A new president doesn’t get four years to shape health care; he gets six months. And for President-elect Joe Biden, the most pressing health care issue is – no surprise here – COVID-19.
On the latest episode of The Dose, the Commonwealth Fund’s President David Blumenthal, M.D., talks about Biden’s opportunity to leave a lasting health care legacy by bringing the pandemic under control.
Blumenthal says history will judge Biden by how he rises to our new reality, in which one in every 1,300 Americans has died of COVID, millions have lost their jobs, and science has been undermined and ignored.
Illustration by Rose Wong
Bio: David Blumenthal
SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. Today’s show is about what the results of the presidential election mean for health care. In less than two months, President-elect Joe Biden and Vice President-elect Kamala Harris will take office, facing a pandemic that’s still out of control as well as several other health care challenges. My guest, David Blumenthal, is the president of the Commonwealth Fund and an expert on how U.S. presidents approach health care reform.
David, welcome to the show.
DAVID BLUMENTHAL: Great to be here, Shanoor.
SHANOOR SEERVAI: So let’s get started with a little bit of presidential history. So it’s probably safe to say that this is the biggest health crisis an incoming president, at least in the modern age, has faced.
DAVID BLUMENTHAL: That’s fair. And fortunately, this happens or has happened in the past only once in a century. It would be not surprising if we had another pandemic as has been predicted many times before that. But we can always hope that it won’t occur more commonly.
SHANOOR SEERVAI: So when we think about what a president can do for health care, what do we think that President-elect Biden will do?
DAVID BLUMENTHAL: History will judge President Biden by how well he manages the pandemic. There is no other comparable issue on his agenda. He was elected in large part because of public discontent with the status of the pandemic in the United States. And if he bends the curve nationally on the spread of the virus and the rates of new cases and hospitalizations and deaths, he will have an important legacy. If he fails at that, I don’t think anything else he does will be remembered with the importance that it might deserve.
SHANOOR SEERVAI: So any other promises he made around health care earlier on in his campaign, they’re probably not relevant given the scale of the pandemic.
DAVID BLUMENTHAL: Well, they’re relevant and important, but the reality of a presidency is that presidents get to do one big thing in health care and actually only one or two big things overall. And a health care presidency is not a four-year presidency. It’s a six-month presidency. And if President Biden wants to tackle this pandemic in its full measure, doing all the things that need to be done, it will require not just an enormous amount of leadership and moral suasion, but also probably a pandemic relief package of legislation that will provide financial relief and also dramatic support to the states and localities to implement vaccine distribution and public health measures. And he will use a great deal of political capital on securing that result. And that will be critical to his legacy. So though there may be other things he can do through executive order, they will not, despite his best intentions and his wishes, and I think the hopes of some members of his party, I fear that he will not get the traction to do another big thing.
SHANOOR SEERVAI: You mentioned the vaccine, where a time when drug companies are having pretty successful results coming out of their clinical trials. So what could or should President Biden do when it comes to vaccine distribution?
DAVID BLUMENTHAL: Well, he will need to have a plan and that plan will need to be supported by resources. And the fact of the matter is that in the United States, the distribution of vaccines to state and local activity for the most part. So a critical aspect of his leadership will be providing the resources close to the ground that only the federal government can provide. So that if it’s a vaccine that requires freezers, that we have freezers, and that may require using the Defense Production Act to redirect resources toward that piece of work. But in the end, states and localities will have to have the resources in their public health systems to make sure that the vaccine distribution takes place. We are a federal system with divided powers and the federal government does not do vaccine distribution. States and localities do it.
SHANOOR SEERVAI: So this is a complicated process, distributing this vaccine. I had Peggy Hamburg on the podcast a few weeks ago and she talked about just how complicated it’s going to be. And she also pointed out that until we get the vaccine distributed and we get most Americans vaccinated, which could take several months, that we’re going to have to continue following social distancing and mask wearing and other guidelines. How could President Biden approach some of these issues?
