As the last gyrations over the 2020 election move to the sidelines and the new Biden/Harris Administration names its Health Team – what can healthcare executives, professionals, and systems expect in 2021?

What To Expect in Healthcare in 2021

The trajectory of the American medical system will pivot back to center with a re-affirmation of the Affordable Care Act under President Biden. Never one to espouse the “Medicare for All” revolution, Joe Biden will restore aspects of the ACA marginalized over the last four years. For example, look for repudiation of Association and Short-Term health policies as the “essential benefits” for insurance under the ACA return as the enforced standard. Expect also the tightening of waivers allowed by CMS for alternates to “pure” Medicaid expansion. Funding and support will return for ACA Exchanges as people flood the market in the post-COVID-19 economy (as early as May, the Urban Institute predicted 43 million newly unemployed people would be seeking coverage).

The Biden Administration has a slim chance to expand the ACA with the addition of a “Public Option” to the insurance alternatives in those exchanges (also called “marketplaces”). The possibility of anyone being able to purchase government-run insurance was a key component of Joe Biden’s campaign platform. In part, any growth of the ACA depends on control of the Senate after the two run-off Georgia elections in January. Still, even with Democratic leadership, a “Public Option” has tenuous survivability. Remember that it was Democrats (specifically Joe Lieberman) that killed the Public Option in the original ACA insurance blueprint in 2009 (for more on the long history of the Public Option, go here).

All of this assumes the ACA is saved once again by the US Supreme Court in California v. Texas, the ACA Challenge that originated in Fort Worth and is now advanced by 18 “Red” states under the leadership of Texas. There was a sigh of relief among ACA supporters after the Supreme Court oral arguments on November 10th, but predictions based on oral arguments are always tea-leaf-reading at best. We will not know the fate of the ACA until the Supreme Court releases its decision in the case, presumably next June.

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If the Supreme Court takes the opportunity to strike down the ACA in its entirety, that will be the all-consuming health care issue for the second half of 2021. Millions of people insured through Medicaid Expansion under the ACA (which now includes 39 states plus D.C.) will become uninsured overnight as federal support (90% in most cases) for the cost of expansion vanishes. Providers everywhere will undoubtedly witness a significant increase of the uninsured in their communities as federal subsidies that help people purchase policies on the ACA exchanges (approximately 84% of purchasers receive federal money) also disappear upon an adverse Supreme Court ruling.

A loss of the ACA will consume the nation’s attention with children between 18 and 26 falling off their parents’ insurance, the loss of out-of-pocket spending limits, and the (presumed) return of life-time caps in insurance policies. As polls demonstrate, the most significant implication for the public would be the loss of protections for preexisting conditions. The September 24th Executive Order by President Trump was aspirational about pre-existing condition protections, but is not in itself sufficient to save them; recreating the ACA protections would take, literally, an Act of Congress!

Speaking of Congress – the gridlock we have witnessed for most of the last six years (if not decades!) is likely to continue. Either party in control of the Senate (most likely the GOP) will have a razor-thin majority, necessitating the continued use of “Reconciliation” for most legislative efforts to avoid a filibuster (the filibuster being one of the “blue wave” dreams now unlikely to happen). Reconciliation is a procedure that prevents filibusters, allowing legislation to pass with a simple majority of votes. It also restricts amendments and the time for debates but can only be used for bills that address federal spending, revenues, or the federal debt limit. It certainly can’t be used to pass sweeping legislation impacting health care or any other substantial societal issue (for more about Reconciliation, go here).

If Congress does get anything accomplished in 2021, look for breakthroughs in surprise billing legislation (which was doing reasonably well before Washington descended into election-year politics in the Fall) and the regulation of drug pricing (which was also proceeding as a bipartisan issue before COVID consumed all the energy remaining on the Hill). Speaking of Drug Pricing, President Trump’s Most Favored Nation Executive Order on November 20th may have pushed that debate farther along, but is already subject to attacks from PhARMAprovidersseniors, and fellow Republicans; Newt Gingrich tweeted, “The GOP is for free markets, not socialism.”

One healthcare effort that will continue merrily along in 2021 is the evolution of a “Value-Based” reimbursement structure, including bundled payments and an emphasis on increased integration and coordination across the health care sector. New Rules regarding Stark and Antikickback regulations released by HHS on November 20th will allow more coordination of care and partnership possibilities between hospitals and physicians to encourage Value-Based arrangements. These revised rules have been years in the making and will not change.

Modifications of  MACRA under the Trump Administration (specifically a revamping of the MIPS track) will also go forward as announced last year. MACRA passed in 2015 with a 91% affirmative vote (R- 212  D- 180); it will continue to receive Congressional support regardless of who lives in the White House!

The most predictable path in health care moving forward will be a continuing national commitment to Healthcare Information Technology, electronic health records, and advancing how technology can enhance quality of care, improve access, increase efficiency, and decrease cost.

Transparency in healthcare has also been a constant across this past decade. Interoperability is key to that quest and part of new HHS rules aimed to provide “patients more access to personalized health information in a standardized format.” [quote] As transparency is a core foundation of the ACA, this focus is unlikely to change in the Biden Administration.

And lastly, one thing we know with certainty is Telemedicine will become increasingly prevalent in 2021. COVID has taught us that telemedicine works far better than many traditional providers anticipated; more importantly – patients like it. Watch for some tightening of CMS Rules as COVID is contained (such as allowable platforms and some relaxation on privacy precautions to address patient needs early in the pandemic). Also, be aware that CMS just expanded the list of services reimbursable through telehealth in October, and the government announced $12 million in grants to expand telehealth in rural America in August. In June, CMS Administrator Seema Verma said telemedicine for the Medicare population had proven to be so successful during COVID that “I can’t imagine going back… it would not be a good thing to force our beneficiaries to go back to in-person visits.” [quote]

In summary, 2021 promises to offer incremental movement on many issues as the Biden Administration resurrects much of the structure and priorities of the Obama years. Expect more of a return to the past than a bold step forward. Prepare yourself for more gridlock in Congress and waiting- not enormous transformations. At the same time, you need to be watching for regulatory changes from HHS and your state legislators and authorities.

The best advice for the immediate future is to continue to advance your access, quality, transparency, and efficiency in your practice/hospital/system. More than anything else, keep focusing on the patients in front of you today!

All information contained herein is intended as general introductory information, is provided for informational purposes only, and is not legal advice. It should not be construed as legal advice and should not be relied upon as such.  If necessary, please contact an attorney to obtain advice with respect to any particular issue or problem that may be related to the subject matter herein. The ideas and opinions expressed herein are the ideas and opinions of the individual author and may not reflect the ideas or opinions of ImagineSoftware, Technology Partners, LLC or any of its affiliates or subsidiaries.



A former nurse and practicing attorney, Sarah Freymann Fontenot, BSN, JD, CSP is a professional speaker who specializes in explaining how health care is changing and what those changes mean for health care providers as well as patients. She has taught health law at Trinity University since 1997 and has been a frequent speaker for numerous national provider groups for the last two decades. Her twice-monthly newsletter “Fontenotes” provides concise information about our health care system and currently reaches 25,000 readers. Sarah is a proud member of the Board of Directors at Peterson Health in Kerrville, Texas.

You can contact SARAH FREYMANN FONTENOT via email at