Looking Back/Looking Forward: Taking Stock of 2019 and What to Anticipate in 2020
When it comes to health care, 2019 was an intense year full of many challenges and also some bright spots. As it recedes in the rear view mirror, let’s take a look at some of the key developments from 2019 and what they might portend for the future.
Starting with some bright spots: thanks in large degree to outstanding legal work from NHeLP, many harmful barriers to Medicaid coverage sought by states and approved by the Trump administration have been put on hold.
In addition, despite ongoing efforts to undermine the effective functioning of the Affordable Care Act (ACA), we saw millions of people continue to enroll and receive financial assistance to make health care coverage more affordable.
And in the face of varying degrees of opposition from state legislatures, the states that approved Medicaid expansion via ballot initiative in 2018 – Idaho, Nebraska and Utah – are all moving forward. In Idaho, the state that is furthest along in implementation, 52,000 people have enrolled. Furthermore, off-year elections for governor in Louisiana and Kentucky showed that popular support for Medicaid expansion is not limited to ballot initiatives, as the candidates in those states who supported retaining Medicaid expansion won victories over opponents who were less supportive or opposed to it.
Meanwhile, many states made progress advancing affordable health care. For example, Maryland broke new ground by creating a state drug price review board. Although it will take time for the board to become fully operational, the measure marks a new degree of willingness, at least at the state level, to confront the rising cost of prescription drugs. On the other side of the country, California expanded insurance subsidies above 400% FPL and expanded Medi-Cal (the state’s Medicaid program) to income-eligible young adults regardless of immigration status, as well as to low-income older adults and people with disabilities.
On the less good side, while the casual observer might be forgiven for thinking that the next health policy debate will be over which version of Medicare for All you prefer – public option versus single payer – a closer look, both in Congress and the states, tells a different story. 2019 was a year that underscored the abiding power of the health care industry – including providers, insurers and drug companies – to shape the outcome of policy debates. Their influence was felt in Congress, where neither prescription drug pricing nor surprise out-of-network billing protections made it across the finish line, largely thanks to industry opposition. At same time, Congress wrapped up the year by passing a wish-list of measures backed by hospitals, device makers and insurers.
Similarly, in states that pursued expansion of public coverage, we saw industry opposition resulting in watering down or delaying several measures that would have expanded public coverage. Ideological rather than industry opposition blocked Medicaid expansion in several states including Wisconsin, Kansas and North Carolina, despite public support.
Finally, the U.S. 5th Circuit Court of Appeals ended the year on a sour note by failing to dispose of a spurious legal threat to the ACA. Instead, the appeals court remanded the case to a judge already proven hostile to the law and prepared to dismantle it in its entirety. At same time, delayed resolution places a cloud of uncertainty over the ACA that could interfere with its operations and further impede efforts to expand Medicaid in additional states.
Looking Ahead to 2020
Congress will struggle to get the unfinished business of 2019 across the finish line, with prospects for meaningful action on out-of-network bills looking somewhat better than prescription drugs. But it is entirely possible that as the election nears, action will bog down.
The issues of medical debt and hospital bill collection action are picking up steam, both federally and in states. Other issues that made progress but didn’t get across the finish line such as improving access to health care postpartum also could see action next year.
In the context of the presidential campaign, we can expect to see dueling narratives seeking to activate “loss aversion” in voters – with Democrats highlighting Republican attacks on the ACA and Medicaid while Republicans seek to recast Medicare for All as a threat to people’s private coverage.
The Texas v. U.S. case will continue to make its way through the courts. Ideally, the Supreme Court will take the unusual step of granting the defense petition and take up the case and resolve it this year. Failing that, we can anticipate another adverse ruling from District Court Judge Reed O’Connor followed by another appeal in the 5th Circuit, meaning the threat would not be resolved until 2021. Other legal threats will include further litigation on Medicaid enrollment barriers and a likely Medicaid block grant proposal.
The Job Ahead
Get the wins that can be gotten.
While it won’t be easy (when is it ever?), there is a shot at making progress on issues such as prescription drug prices, out-of-network bills, maternal mortality and more.
Keep up a strong defense.
It is a myth that judges are not influenced by their surrounding environment. In the context of the Texas v. U.S. lawsuit, it is important to continue to uplift the harm that repeal of the ACA would do in order to increase the likelihood the case will ultimately be dismissed. In terms of Medicaid block grants, as we saw with work requirements, documenting harm from administration policy and creating a “paper trail” of substantive opposition were key parts of the legal pushback (and also set us up to overturn harmful policies if there is a new administration.) This brings us to…
Be prepared for new opportunities – or threats – that could flow from outcome of the 2020 elections.
The outcome of the 2020 election is entirely up in the air at this point and the implications for health care policy cannot be overstated. At one end of the spectrum of possible outcomes is yet another Congressional attempt to repeal the ACA and slash Medicaid funding. At the other end, we could have an opportunity to advance affordability, quality and equity in our health care system. Particularly with regard to the latter opportunity, the more work that is done in advance and the more agreement there is on a set of policies, the greater the likelihood of passage in Congress if the opportunity is there.
And by no means does all of this work occur federally. Many times we have seen policy in the states serve as a template for federal action. With Congress still mostly gridlocked, states remain the best hope in 2020 for both substantive progress and to create models for future federal action.