L.E.K. Consulting Report States that Public Option and Medicare Expansion within the ACA are Unlikely Due to Slim Democratic Majority and Smaller Bipartisan Reforms May Challenge Healthcare Industry

BOSTON (March 22, 2021) – The two-year expansion of Affordable Care Act coverage, contained in the $1.9 trillion COVID-19 relief bill, may be the high water mark for healthcare reform under the Biden administration. Beyond this provision, legislative changes in Washington won’t have a dramatic impact on the U.S. healthcare industry, according to a new report from L.E.K. Consulting, the global management consulting firm.

The bill increases ACA subsidies and would lower payments for the nearly 14 million Americans currently enrolled in the program. The legislation also expands Medicaid coverage for pregnant women and provides Medicaid expansion incentives to states that have not yet expanded the program. The provisions are due to expire in two years – which all but guarantees they will be campaign issues during the 2022 midterm elections.

Other healthcare measures will be limited. Democratic control of the Senate increases the likelihood of legislative action on healthcare. But the narrow Democratic majority in Congress makes it unlikely that the major reforms that were flagship issues for the Biden campaign – an ACA public option and the extension of Medicare eligibility to age 60 – will be enacted, according to a new report from global management consulting firm L.E.K. Consulting.

Narrower initiatives with bipartisan support, however, may be enacted, and a dozen executive orders related to healthcare have already been signed by President Biden. Chief among those with bipartisan support are some limited forms of drug pricing reform.

While these policy initiatives won’t be large-scale, they will nevertheless pose challenges and spark opportunities, and may require quick action from participants across the healthcare value chain.

Those are among the predictions in Election 2020: The Biden Administration, U.S. Healthcare and the Next 4 Years, the third in a series of healthcare industry election impact reports from L.E.K. Consulting.

“The slim Democratic majority effectively rules out major reforms,” said Wiley Bell, Managing Director at L.E.K. Consulting and a report author. “The healthcare industry should instead prepare for more incremental changes of a kind that can generate at least some Republican support.”

Congress has given ACA more financial support – but probably won’t go beyond

The L.E.K. report states that the Biden campaign’s flagship proposal most likely to win in Congress was an expansion of ACA financial support – along the lines of the measures included in COVID-19 relief.

Biden’s farther-reaching proposals are unlikely to be realized. The campaign had called for lowering the Medicare eligibility age to 60 – a measure that would shift 80% of Americans aged 60-65 into Medicare, lowering their total cost of care by $100 billion – and the creation of an ACA public option. The ACA public option was to extend coverage free to low-income individuals not eligible for Medicaid because their states chose not to expand, and at an affordable price to other Americans.

While these proposals are theoretically on the table, the obstacles are daunting: There is no margin for even one Democratic Senator to defect, Republicans are expected to filibuster major reform legislation, and they are expected to challenge it under Senate rules if Democrats try to use the budget reconciliation process to avoid the filibuster.

“The combination of the narrowest possible Democratic Senate majority and effective use by Republicans of Senate rules effectively takes most major Biden reforms off the table,” Bell said.

Limited coverage expansion and drug-price reductions may be on the table

Other healthcare measures more likely to be enacted include:

  • Expanded access to Medicare and Medicaid and ACA coverage. The Administration’s executive order on the ACA, which predated the latest COVID-19 relief package, got attention mainly because it introduced a COVID-specific special open-enrollment period. But the order also lays the groundwork for a reversal of Trump administration policies; the reversals would increase access to federal health programs.
  • Prescription drug pricing reductions. There are several proposals on the table, and only the narrowest are likely to get the needed level of bipartisan support. A cap on drug price increases at the current level of inflation is seen as an easy win. Also possible is a reform that would allow Medicare to negotiate with drug manufacturers – though it’s not clear the measure can pass with a simple majority. Less likely are a switch to pricing based on international price references – which the industry opposes – and value-based drug pricing, which is hard to implement due to the complexity of the models. The administration may create a panel to investigate value-based drug pricing for Medicare and Medicaid.
  • Increased access to telehealth. Any measures that come forward will have broad bipartisan support.
  • Support for value-based innovation. There is bipartisan support for value-based payment reform – expect progress on this front as well.

Although changes are incremental, stakeholders should act to take advantage

Healthcare industry players should, according to the report, take steps to stay ahead and take advantage of the likely direction of health policy over the next four years:

  • Providers: Accelerate efforts to shift care to lower-cost settings and to manage patients system-wide in order to offset reimbursement changes. Expanded access to telehealth should also be on the boards.
  • Payers: Step up programs to steer members to lower-cost care sites, while doubling down on care management capabilities for Medicare Advantage and managed Medicaid.
  • Supply chain participants: Develop warehousing and shopping capabilities to distribute COVID and future vaccines and expand the use of high-profile generics to counter drug pricing reform.
  • Pharmacies: Look for opportunities for greater generic drug reimbursement and double down on investment in providing additional healthcare services, such as clinics and vaccinations.
  • MedTech players: Get ahead on telehealth by identifying priority therapeutic areas for remote monitoring solutions and offer providers digital patient engagement tools.
  • Biopharma: Plan to upgrade value-demonstration capabilities, prepare P&Ls for flat pricing, prepare teams for government negotiation, and explore investment in infectious disease treatments.
  • Healthcare IT: Partner with providers to develop telehealth offerings and communicate the value proposition of healthcare IT in supporting price transparency and outcomes tracking.

“While there won’t be earthshattering changes in the healthcare landscape – as there might have been with a bigger Democratic margin – changes are coming,” Bell said. “Industry participants should look carefully at the implications of these incremental reforms and be ready to seize opportunities.”

About L.E.K. Consulting
L.E.K. Consulting is a global management consulting firm that uses deep industry expertise and rigorous analysis to help business leaders achieve practical results with real impact. We are uncompromising in our approach to helping clients consistently make better decisions, deliver improved business performance and create greater shareholder returns. The firm advises and supports global companies that are leaders in their industries — including the largest private and public-sector organizations, private equity firms, and emerging entrepreneurial businesses. Founded in 1983, L.E.K. employs more than 1,600 professionals across the Americas, Asia-Pacific and Europe. For more information, go to www.lek.com.