Health+Benefits the Jan/Feb 2021 issue

David Axelrod

On the future of the ACA, prescription drugs, pollsters, and whether Mitch McConnell and Joe Biden can actually work together.
By Joel Wood, Sandy Laycox, Brianne Spellane Posted on January 20, 2021

They have wisdom, insight, and experience that only comes from a decades-long love of American politics. We felt there was no one better suited to tap this keg of political prowess than The Council’s own political guru, Joel Wood.  Pull up a seat (and maybe grab a beer while you’re at it).

This interview was conducted in December. On January 6, less than 24 hours before we went to print, thousands of Trump supporters stormed the U.S. Capitol, disrupting the certification of the Electoral College results. The views expressed here may, or may not, have changed. — Editor

Joel Wood: Looking back to those opening months after President Obama was elected, and now, knowing that COVID relief is going to be the first thing that’s out the door for the incoming administration, and knowing that there should be room for bipartisan cooperation on some things like immigration reform or infrastructure, I just wonder what your thoughts are in terms of sequencing? And do you think the closeness in the Senate now dooms the prospect of a robust public option?
Axelrod: It seems to me unlikely that the public option will move forward. I do think it’s possible that President Biden will try and move forward—and this is not based on inside knowledge, but just speculation—some sort of combined COVID and healthcare bill that would correct some of the things that the Trump administration has done relative to subsidies and other elements of the program that need strengthening to restore it to where it was when he came to office. But the idea that the public option would be in there, it seems pretty remote to me at this point. I don’t see him getting that. If there were a Democratic Senate, I think the prospects would be better. But even if it’s a tied Senate, that’s not a slam-dunk issue, in my mind.

I do think, though, that (Biden) will try and move forward on elements of strengthening the Affordable Care Act. And my guess is he can find a Republican voter to do that. That includes, by the way, reinstating the 100% match on Medicaid for the states that haven’t yet enrolled in that aspect of the Affordable Care Act. Some legislation was moved on that by Senator Alexander, who’s now retiring on the Republican side. So there are possibilities there for that, but I think if your concern is the public option, it’s probably pretty unlikely right now.

How about administrative actions? Biden is not by his nature someone who wants to push the envelope on executive action, but there’s a lot of creative things that you can do within the framework of the ACA itself.
I think there will be administrative actions around the ACA. And one of the things I anticipate is that these low-cost plans that are sub-ACA standards that [President Trump] has pushed—what I think a lot of Democrats would call junk plans—I think, the grandfathering of those is not going to continue. I think you’ll see attempts to expand enrollment dates, and they’ll need funds to have robust marketing and assistance around enrollment in the ACA. But certainly there are things that they can do administratively and that they will do administratively.

You were at the White House signing ceremony for the ACA...What was it Vice President Biden said to President Obama?

It’s a big effing deal.
I don’t think that was the word...

I’m cleaning it up in deference to your organization, but it was a big deal. And I can just tell you that I have a child with a chronic illness that almost bankrupted our family and we had insurance. I wept the night that law was passed. There are a lot of people who have wept to me who are helped by it. And you know, I wish we could take the heat out of this and work together as a country to say, “How do we in the least disruptive way, make sure that everyone can get the basic healthcare that they need?”

And, we’ve taken some steps backward. I think we’ll take some steps forward. I don’t think they’re going to be steps that are so disruptive as to create huge debates.

The other question that’s come up is on Medicare and what the president-elect talked about during the campaign, allowing people between 60 and 65 to buy into the Medicare system at their own cost. I’m not sure that’s going to happen for a variety of reasons. I mean, it may, because it’s politically popular, but I think he’s going to focus on really trying to strengthen the Affordable Care Act. There’ll be questions swirling around Medicare, because some of the steps that were taken by this administration have lowered the solvency date now to 2024. When they take the next look at it, it could be 2023. So, I think even though it’s a buy-in, talk about that may make people very uneasy.


You mentioned your personal experience of not making a lot of money, working for the Chicago Tribune, having a child with a chronic disorder. Personally, in the other room is my son who has Duchenne muscular dystrophy. It’s specific, and it’s very expensive. And we’re blessed to have good coverage.

But the drug companies are extremely powerful in Washington. The only drug that is approved by the FDA specifically for my son’s condition is $88,000 a year. That’s $241 per pill, and it costs them about a buck to make it. Specialty drugs, prescription drug transparency, pharmacy benefit managers—it sure seems like this is an area where Republicans and Democrats could agree. And frankly, Trump has tried to take on, with largely not a lot of success administratively, the drug companies. Might we see something emerge on this front?


