Regardless of the outcome of the November election, and by that I mean both the presidential and congressional elections, health care will once again be on the agenda.
At this point, the most likely scenario is a Clinton victory, a change in the Senate majority from GOP to Dem (though it could be very close) and a diminished, but still majority, GOP in the House. This scenario would set up an opportunity for some real progress on several nagging health care issues. To add to the analysis, there is an outside chance that the GOP could lose majority control of the House, but for this to happen, it would require an electoral landslide by Clinton preceded by a Trump implosion. No one is holding their breath on this but it is notable in that it is being discussed.
A Trump victory would obviously change the dynamic and the results of the Senate and House elections would be critical to what might happen. If Trump wins, it is probable that the GOP's House majority would hold close to its current level with just a few losses, and the outcome of Senate control would be extraordinarily close. Some have even predicted a Trump win could result in a 50/50 split, resulting in the Vice President acting as the tiebreaker. Under this scenario, continued gridlock would be the result.
But under any scenario, neither party is likely to control all branches and chambers, and importantly, no one party will have the 60 votes necessary in the Senate to move any truly controversial legislation.
However, if an opportunity for progress emerges, it would be based less on the raw numbers and more on the message that voters send. The big unknown is will the newly elected and reelected actually hear the message or will they filter it through their own political lens and go forward with business as usual? Arguably, this is what they have done over the last several elections, going forward with their own personal agenda and ignoring what the voters want, which seems to be governance and compromise.
The most important person in a scenario of progress is Speaker Paul Ryan. While a strong conservative, it seems clear that Ryan wants to govern and legislate. He wants to address some of the big challenges facing the U.S. To do this under any scenario requires compromise. In our current political climate, compromise will require will and courage. So the question is does he have both and will he be willing to exercise them if he does?
What are the key issues?
Clearly the Affordable Care Act (ACA) is at the top of the agenda. It continues to be a political issue for both parties with Republicans continuing their promise to repeal the law. Just last week, Speaker Ryan, after six years of saying the GOP would release a health care alternative, finally released a plan. The short of this plan is that it is not an actual replacement for the ACA in that it would not provide insurance coverage to the millions of Americans who have received it under the ACA. How far that number might fall short is anyone's guess right now as the plan is deficient in the detail necessary to do such analysis. It also has few if any financial/budget details to determine how much it would cost. However, despite its shortfalls, it does provide Republicans at least some ground to stand on in the debate over health care.
Interestingly, current Senate HELP Committee Chairman Senator Lamar Alexander (R-TN) has said he will be ready next year to work with whoever is President to fix the many problems with the ACA. Senator Alexander said, "Whoever the president is in January, we're going to have to take a good, hard look at Obamacare POLITICO's "Pulse Check" podcast. "It can't continue the way it is...I don't think Republicans can go another four years, whether we have a Republican president or not, and say just give us a couple more Republicans and we'll repeal Obamacare," he added. He cited the work of his committee to reform the "No Child Left Behind" legislation as the template for how to make changes to the ACA as well as citing the fact that Hillary Clinton is married to a former president known for his deal-making skills. "Hillary Clinton is married to a fellow who made a lot of deals as president," Alexander said. "And if she shows an aptitude for taking a position, listening to other people and looking for the 80 percent instead of the 20 - or if Mr. Trump does, if he's the president - then we can improve the health care system."
Issues he cited for possible change cover less government management, more support for private sector innovation and more flexibility for states regarding Medicaid. He called Speaker Ryan's plan a "helpful" starting point, though he did not specifically endorse it. Throughout, Alexander has had a good working relationship with Senator Patty Murray (D-WA) who would most likely become chairman if Democrats take majority control in the fall election.
All of this points to a possible way forward to making needed changes to the ACA that have been impossible to even try under the current President.
Despite the political fire of the ACA, this may be the most volatile issue facing Congress and the Executive Branch next year. The public relations battle over the impact of drug prices (which actually encompass a couple key issues: the individual price for drugs and whether price impairs access and the overall drug spend on total health care spending) between politicians, the pharmaceutical industry and the health insurance industry has heated up in recent months (it never actually goes away, just fades and returns over time).