DAVID BLUMENTHAL: That’s a great question. And the first thing he needs to do is clarify relentlessly, and empathetically, and nonpolitically, the stakes with mask wearing and he needs to use his convening powers to get governors together. I’ve noticed recently that some governors that have opposed mask wearing are reluctantly coming to the conclusion that they cannot continue to do so and have a functioning health system. So the reality may help him. Unfortunately, the reality of 1 in 1,300 Americans now having died of COVID. But ultimately I think that the nut that needs to be cracked is a behavioral nut. And that is how to get people who have been skeptical and encouraged to be skeptical, how to get them to change their views of mask wearing and social distancing. He needs support at every level of our society for that, not just himself, but he needs leaders of churches and companies and social organizations to come together. And I think that will be a huge leadership challenge for him.
SHANOOR SEERVAI: And so while he’s trying to crack that very hard nut, there is also the issue that our economy isn’t doing well now. Millions of Americans are without jobs. And especially at the beginning of the pandemic, I feel like we were presented with a dichotomy that either we could save the economy or we could address the disease. And it pretty soon became clear that that was a false dichotomy. Can you talk a little bit more about how economic recovery can occur in conjunction with controlling the disease?
DAVID BLUMENTHAL: Well, if you want to know how controlling the disease spurs economic recovery, all you do is look at China, where the economy is growing again, despite the fact that they had a substantial epidemic early on. But they have controlled it completely, and they are now experiencing economic growth with people buying cars and other consumables. Not quite at the level they were growing before, but at a substantial rate and I think you would see the same in South Korea. So there is no question that to liberate our economy, you need to liberate people to act as economic entities. You need to make them feel free to go to Walmart, and to go to clothing stores, and to eat out and to go to theater and to travel. And that will not happen if people don’t feel safe. So it’s not that there’s no contradiction between economic recovery and pandemic control. They are inextricably linked and any short-term effort to open the economy without protecting people from the virus is really going to be doomed to failure.
SHANOOR SEERVAI: I want to really drill into this point you made about people feeling safe. Part of the reason I think it’s difficult to feel safe is because there’s a lot of contradicting information out there. And I’ve really felt as if it’s hard to trust the information that we’re getting. And it’s hard to trust in science sometimes because of the way that the political discourse around it really hasn’t been clear. So is there something that President Biden can do to restore faith in the CDC [Centers for Disease Control and Prevention] and in science?
DAVID BLUMENTHAL: You’re asking really profound, difficult, and important questions. And if I had all the answers, I would be very grateful, but I don’t think there’s any alternative. And there’s no weapon that he has other than consistent, strong messaging and creating symbolic opportunities for science to speak truth with conviction and with authority. And simply by not having the president continually undermining the opinions of people like Tony Fauci or the people who are virologists and epidemiologists, that message will hopefully predominate. Now I fear that we’re going to have a Greek chorus of Mr. Trump and his cohorts in the background continuing to sow discord. I hope that’s not true, but I think it’s quite possible. And that is a wildcard that will complicate the effort to do what seems natural and normal.
SHANOOR SEERVAI: We’ve all been living with the pandemic for almost a year. So listeners, I wanted to ask you, what has taken the biggest toll on you? What would make you feel safe? Tell us what’s on your mind, send us an email. Our address is [email protected].
SHANOOR SEERVAI: Another point I wanted to discuss with you, David, which the pandemic has revealed, and then perhaps has been heightened by the protests we’ve seen in recent months around racial equity and racial disparities. We know that people of color and in particular, black Americans and Latinos are worst and worst impacted by the pandemic. Is there something that President-elect Biden can do to address the racial disparities and tensions in our country?
DAVID BLUMENTHAL: Sure. He has to do that. And there are a variety of things you can do. First of all, one of the most antiracist elements of recent policy has been the Affordable Care Act, which has narrowed disparities and insurance and use of care dramatically. So by fully enforcing the Affordable Care Act and using its authorities to their full potential, he can help people of color get critical health care protections that they need. And we could discuss what some of those specific things are.
And then there are some things he can do directly to hold organizations accountable and prioritize reducing disparities. And one of them would be that as a condition of Medicare participation, all health systems should be asked to measure disparities in care at their institution, to make those disparities public, and then to have remedial programs for addressing them. And that could be done by regulation, I believe, and might be challenged, but I think it would be a great symbolic statement because remediation begins with transparency and acknowledgment. And I think many health care systems believe that they treat everyone fairly and would be surprised to learn how different the experiences are of the people of color from their majority population in many localities. So I think it would be therapeutic and instructive for many of those organizations.
SHANOOR SEERVAI: What can President-elect Biden do to build on the Affordable Care Act, as he promised in his campaign?
