The beginning of a new administration always brings apprehension and anticipation. How dramatically will the next President change the trajectory of the country, if at all? Who will take leadership roles in the Executive branch, and will Congress enhance- or defeat- the new President’s priorities?
With the inauguration of Joe Biden, in the middle of a pandemic, these questions are particularly acute this first half-year. Many of the questions swirling around the transition between the Trump Administration and new leadership under President Biden involve health care.
What should you be watching for?
Addressing the COVID-19 Pandemic is Job #1
Obviously, the COVID-19 crisis is the prominent concern of the incoming Biden Administration.
The development of two vaccines (and at least one more waiting for approval) in record-breaking time under the Trump Administration’s “Operation Warp Speed” deserves all the acclaim and appreciation we can offer as a country.
Now the Biden administration must dramatically escalate the efficiency and effectiveness of vaccine distribution nation-wide. To get one hundred million shots into arms in one hundred days (and hopefully a lot more), multiple aspects of the current delivery system need to be fixed.
Ultimate authority for healthcare falls under state sovereignty and each state’s Police Powers, but the prior Administration’s reliance on every state to determine its own strategy for vaccinating their population has led to confusion and inconsistency. In his first week, President Biden demonstrated a willingness to use the “Bully Pulpit” of the White House to provide focused federal leadership and foster coordination with and among the states.
Federal governance will include standardization of vaccine rollouts and eligibility, a federally run, locally-focused public education campaign, and the “100-day masking challenge” announced on inauguration day. The mask mandate was the first Executive Order of this President and requires masks in federal buildings, on any form of interstate travel (such as planes, trains, and buses), and for all federal workers. Although he wanted a broader mask order as a candidate, the confines of the mandate reflect the boundaries of state sovereignty. Still, the hope is the 100-day challenge will inspire the public and encourage states to take similar action.
Utilizing available Federal powers and resources will also carry a new Biden stamp. This President will employ the Defense Production Act more aggressively than his predecessor to compel the manufacturing of N95 masks, glass vials, syringes, gloves, needles, and other equipment necessary to support a significant increase in the national vaccination rate.
Critically, the production of vaccines will ramp up under pressure from the new Administration either through the Defense Production Act, or interestingly, utilizing “Government Patent Use” that would require the pharmaceutical companies to share information with their colleagues to put more vaccine manufacturers in action.
Exponential growth in the vaccination rate will also require, literally, boots on the ground. One hundred mass-vaccination clinics, operated by FEMA and staffed by the National Guard, will be set up within the first month of the Biden presidency. Mobile vaccination units will expand vaccinations in remote rural areas, and 100,000 public health workers will be hired to assist in vaccine outreach and contact tracing. Federally Qualified Health Centers [FQHCs], which offer healthcare to some of the neediest populations in the country, will likely receive vaccines directly to spread inoculation in their catchment areas.
Most of all, what Joe Biden can bring to the COVID battle is money. Lots of money. The $1.9 Trillion Covid Relief Bill announced even before he was President is already in the middle of vote-counting and political strategy.
We will not be beyond the pandemic on President Biden’s 100th day in office (April 30th), but we will have moved much closer to turning COVID-19 into “the common cold.”
Strengthening and Protecting the Affordable Care Act
The second most-cited pledge of Candidate Joe Biden was preserving and protecting the Affordable Care Act (ACA, or “Obamacare”). Watch for a return to essential health benefits for all insurance policies (the loosening of that requirement paved the way for short-term and association health plans under former President Trump), the reinstatement (and funding) of ACA Navigators to assist people searching for insurance, and an expansion of the ACA enrollment period. Medicaid waivers requiring work (already in trouble with the courts) will cease, and pressure will increase on the last 12 states to expand Medicaid, providing coverage to all people below 138% of the poverty line. These repairs are all likely to come through Centers for Medicare & Medicaid Services as administrative regulations (or from the White House as Executive Orders), not necessitating legislation from Congress.
With Democratic control of the Senate, look for the reinstatement of the tax associated with the ACA individual mandate through the reconciliation maneuver, which only requires a majority vote in the Senate. (This is the same procedure the GOP used to take the penalty to zero in December 2017.) Bonus: With the tax penalty restored, the current constitutional challenge to the ACA in the Supreme Court will be moot.
In addition to ensuring the ACA is saved, refreshed, and replenished, President Biden will try to fulfill his vision of adding a “Public Option” to coverage choices available on the Exchanges (A.K.A. “Marketplaces”). The inclusion of a Medicare-like policy for purchase on the Exchanges is not a new idea; it was part of the original ACA blueprint. (see also Hillary Clinton’s platform). Despite this, Democratic Party control of both the House and Senate may not equate with the successful passage of the Public Option. It was the combined forces of the insurance industry and the Democratic Party (a threatened filibuster by former Senator Joseph Lieberman, specifically) that killed the Public Option in 2009.
Other key Biden proposals related to the ACA, such as reducing the age for Medicare eligibility to 60 and increasing the subsidies to purchase insurance on the exchanges, may require Executive Orders to bypass the closely divided Senate.
Where is The Big Flash of “New”?
“Exciting” and “revolutionary” are highly unlikely in these first six months of the Biden Presidency. Partly that is due to the attention necessary to end the COVID-19 pandemic, but more so because we have a 50-50 split in the Senate. With a majority in name only (i.e., the tie-breaking vote of Vice President Harris), progress will require consensus across the aisle and within the Democratic Party.
The path forward for Congress is following the bright line down the middle of the road.
[a shorter version of this piece appeared as a blog for the American College of Healthcare Executives [ACHE] on Wednesday.
Want to know more?
1. The Kaiser Family Foundation has a list of fifty actions President Biden could take to reverse changes affecting health care without Congressional support. As the annotated chart explains, these actions can all happen through Executive Order or regulatory changes by CMS and other Executive Branch agencies (the resource was published in December, when it was widely believed the GOP would retain leadership of the Senate). Now that the Democratic Party is in control (counting Vice President Harris’s tie-breaking vote), these actions are even more likely. The KFF article is available here.
2. Interest in a Medicare-type insurance policy available for purchase by people regardless of age (i.e., a “Public Option”) is under consideration in several states, including Washington, Colorado, New Mexico, Connecticut, Delaware, Illinois, Massachusetts, Minnesota, Nevada, and Oregon. For more (including an excellent interactive map) see Modern Healthcare’s June 2020 article here.