What the Democrats hope to do on healthcare now

U.S. President Joe Biden signs an executive order as part of his administration’s plans to fight the coronavirus disease (COVID-19) pandemic during a COVID-19 response…
U.S. President Joe Biden signs an executive order as part of his administration’s plans to fight the coronavirus disease (COVID-19) pandemic during a COVID-19 response…
Image: Reuters/Jonathan Ernst
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Less than three days in office and US president Joe Biden has taken more executive actions than his three predecessors combined did in their first weeks. As the Covid-19 crisis would warrant, many of them have to do with tackling the pandemic and strengthening healthcare.

From requiring people to wear masks and observe social distancing on federal property to rejoining the World Health Organization, to reestablishing a team in charge of pandemic response within the National Security Council, the president’s actions reflect his campaign promise to address the healthcare crisis head-on.

But that’s only the beginning of the healthcare ambitions for Biden and Democrats in Congress. Although Democrats were able to pass the most significant healthcare policy reform in decades with 2010’s Affordable Care Act, plans to improve on it and further expand access to healthcare have been blocked by Republicans in Congress. While the attempts to repeal and replace Obamacare were ultimately unsuccessful, the focus of the outgoing administration has been on substantially reducing its impact.

Now, Democrats once again get a chance to build on existing Obamacare provisions, and even if their majority is narrow and sweeping reform has little chance to get the 60 votes it requires in the Senate, they are still in a position to get a few things done.

The Covid-19 train leaving the station

When a train is leaving the station you’d better get on it, goes Capitol Hill’s wisdom, because there’s no knowing when the next one will go by. Covid-19 response is the healthcare train of the Biden administration—and it’s going to move quickly.

This means that Democrats interested in specific healthcare reform will try to take this opportunity to tack as much of it as possible onto Covid-19 provisions. While the bigger proposals already put forth by Biden, such as the $1,400 stimulus check to Americans, will likely take up much of the attention and debate, there are smaller yet important measures that could get passed as apart of the Covid-19 legislation. Two are especially urgent:

COBRA subsidies. It has become very clear in the past year that linking health care to employment is not particularly smart public policy, as the job losses stemming from pandemic have resulted in the loss of healthcare coverage for many in the middle of a protracted medical emergency. To help employees who have been laid off, the president will propose a 100% tax credit for premiums paid toward COBRA, a program that allows former employees to stay on their  employer-sponsored health care policies, until Sept. 30, 2021.

Expanded Affordable Care Act tax credits. According to the proposal, those who get their insurance through the Affordable Care Act marketplace will receive a higher take credit for doing so than they currently do, ensuring they don’t spend more than 8.5% (it is currently 9.86%) of their income on health insurance. The existing tax credit would also be expanded to those who earn more than 400% of the federal poverty line, which is the current cap.

Beyond these big-ticket items, there are a few other changes that might get less attention but could greatly improve healthcare services in specific areas.

Expand access to mental health and substance abuse treatment. The pandemic has caused a mental health crisis, as well as increased substance abuse and overdoses. Mental health services, which have lower reimbursement rates than other healthcare provisions, and therefore generate less revenue for healthcare providers, are bound to be further cut as hospitals deal with revenue losses. To help, the administration is proposing to appropriate $4 billion to expand access to them.

Better support for victims of domestic violence. The Biden administration has proposed $800 million funding to programs dealing with domestic violence, a crisis exacerbated by stay-at-home recommendations.

Additional funding for veteran healthcare. An additional $20 billion would be added to the budget for the health care needs of veterans through the pandemic.

Increased investment in Native American health. Ethnic minorities have faced the highest Covid-19 toll, and Native Americans, as with other healthcare crises, have been disproportionately affected. The administration has pledged to request higher funding for Indian Health Services, as well as to strengthen community healthcare, which is essential for underserved communities.

Beyond the emergency

While the Biden administration has clearly signaled it will be laser-focused on Covid-19, there will still be openings for healthcare policy that isn’t dealing with the emergency.

Big progressive changes in healthcare coverage might be hard to pass—after all, while the president is elected for four years, but the current, and very slim, Democratic Senate majority might be gone in two. Still, here is what might have a chance:

The public option. Biden is no fan of Medicare for All, but he has pledged to create a public insurance option, which would give anyone who wishes it the option of buying into a government-managed health insurance with lower premiums but a high level of coverage. Exactly what that option looks like will be grounds of negotiation. For progressives, it’s important that it be modeled after Medicare, and not after private insurance, to make it more affordable. Their hope is that offering such a choice would lead a larger number of policyholders to buy into the public option, which with time would get the country closer to a de-facto Medicare for All.

Expanded Medicare eligibility. Medicare expansion, too, is on the cards. Biden has promised to lower the eligibility age to 60, down from the current 65, and there is even a push to move it to 55. This is a policy change that might get support beyond the Democratic party, as representatives of many states have seen the impact of Covid-19 on the older population and are probably keen to bring in federal relief for their medical expenses.

Get rid of the patchwork. A bit of tidying up might be in order, too. Currently, government-funded healthcare coverage includes many separate pieces, which could somewhat easily be brought together under one plan. The Children Health Insurance Program (CHIP), could be replaced with so-called MediKids, which would essentially be low-cost, federal health care for young people, with no income threshold. Including all kids and lowering the eligibility age for seniors to 60 would add a large number of healthy people to Medicare’s risk pool without proportionate costs increases since it would dilute the percentage of policy holders with serious medical issues. Medicare could also be expanded to include dental and vision care.

The bi-partisan favorite

But these proposals will struggle to find support from more than a few Republicans. A policy likely to do so, however, is one that would cut drug costs.

Lowering drug prices could be done through executive action, although there is bipartisan support for the measure. There are essentially no budget costs associated with keeping drug prices under control—it’s a money saver, and would put billions in the economy without requiring investments from the government.

Until now, the opposition has been ideological. Measures to reduce drug costs are naturally opposed by pharmaceutical companies that have lobbied hard to promote the message that such interventions would impact research and development. But in the past years, increased public outrage towards price gauging has moved the needle.

Support for cutting drug prices has traditionally been a Democratic issue, but some Republicans have warmed up to the idea, particularly in light of the country’s approval of former president Donald Trump’s efforts in that direction. In October, Trump signed an executive order to use international drug pricing as a benchmark for US prices. The order, however, had limited scope, as it only applied to drugs administered in hospitals or in doctors’ offices, and not those bought from pharmacies. Advocates are seeking further intervention from Biden, including imposing pricing limitations on drugs developed with government investments, and requiring pharmaceutical companies to license their patents for a list of essential drugs to be made as generics.