Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
Hello and welcome to Health Affairs This Week. I'm your host, Jeff Beyers. We are recording on 03/20/2025. Before we begin, heads up, we have a virtual briefing for our upcoming food, nutrition, and health issue on April 8. That event is open for all.
Jeff Byers:Check the show notes for that to get more info. We also had a very, very successful event for our Health Affairs Insider Program on Medicaid's uncertain future. Our next insider event is April 23 with Brady Post on-site neutral payments. Sign up for Insider to watch all of our past events, including the Medicaid one, and join us in April. And with that, today on the program, I am joined by health affairs own Chris Fleming and Georgetown Law's Katie Keith.
Jeff Byers:Katie and Chris, welcome back to the program.
Chris Fleming:Thank you, Jeff. And I really wanna welcome Katie, who many of our longtime listeners and readers will be very familiar with. For several years, the rapid responder for our Following the ACA feature topic on Forefront. That was the rapid responder for our Health Policy at a Crossroads track, which is designed to keep track of, the many new, health policy developments and debates that are happening under the new administration and the new congress, which as anybody who follows that at all remotely, will know. We have our hands full.
Chris Fleming:In between those two stints, Katie was at the White House where she was the deputy assistant to the president and deputy director of the White House Gender Policy Council. And now in addition to, doing her work at health affairs, she's also, as Jeff mentioned, at Georgetown, where she's the director of the Health Policy and Law Initiative at the O'Neill Institute for National and Global Health Law at Georgetown. Katie, welcome and thanks for joining us.
Katie Keith:Thanks, Chris. And you should get all the credit, as my one time editor, which is a lot more work than than most people probably realize. So thank you as always.
Chris Fleming:Well, I've I've enjoyed every minute of it. It's it's been a lot of fun. As I mentioned, you are now doing the rapid response work for, health policy at a crossroads. So as we hit the two month mark of the new administration, I'll be asking you to look forward in terms of what we should be watching. But I want to start with something that involves looking back as well as looking forward, and that's on March 23 on Sunday, we will hit the fifteenth anniversary of the Affordable Care Act.
Chris Fleming:And as I mentioned, you did for several years a lot of work looking at the implementation of the ACA under the following the ACA topic on on forefront. So you obviously will have a lot of thoughts about the legislation and what we've learned. So can you talk to our listeners a little bit about, you know, what we've learned over the past fifteen years? What are the takeaways from decade and a half of of having that landmark legislation in effect? And then after that, we'll we'll look a little bit forward as to what's at store for the ACA now.
Katie Keith:So I'll start by saying, you know, it's good to be here. I think fifteen years in, there were many pivotal moments throughout this decade in a, you know, fifteen year history where that was not always guaranteed between supreme court, challenges, you know, really existential legal threats, attempts to repeal the law broadly in 2017, and then efforts to undermine its implementation during the first Trump administration, which, spoiler alert, are back. There have been a lot of threats and wrinkles all along the way. But I think it's really worth recognizing at this moment right now, we're really seeing, I think, the benefits of the Affordable Care Act, the successes of the law itself. We're at record high enrollment.
Katie Keith:That is thanks in large part to changes made by the Biden administration and Democrats in Congress to, extend premium tax credits, first during the American Rescue Plan and then again during the Inflation Reduction Act. We again, more than 24,000,000 people have marketplace enrollment. You have many millions more people enrolled through Medicaid expansion. And I would just give a recommendation to some pieces coming out on forefront from some of the architects of the Affordable Care Act to do an even better job kind of looking back at the history and some of the lessons learned. I will spare you, you know, talk of the individual mandate.
Katie Keith:Did it matter? Did it not? And even some of those big lawsuits. But I think we are really at a pivotal moment where we are seeing, again, record high enrollment and yet, you know, the potential that those, enhanced premium tax credits will expire if congress does not take action. That would lead to millions more people being uninsured.
Katie Keith:Consumers would feel much higher health care costs, leading them to drop their coverage, lead to more uncompensated care. All of that could come to fruition early next year if congress doesn't take action, and I think you would really see the erosion of many of the gains that we've seen in recent years. And then the Trump administration in its first major health care rule is is focused on the Affordable Care Act. We're we're sort of very far from talks of repealing it replaced that, you and I and and some of the listeners will recall from 2016 and 2017 in particular, but there are still sort of fundamental differences in how the Trump administration approaches the Affordable Care Act marketplaces in ways that I think are definitely going to reduce eligibility, lead to coverage losses, raise premiums, erode the value of coverage, and and sort of in general, I think, raise health care costs for consumers, which ironically is maybe not what the administration was elected to do.