Well, you know, (Trump) toward the very end of his administration, he has now tried to move on this “most favorable nation” approach so that Americans will pay the same drug prices that are paid overseas. I don’t know whether that is a vehicle that Biden will continue. But I think this issue is one that is really, really meaningful. I had flashbacks, Joel, when you held up that bottle of pills, because that is exactly what we faced. My daughter had very complex epilepsy, she needed drugs that were not the common drugs; some were new on the market. My insurance didn’t cover prescription drugs. And that was a large part of our challenge.

A lot of Americans are going through that and having to make terrible choices. That is something that transcends—listen, one thing about illness is it’s not a partisan thing…I think there is pressure on both sides of the aisle. And yes, they are very, very powerful. And we had to navigate that during the fight for the Affordable Care Act. But I think this thing has reached a point where there may be some action that will be taken and they’ll find partners on the other side of the aisle to do it. I can’t describe what form it will take. But if Biden’s looking for issues on which he can pick off partners, that may be one.

One of the things that we found most attractive in the ACA was that it called for HHS to create a national benchmark plan that would be basic elements of care, sort of a copper-level plan. But HHS never fully implemented it. With the theory being that that would help drive down some of the costs on the exchange, might that be something that could be revisited in the Biden administration? Because the administrative ability already exists.
Yes, I think so. If you look back to 2017, there was a lot of optimism. It seemed like the markets had settled. They had figured out what the appropriate price levels were. You didn’t see these huge jumps in price coming. But President Trump, for whatever reason, has decided that the Affordable Care Act needed to be destroyed. Tried to do it legislatively, through the courts, and tried to burrow under it administratively, and that has put insurers and patients in a very bad position. I think you’re going to see more stability now and an effort to shore the whole thing up in ways that reduce costs and stabilize the markets.
Much has been made about the reality that Leader McConnell and President-Elect Biden served together for decades. They’re not chummy, but they’re friendly, and that they’re both institutionalists. Yet we have, obviously, a deeply divided country right now. How do you characterize what, if any, working relationship there will be?

I will tell you, in the two years that I was here [in the White House], which was the most eventful two years in some ways, it was the vice president who went to the Hill and was able to talk to McConnell. Part of it was that McConnell and Obama didn’t have a very good relationship. Biden knew how to talk politician to politician with McConnell. We did a series of really important things after the midterm elections in the lame duck session in 2010; we were able to accomplish a lot. A lot of it had to do with Biden’s negotiations with McConnell. But McConnell had an impetus then. We had a whole new group of legislators coming into the House in the new Republican majority who were averse to compromise. He knew they were coming, so he had an impetus to try and get a lot of things done that he wanted and give the administration some of the things that they wanted to clear the decks before the new group came in. We’ll see what he does here.

One of the reasons that we didn’t have much luck with McConnell generally was because he didn’t see it in his interest for us to be successful on a bipartisan basis. He thought that would help cement our majorities, help re-elect the president. And he fundamentally sees his first mission as maintaining his majority. We’ll see whether he feels like cooperating with Biden is politically helpful to him and at what level he needs to cooperate to do that.

I think the idea that he would green-light some significant rollback of the Trump tax cuts is unlikely. But is there an infrastructure program that he’d be willing to work on? Or will he allow some of these healthcare things to go forward? I mentioned reconciliation earlier, because all you need is 50 votes for that. And they may be able to find them. One of the great ironies is one of the people who they may go to is Susan Collins, who Democrats fought so hard to defeat but who has taken a relatively progressive viewpoint on the Affordable Care Act now that it’s been implemented. But there are others as well they may go to. So that relationship is going to be very important. The ability to put majorities together on a thing like reconciliation will be important, as well, in case that route doesn’t work.

Should we ever believe pollsters again?

You know, I’m just putting together a symposium at my Institute of Politics at the University of Chicago to do a deep dive on what exactly happened. I think clearly, there was something missed and it was largely, again for the second straight election, an inability to properly gauge what was going on with white non-college voters.

I heard an interesting theory the other day, which was that when there was polling during the pandemic, a lot of those people were out working because they have to and a lot of white, college-educated voters and other college educated voters were home and answering phones. That may have skewed some of it. I don’t know, but I think there’s still a place for polling. I think polling on issues is probably easier than polling on politics, particularly when Donald Trump is on the ballot.

David Axelrod is best known for his role as the chief strategist for Barack Obama’s successful presidential campaigns. He served as a senior advisor to President Obama from 2009-2011. He is the founding director of the University of Chicago’s non-partisan Institute of Politics and can be seen almost nightly as senior political commentator on CNN.


Joel Wood Senior Vice President, Government Affairs, The Council Read More
Sandy Laycox Editor in Chief Read More
Brianne Spellane Director of Membership, The Council Read More

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