DAVID BLUMENTHAL: With respect to the Affordable Care Act, the Affordable Care Act was designed to help people during times of stress like this. And it has been handicapped by the loss of funding for outreach. The current administration has not done what it could. For example, they could create a special open enrollment period for people who have lost their jobs as a result of the pandemic who are eligible now for subsidies and could buy insurance through the Affordable Care Act marketplaces. It could also stop using the Medicaid waiver process to restrict access to Medicaid and use that to expand access to Medicaid. And again, some of the folks, unfortunately who’ve lost their jobs are now, because of their falling incomes, eligible for Medicaid coverage. And that would be something that would be of great assistance to those people. As you watch people on television in long, long, long lines, waiting for food, you realize that those same people are almost certainly not, many of them not insured anymore. And that Medicaid could be a big and the Affordable Care Act could both be very important parts of that solution.
SHANOOR SEERVAI: Before the election, the Fund surveyed voters about which health care issues mattered to them most, and the top concerns that came out, the pandemic, no surprise, and then protection for people with preexisting health conditions. So we’ve talked about the pandemic. What can those who are worried about preexisting conditions think at the moment? What would you say to a voter who’s really worried about this right now?
DAVID BLUMENTHAL: Well, I would say first of all that, from a legislative and executive standpoint, their protections are secure. The Affordable Care Act will be enforced and its protections for preexisting conditions will be enforced for the next four years. There is one important threat to those guarantees of coverage for preexisting conditions. And that is a Supreme Court case that is now pending. The constitutionality of the Affordable Care Act has been challenged by a number of conservative states. And the Supreme Court has heard oral arguments on the topic and will rule sometime in the spring about whether, again, the law is constitutional. If it is declared unconstitutional in its entirety, then preexisting condition protections will disappear. It is possible that the Supreme Court will find elements of the law unconstitutional and not the law in its entirety. And that the guarantees of coverage for preexisting conditions will be preserved. I don’t have a crystal ball that’s powerful enough to see exactly what would happen one way or the other.
SHANOOR SEERVAI: Finally, David, before I let you go, I will bring the conversation back to the pandemic because all conversations come back to the pandemic. Infection and death rates show no sign of abating. And we’re at this crucial period over the next few weeks, when there has to be a transition from the administration of President Trump to the administration of President-elect Joe Biden. How is this transition going to work and how will it impact President-elect Biden’s ability to carry out his health care agenda?
DAVID BLUMENTHAL: Well, it’s interesting to see this emphasis on the transition because as someone who has studied presidents’ transitions often get much too little attention. There’s an enormous public education going on right now about the value and importance of transitions. It’s not worth the cost that we’re paying for it, but it is interesting to see it happen. Obviously, ideally there would be a seamless collaboration between the leadership of the pandemic response and the current administration and the people who are going to be assuming roles in the Biden administration. And by the way, we don’t know who those people are yet. So one of the biggest obstacles to seamless transitions and no one’s talking about is the time it takes to get senior officials confirmed by the Senate and that always frustrates transitions. And that’s a big unknown right now. I am strangely optimistic about the likelihood that the President-elect Biden will hit the ground running on this. And there are a couple of reasons for that.
One is he’s an experienced government official who understands the government inside and out. When I was working in the Obama administration, I actually worked with his office quite a lot. And that office was a sophisticated leader of then the response to the recession of 2008, and both he and Ron Klain and the other people he’s surrounding himself with know government and know how it works, and they know how to make it work. And that is often not true of new presidents. It wasn’t true of President Obama. Certainly wasn’t true of President Trump. Wasn’t true of President Clinton. So we are very much better off than we could be. But beyond that, the very fact that he and his people are so focused on this one issue tells me that they are going to find out what they need to know before January 20th. Much more so than would have been the case were he less experienced and were this issue less prominent.
SHANOOR SEERVAI: Well, let’s end on that note of hope then. Thank you for joining me, David.
DAVID BLUMENTHAL: My pleasure, Shanoor.
SHANOOR SEERVAI: The Dose is hosted by me, Shanoor Seervai. I produce this show along with Joshua Tallman for the Commonwealth Fund. Special thanks to Barry Scholl for editorial support, Jen Wilson and Rose Wong for our art and design, Oona Palumbo for mixing and editing, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions, with additional music from Podington Bear. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. Thanks for listening.