Chris Fleming:You mentioned that, the the rule that just came out, you and Jason Lovitis did a great job on ForeFront of analyzing what that rule did and and the the ways it changed the Affordable Care Act's implementation. Can you give us sort of one or two of the most, important ways in which the rule changes the way that the Affordable Care Act is being implemented that might hinder, the kinds of enrollment and access that you just talked about?
Katie Keith:Yeah. Absolutely. So it really is, Chris, you said this, but to step back, it's a pretty comprehensive rule where they make a whole series of of changes. Yeah. This rule, even as HHS itself acknowledges, will lead to coverage losses.
Katie Keith:They they themselves estimate up to 2,000,000 people could lose coverage in 2026 alone because of these changes. Chris, you asked for some examples of the changes in general. A lot of it is reversing back to policies that were in place during the first Trump administration. So a shorter annual open enrollment period limits on the ability of people to enroll during the year, sort of through special enrollment periods outside of that annual period, more paperwork requirements, whether through the tax filing system or to show your eligibility. One of the things that they really target that is something the Biden administration put in place was a low income a special enrollment period just for low income people to give folks under a 50% of the federal poverty level the opportunity to enroll each month.
Katie Keith:They would get rid of that as soon as the rule goes into effect, so that could be something that's changing as quickly as this year. They recognize, I think, lot of these policies would disproportionately impact consumers in states that have not expanded their Medicaid programs in part because a lot of the changes target folks at the lowest income levels. And so states like Florida and Georgia and Texas are most likely, I think, to face some of the coverage losses as a result of this rule. So it is a proposed rule. Do recommend the pieces to folks if you haven't seen them yet.
Katie Keith:Comments are due April 11, and then it will take the administration a little at least some time to issue the final rule. But a lot of the changes would go into effect sixty days after that, so we could be seeing some of this disruption in 2025 and then other changes to come in 2026.
Chris Fleming:Well, thanks, Katie. I wanna shift a little bit, and talk about, some of the other issues that I know you're watching. We'll start with some some budgetary issues. We just had, as you know, a continuing resolution passed by congress signed by the president that back in the old days, used you know, quaint old days, we we had appropriations bills. Now we seem to live on continuing resolutions.
Chris Fleming:This will fund the government through the end of the fiscal year. Can you talk a little bit about what the health elements or perhaps the lack of health elements is maybe the more, accurate way to put it, you know, that were, part of that CR?
Katie Keith:No. I think it is the most notable for what was not included in that package. There were some changes like extending telehealth flexibilities, for example, that I know a lot of stakeholders were interested in. There were some cuts to NIH funding, for example, but I think most notably, things that were not included in the continuing resolution was a fix to the physician fee schedule, which continues to be delayed, and historically has not been delayed, has actually been taken care of on a regular basis, at least put off over time, and here that was not included. I think, physicians have been advocating for that fix over and over and have now been told it will be in the coming budget reconciliation package.
Katie Keith:There were not sort of bipartisan reforms that have been talked about, things like site neutral payments. Shout out to that insider program that Jeff just mentioned. You know, there was a whole package of health policy changes with bipartisan support that were not attached to this, vehicle. So I think more to come. There there wasn't a ton to say, but I do think that's notable for some of the policies that were not included this time around.
Chris Fleming:And then, of course, one of the other budgetary elements that we're watching is, we've got this reconciliation bill. The record for for folks that don't know, budget reconciliation is a mechanism that is often used because you need generally 60 votes in the senate to to pass anything. But under reconciliation, there's restrictions, but you can pass and you can pass budget bills with a bare majority, 50 votes plus the the vice president or 51 senators, obviously. Unlike the CR you just mentioned where there wasn't a lot of health policy involved, that's gonna involve a huge amount of health policy and and fights over, in particular Medicaid, I think we would definitely say is perhaps the main area in terms of health policy that where there's going to be a huge battle. You talked about how Medicaid expansion was part of the ACA.
