The New Ideas Conundrum in Health Policy
Democrats are casting about for new health reform ideas in the hope that they can gain traction in the run-up to 2028 and be enacted afterward. Jonathan Cohn wrote artfully about it in the Bulwark, and as is always the case, it’s not possible to improve on Jonathan’s take. I am frequently asked now: “What are the new ideas?” There are lots of ideas. Recently, I wrote about one that would resonate with voters: getting rid of prior authorization review.
What I see is a conundrum facing those who are thinking about big new health policy ideas for a possible new political and policy world. The subject is near and dear to my heart because we have to be prepared to analyze, poll about, and report on whatever may come at KFF.
It’s a conundrum for Democrats because only so much can be done at one time by one president, Congress, and secretary, and there are real tradeoffs to be considered. The voters’ priorities and the candidates’ needs are often not the experts’ priorities, and choices will need to be made between the ideas that will be popular and resonate with voters in campaigns and after elections, and those often more weedy and wonky things that are deemed important to do to lower spending or improve coverage, restore agencies, or grapple with AI. Funds will need to be divided between restoring huge cuts in coverage and public programs and doing new things in an environment where the deficit and debt have grown, and new funding will be tough to come by. The most important thing candidates need to do is not present plans, it’s to show voters they care.
There are at least three equally important big priorities Democrats will be thinking about that are in themselves challenging and, in a world of limited dollars and political capital, will be in tension.
One is to rebuild Medicaid and the ACA and replace lost federal funding. It will take more than a trillion dollars in funding over 10 years to replace all of the lost funding. And since restoring funding is not a rallying cry for politicians, they will need to decide what cuts they want to replace and how to fashion funding replacement into popular ideas that can sell with voters. What would the Democratic plan look like in 2029 to provide enhanced tax credits? How will Democrats handle Medicaid work requirements? They are harmful and inefficient, but popular. Repeal them? Leave it up to states? Coverage for millions and more than 300 billion dollars in hard-to-replace Congressional Budget Office-scored savings will be at stake. What about the cuts to provider taxes and payment providers and states will be clamoring for? Coming up with a trillion dollars over 10 years is a steep hill to climb in the face of the deficit and debt, and it wouldn’t leave much else for new initiatives requiring more new spending, such as improving the traditional Medicare benefit by covering dental and vision services, as many Democrats want to do.
There is also a massive task ahead to rebuild federal health agencies, which isn’t receiving enough attention yet, mostly because it’s early and it’s not a glamorous topic. Just to throw out a few related issues: Nobody thought the CDC was even close to perfect before (including every White House I ever knew); or thought the Surgeon General/Assistant Secretary for Health arrangement made perfect sense (at times in the past they were combined). The FDA has been a perennial lighting rod (especially out in Silicon Valley, where I live). CMS is divided by program (ACA, Medicaid, Medicare) and has a difficult time using its purchasing and policy power across programs, which (before the ACA) was the original vision behind the agency when it was formed. What should staffing levels be in HHS and each of its parts? Should their new missions be the same as their old ones? Where should they fall on health equity in the future?
It’s easier to tear agencies down than rebuild them and if these issues are left entirely to a new secretary without a head start, it will be at least two years into a new administration before there is a coherent plan and there is some risk not enough will actually happen. With current views of government as desultory as they are, however, it will take some creative messaging and packaging to make this essential job popular, much less something to campaign on, making it a task requiring careful thought and planning.
Then there is the third priority—that it’s time to deal with underlying health care costs. It certainly is time, as spending is increasing more rapidly again, but it has been time for as long as I have been in health care and there is no evidence that new political will to seriously take on health care costs has suddenly materialized. The health care industry is concentrated, making efforts to promote competition difficult, if still necessary, and regulation to control costs in various ways has always met stiff resistance. That has left us with a hodge podge of strategies to change delivery and payment at the margin to promote “value,” with the Hail Mary, Medicare for All, still out there with very strong advocates and critics, and limited prospects in a polarized Congress and politically divided country. As I have written, every payer is on their own trying to reduce their own spending, with no national strategy or plan. Everyone knows we are not giving enough attention to our high health care prices and except for some scattered state initiatives, we’re doing little about it.
To these three potentially competing priorities I would add a fourth: making the health system we have work better for patients frustrated by its complexity. This is the world of apps and AI (which can both simplify and complicate) and streamlining prior authorization review. Dr. Oz has talked a lot about this. There is discussion again among Democrats about a “patient’s bill of rights.” Assuming we don’t change the entire health system, complexity is almost as big of a problem as costs.
As discussions unfold, history suggests a few lessons for idea generators to keep in mind:
A trillion dollars is a lot. New funding will likely have to be split between restoring cuts and new priorities. And there is no question that the public’s priority is not underlying costs or payment reform or value, or AI, or many of the things that occupy the attention of experts: people simply want to be able to afford their health care coverage. Assuming new spending is paid for, how it’s paid for also matters, with cuts and offsets or new taxes creating new tradeoffs and rivals.
Experience also suggests a golden rule: “keep it tangible and simple.” But that’s not usually what the “idea machine” produces. Traditionally, ideas have been developed by groups of experts and stakeholders, often generating the classic 35-point plan that checks every stakeholder’s box but cannot easily be explained to voters and isn’t useful to candidates.
And again, reconstructing the agencies and along with them the national commitment to public health and science while working longer term on restoring trust is less flashy work that needs to be done.
Of course, 2028 is a long way off and there is also the possibility of a President Vance or a President Rubio. The agenda, and the ideas that may need to be generated and the work that needs to be done, may be wholly different.
