Authored by RSM US LLP

With the election approaching, RSM is looking at the economic stakes and the key issues for various industries and sectors. This is one in our series of election previews.

The top policy issue for health care

The top policy issue for health care is undoubtedly the future of the Affordable Care Act. This law is the cornerstone of current health care policy and undergirds much of the industry activity. It has also seen several significant legal challenges as well as Congressional and administrative changes over the years. The nomination to Justice Ginsburg’s former seat on the Supreme Court just weeks before oral arguments in the most recent challenge to the ACA’s constitutionality is the latest cloud of uncertainty to emerge over health care. We’re also watching drug and procedure price, quality transparency and the future of telehealth regulations and reimbursement.

If Trump wins

If Trump wins, we expect expanded price and quality transparency mandates and additional options for consumers to purchase less expensive health insurance with less coverage. We have little reason to believe a second term of the Trump administration would deviate significantly from the first. However, in late September, President Trump signed a series of executive orders, including one declaring that Americans with pre-existing health conditions are protected. Department of Health and Human Services Secretary Alex Azar has pledged to work with Congress to ensure those protections remain should the Supreme Court find the ACA unconstitutional. The executive orders also discuss drug discounts for seniors and promise to ban surprise medical bills if Congress doesn’t fix the issue by the year’s end.

If Biden wins

If Biden wins, we expect the ACA will be reinforced and a public option will be introduced to allow Americans to buy into Medicare as early as age 60. Former Vice President Biden was instrumental in passing the ACA and will defend it while expanding government coverage to more Americans. Much of his ability to do so will be based on state elections happening across the country. Most analysts expect the House will remain in Democratic control; however, if the Republicans retain control of the Senate, Biden will be limited in his ability to execute his agenda. On the administrative side, Biden has expressed interest in continuing the push for pricing transparency.

Other health care issues:

The future of virtual health care will affect the entire health care ecosystem. As state governments and health care systems suspended non-emergent (i.e., elective) procedures in the wake of the COVID-19 outbreak, we saw an unprecedented surge in telehealth visits. While the wave of telehealth visits was mandated by the pandemic, it was enabled by massive and temporary changes to the regulatory and reimbursement environment related to telehealth. For the first time, many virtual procedures were covered—and at parity with physical procedures. Few expect this environment will completely revert to the pre-pandemic framework, but exactly how it all shakes out will have a significant influence on the future of American health care. Trump has publicly called for permanent expansion of some telehealth benefits; Biden has remained relatively quiet on the issue.

The Trump administration’s affect on the industry has been:

It has been challenging for industry participants to navigate changes to the ACA, which came at a time when the health care ecosystem’s payers were becoming comfortable with the new post-ACA environment. Meanwhile, the administration’s pricing transparency requirements created administrative and reporting burdens for most ecosystem participants. Others can debate the effectiveness of the policies, but it is clear that the change and uncertainty surrounding them have created a difficult operating environment for most.

By the numbers: $21,342

As the election plays out, a focal point for many will be which candidate’s platform will focus on lowering health care costs. According to the 2020 KFF Employer Health Benefits Survey, annual family premiums rose 4% this year to approximately $21,342. The annual change in premiums is similar to the year-to-year rise in workers’ earnings (3.4%) and inflation (2.1%). It is clearer than ever: Consumers want and need affordable health care, along with a higher quality of care. 

In preparation for the outcome, health care organizations and companies should consider:

Pricing transparency and rational pricing approaches are crucial, given that both candidates espouse pricing transparency as a way to drive cost out of the system. The timing and requirements may change, but health care participants can expect increased pricing scrutiny. Now is also an ideal time for participants to evaluate their rational pricing strategies. In our view, it will not be enough to state that the cost of a procedure is $X; a provider must have confidence that the price is consistent with and can be borne by the local market. This requires a rigorous evaluation of cost accounting that will also benefit organizations if the payer mix shifts toward more government pay as the population ages or Medicare and Medicaid expand.


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This article was written by Jessika Garis, Lori Kalic, Rick Kes, Matt Wolf and originally appeared on 2020-10-14.
2020 RSM US LLP. All rights reserved.

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