Chris Fleming:We saw growth in Medicaid as well as in the marketplaces. Can you talk a little bit about the fights that we're gonna see over Medicaid and, know, everything from work requirements to budget cuts? What should we be watching there?
Katie Keith:So first, I would highly recommend a piece by, star Rosenbaum and Alison Barkoff for forefront that really goes through kind of what is at stake and, the details of exactly what you laid out and and the fight. I think if if Republicans in congress get anywhere close to to the cuts that they have talked about making that were sort of laid out in their budget blueprint for this, budget resolution process, it would be the largest cut to Medicaid in the history of the program. And and I think the step back there, of course, is Medicaid insurers more than 80,000,000 Americans all across the country, the size and scale of the cuts that are being discussed, whether from work requirements to rescinding Biden era regulations on Medicaid to, I think, per capita caps have fallen off the discussion table, but anything can happen. And if those kinds of things come back, provider tax, there's a whole range of elements that I think have been batted around. I think the takeaway is anytime you were making this scale or even discussing the scale changes, it's going to come down to cuts to state budgets, to health care providers, to benefits for beneficiaries, and to cover huge dramatic coverage losses.
Katie Keith:So again, the largest cut to Medicaid in the history of the program is what's at stake. And it's why I think you've had, even earlier this week, former Republican members of Congress come out and sort of warn against this type of cut. You've seen some moderate House members already raise concerns about cuts to Medicaid. And and this was a huge part of the Affordable Care Act repeal and replace debate in 2017. And I think the cuts to Medicaid, in addition to the Affordable Care Act, but there was a huge amount of discussion on Medicaid, helped stave off those broader cuts because it's an extremely, popular program.
Katie Keith:And I think Republicans sort of underestimated that in 2017. We will see if that has changed. I think Billy Wynn also had a great piece for Forefront talking about some of these dynamics, And I think his take is that congress will not get there, but, of course, there's more to wait and see. And I guess, Chris, maybe on the to make a little bit of a bigger political point too, I think you've got the budget resolution process, which could be sort of the first big fight on health care in, you know, president Trump's first year here, which we've seen before. And then you do have these premium tax credits for the Affordable Care Act that will expire at the end of this year.
Katie Keith:And so that sets up almost a second health care fight, again, during the first year on an issue that it does not seem like the president himself has really prioritized. And so I don't you know, other politicos could talk about the wisdom of teeing up two major health care fights, but but more to come there. And I just think it's really important to keep that in mind, especially ahead of the twenty twenty six midterm elections.
Chris Fleming:Let me we we're running out of time, but let me, go a little bit to you did a piece just recently, the first fifty days of the, new administration. Now I guess we're at sixty days as we record, on Thursday the twentieth. So so, Katie, you know, we obviously, we don't have time to go through the whole piece, but maybe pick, one of the most interesting elements, from what you wrote that we're you're watching, as we move forward in the new political environment.
Katie Keith:Yeah. So instead of maybe picking one, I guess what I would emphasize to folks is my observation is there's a lot of old that is new again. So you can really see an emphasis on some of the priorities from the first Trump administration. I'm thinking of health care, price transparency, I'm thinking of reproductive health, I'm thinking of tax on sort of gender affirming care. So all of that is discussed there.
Katie Keith:And then really keeping an eye on some of the new changes, the Make America Healthy Again commission that's being set up at Med Quietly, I think, recently in private, which I didn't have a chance to cover, some of the attacks on public health and vaccine access that we're already starting to see, and then recissions of Biden era guidance on anything, everything from Medicaid to HIPAA. So I I think a lot more to come. There there really is a lot to unpack, and and we'll you know, I will do my best, to to continue to try to do that at Forefront and beyond.
Chris Fleming:Well, thanks, Katie, and I and I encourage listeners to watch Katie's article on Forefront for further developments of which there will be many, we can be sure. Let me turn it back over to Jeff to close us out.
Jeff Byers:Yeah. Yeah. Thanks, Chris. Thanks, Katie. And what better way to stay on top of Forefront than to be a Health Affairs Today or Health Affairs Sunday Update newsletter subscriber.
Jeff Byers:So those are free newsletters that you can get updated on all those new articles if you don't go to our website. And with that, thank you, Chris and Katie, for joining us today on Health Affairs This Week. If you, the listener, enjoyed this episode, send it to the text enthusiasts in your life, convert them over to audio, and we will see you next week. Thanks all.