“It’s not like some big partisan litmus test,” Sirota said. “You can actually try to work on them, actually make progress on them in ways where Congress can, in sort of a ‘West Wing’-style utopia, do the work.”

The reasons why there is less attention in this election to healthcare issues also is something stakeholders should consider, because it is part of the broader world in which Congress will legislate.

From the perspective of the left-leaning Sirota, it reflects a disconnect between the public and party politics that he and other progressives would like to change, perhaps to reinvigorate Sanders-style plans.

“We’re all living in a healthcare crisis and it’s not part of our elections. That is the democracy crisis,” Sirota said. “We’re all living among this problem that’s not even part of the conversation.”

From the perspective of consultants and lobbyists who see plenty of serious problems in healthcare, the relative lack of campaign attention comes at least in part because Democrats did succeed in expanding coverage, and Republicans have suffered from trying to roll that back.

“We have actually never gone through a presidential election where our U.S. coverage numbers were as high as they are today,” said Meade. “This is a high point in U.S. history. That has actually reduced in some ways the heat around healthcare coverage as a top issue.”

What voters think

Healthcare does remain a top issue for the electorate, with recent surveys from the Pew Research Center, the health policy research institution KFF and the Harris Poll finding it near the top of voters’ priorities, suggesting it could be a galvanizing issue again. The Harris Poll is a private company not affiliated with Kamala Harris.

To be sure, Democrats are still running on healthcare, if not as loudly. The Harris campaign and Democratic campaign organizations acknowledged the emphasis is on other issues, but still pointed to health-focused efforts in the presidential race and other contests and to various forms of voter microtargeting on the issue.

Harris rolled out a proposal to expand Medicare to cover home care and lower those costs and her campaign launched a week of ads hitting Trump’s “concepts of a plan” line. She also often references pharmaceutical costs and the Inflation Reduction Act of 2022, which empowered Medicare to negotiate drug prices and capped Medicare Part D out-of-pocket costs at $2,000.

The lesser elevation of healthcare issues, though, can be seen in polls. For instance, even with Harris’ attention to drug costs, 60% of people had heard nothing about the $2,000 cap, according to survey results the Harris Poll and the Patient Access Network Foundation’s Center for Patient Research published in July.

And there is much less focus on healthcare coming from the GOP side.

The Trump campaign recently has left healthcare messaging to former independent presidential candidate and Trump convert Robert Kennedy Jr., though that hasn’t gotten much attention. A planned town hall to “Make America Healthy Again” that was supposed to feature Trump, Kennedy and Democratic-turned-Republican former Rep. Tulsi Gabbard (Hawaii) set for last Tuesday was canceled.

The Trump campaign and Republican groups did not respond to questions about their healthcare policies.

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