But next year may see a convergence that the pharmaceutical industry may not like. For decades Republicans have been their stanch defenders. That rock solid support is eroding. Last fall, Senator Marco Rubio (R-FL) referred to some drug industry practices as "pure profiteering." "The companies decide, We can get away with charging it, and so we do.'" Senator Rubio - Bloomberg
Donald Trump has also taken shots at the industry by criticizing drug prices and suggesting Medicare should be allowed to negotiate prices among others issues. The problem with handicapping Trump on issues is that he often changes his position, sometimes in a matter of minutes. So where he would land as President - who knows?
Hillary Clinton has been clear where she stands and has taken a hard line. She wants to allow Medicare to negotiate prices as well as require higher rebates in Medicare; end the tax break to direct-to-consumer advertising; in exchange for any government support, demand some level of R&D investment; move to get more generics in the market as well as biopharmaceuticals and/or specialty drugs, allow drug re-importation, and; prohibit "pay for delay" of generics among other positions.
Exactly what a drug price agenda would or will look like next year is not as important as understanding that the ground has shifted underneath the pharmaceutical industry and it is unclear how they will respond. One thing they need to know, the "Maginot Line" once created and defended by the GOP is no longer.
The 21st Century Cures Act
Once thought to be legislation that would pass fairly easily, the 21st Century Cures Act and related legislation has become bogged down in the partisan divide that Congress has become on almost all issues. Most agree, given the changes that have gone on and are underway in the scientific and drug discovery world, the FDA and the processes it follows to approve new drugs and devices must be modernized to keep pace with the changes going on all around it. But that's where the agreement seems to end.
The House on a fairly partisan basis moved an Omnibus bill that captured all the various changes the majority agreed upon while the Senate, because of its unique politics and rules, took a piece meal approach and passed several bills. Besides making it difficult to go to conference, neither side has fully addressed the elephant in the room - funding.
Republicans in the House are very reluctant to approve any new funding even for things they want to do, preferring to take money away from some other related or not federal program, while in the Senate there is more appetite to fund new legislation - hence the deadlock that does not seem likely to get resolved this year.
Next year with a new Congress and President, it is hoped this hurdle can be overcome as reform is clearly needed.
Public Health Funding/Zika
Despite the fact the Zika virus is creeping closer and closer to U.S. shores (we already have cases of Zika in the U.S., though they were contracted outside the U.S. and the U.S. has already seen a baby born with microcephaly here), as well as one confirmed death from Zika, Congress has so far failed to pass any specific funding for vaccine research and response. The fight, in what has become all too common, is over money. Republicans want to take funding from other areas or disease research and response - specifically Ebola - and apply it to Zika, or take funding from the ACA and shift it to Zika. Democrats have resisted and thus we have no bill.
Meanwhile, Dr. Anthony Fauci, one of the world's top infectious disease experts and Director of the National Allergy and Infectious Disease Institutes at NIH, on C-SPAN said, "If we don't have a firm commitment to get the money to us within several weeks into the summer, then we're going to have to scramble around and figure out how we can work so as to not slow down the process." He added, "We're reaching the point now that...we're not going to be able to do the proper preparation and implementation of the more advanced Phase 2 trial."
Congress is likely to eventually clean up the mess they find themselves in, but the question it raises is given the ever increasing number of disease outbreaks we're seeing whether from disease we know - Ebola - or emerging infections - like Zika - is the current debacle in Congress the new normal or is it an exception? For our country's health, we should hope it is the exception.
And bear this in mind: the $1.9 billion the White house asked for is only for short-term projects. It will be years before we have a vaccine that can be used widely on the public. In the meantime, Zika will come to our shores and we will have babies born with microcephaly who will need intensive and expensive care. That is a reality that no amount of political fighting and figure pointing can erase.
If not next year, then sometime soon, there will be some new emerging disease we will need to respond to in addition to Zika. You can count on it.
Like the weather, which is notoriously hard to predict as so many factors can impact what ultimately happens in any one location, predicting six months out what Congress and the White House will do next year is tricky and fraught with unknowns. But based on what is known, likely and the "known unknowns" as former Defense Secretary Donald Rumsfeld liked to say, there is a chance for action next year on health care, unless it rains first.