By MATTHEW HOLT

The Democratic convention wrapped with a fine speech from Kamala Harris, star power from the Obamas and Clintons, and a bunch of Republicans telling their ideological brethren that it was better to be a Democrat than a Trumper. More importantly no Beyonce/Taylor Swift duet–as we were promised by Mitt Romney.

There was a lot of talk about some aspects of health care. But overall if Harris wins, don’t expect much change to the current health care system. 

Why not?

First there’s the pure politics. The Dems need to win back the House (probable but not certain) and hold the Senate to pass legislation. Right now they have a 51-49 edge in the Senate. Most likely that goes to 50-50 as the Republicans will definitely pick up Joe Manchin’s seat in West Virginia. There’s a series of seats the Dems currently hold in close races (Montana, Ohio, MIchigan, Nevada, Arizona) that they’ll need to keep to maintain it at 50-50, and it’s hard to see any pickups from Republicans (perhaps Florida or Texas if you squint really hard). The good news is that Manchin (WV) and Sinema (AZ) will soon both be gone, so the Dems that will be there won’t be as difficult to persuade to follow a Presidential agenda. But that will still leave Walz as VP to do what Harris did and pass a bunch of deciding votes under reconciliation, which massively limits what the legislation can do–it has to be “budget related.”

Which leads us to what we have been hearing from Harris and her campaign about health care? We’ve heard a lot about issues that have impacts on health, specifically creating affordable housing and fighting child poverty, but little that is directly related to health care itself. Really only two issues stand out. Abortion and reproductive rights, and drug prices.

Clearly Harris will take a swing at reversing Dobbs and passing a national right to abortion. This will need either a packing of the Supreme Court (my favorite) or ending the filibuster or both. Either of these will be incredibly tough to pull off constitutionally and politically and will take huge amounts of political oxygen. Of course the cynics would say, the Democrats are better off leaving this as an issue to use to beat up the Republicans on. But if it gets done, womens’ and reproductive rights will only be back where they were in 2022. 

Regarding the cost of drugs, there will continue to be much justified bashing of big pharma, but the extension of insulin price controls is something that (eventually) the market via CivicaRX and others is getting to anyway. Meanwhile the IRA gave Medicare the right to negotiate drug prices and the results are not exactly earth shattering. For example, CMS says it’s negotiated the cost of blood thinner Eliquis from about $6,000 a year to under $3,000 This sounds good until you realize that the price is only that high because of patent games the manufacturer BMS plays in the US, and the price in the rest of the world is under $1,000. We’ll hear more about this as the price cuts come into effect, (although not till 2026!) and more drugs get negotiated, but overall this isn’t exactly an earth-shattering change.

Finally there’s already a guaranteed fight about extending the premium subsidies for ACA plans. These were first in the pandemic American Rescue Act, then extended in the IRA, but they currently are scheduled to end in 2025. It’s hard to imagine them not being extended further whatever the makeup of the Senate, assuming a Democratic House of Representatives. (A Marjorie Taylor Greene speakership does give me pause!). But again there’s nothing new here and the overall flavor of expensive premiums and high deductibles in the current ACA marketplace won’t change.

So what’s not going to happen? Virtually all the interesting stuff we were promised by Harris and for that matter Biden in 2020. You may have missed the one actual “policy-first” speech at the convention which came from Bernie Sanders. To be fair a lot of his agenda was already in the Biden legislation. That was no accident as Biden deliberately reached out to him in 2020 and 2021 and enacted a pretty radical agenda on infrastructure, climate, industrial policy and more. And when I say radical I mean milquetoast social democrat by European standards! But what wasn’t in that agenda? No Medicare for all, which Bernie ran on in 2019/20 and brought up again at the convention. Who else proposed that in 2019? Why, a certain Kamala Harris. That never made it into the Biden agenda. We didn’t even get legislation introduced about lowering the Medicare age to 60, which was a campaign promise. There’s been no conversation about any of this from Harris or from Biden before he withdrew. It’s just a bridge too far.

Which leads to the stuff that gets debated about in THCB and elsewhere as to how the system actually works. There’s been nothing about Medicaid expansion (or its continued contraction). No talk about reining in hospital consolidation. No mention even of insurers gaming Medicare Advantage or private equity buying up physician practices. Nothing about the expansion of value-based care.

What we can expect in a Harris administration is more of the same from CMS and potentially a slightly more aggressive FTC. That will mean continued efforts to veer slightly away from fee-for-service in Medicare, a few more constraints on the worst behavior in Medicare Advantage, and possibly some warning shots from the FTC about hospital monopolies. But the trends we’ve seen in recent years will largely continue. We’re not getting a primary-care based capitated system emerging from the wreckage of what we have now, and unlike the Clinton and even Obama administrations, there’s not even any rhetoric from Harris or Biden about how that would be a good idea.

So politically I don’t think the Harris administration will be very exciting for health care. And if the other guy wins, as Jeff Goldsmith wrote on THCB last month, expect even less.