Americans can expect major changes to the nation’s approach toward healthcare following President-elect Joe Biden’s inauguration on January 20. The enactment of those changes, however, is dependent on the balance of power in the Senate, which will be decided by the Georgia runoff elections in January. The Biden administration has extensive plans for scaling up the Affordable Care Act (ACA)—much of which stands in stark contrast to the Trump administration’s approach. “I would say they’re kind of polar opposites,” says Ann Keller, an associate professor of health policy and management at the University of California, Berkeley. “Biden clearly believes in the Affordable Care Act and would like to strengthen it and close gaps within it, while Trump wants to repeal and potentially replace it.”

Biden’s plan for tackling the pandemic is equally at odds with Trump’s actions over the past eight months. “First and foremost, President Biden will put forward a national strategy and empower the top health agencies and support the top health scientists in his administration, which is absolutely critical in the worst pandemic we’ve had in a century,” says Howard Koh, a physician and professor of public health at Harvard University and the former assistant secretary for health for the Obama administration. “Until now, we’ve had 50 states going in 50 different directions.” 

What Biden will actually be able to accomplish at the outset of his presidency will depend on a number of factors, though, including whether the Democrats gain control of the Senate, how the Supreme Court rules on the latest challenge to the Affordable Care Act and the state of the pandemic when Biden takes office. Here’s what we might expect to see.

COVID-19 response overhaul

Getting a handle on the COVID-19 pandemic will no doubt take center stage as soon as Biden is sworn in. The president-elect has already announced an expert team of scientists, epidemiologists and doctors as his COVID-19 advisory board. Public communication about the pandemic will drastically change, too, becoming more frequent and consistent. “We don’t even hear from the current White House coronavirus task force anymore, and right now, we’re breaking records in terms of daily cases and hospitalizations,” Koh says. “Biden getting guidance out and showing there’s a one-government approach will be very important for the public and also for health professionals and physicians.”

For starters, the Biden administration will demonstrate a united federal front about the importance of wearing masks. The new president will probably stop short of issuing a national mask mandate, however, because of potential legal challenges as well as the fact that “we’ve got a split country, and a lot of people would fight this,” says Stuart Altman, a professor of national health policy at Brandeis University. But Biden may start requiring all military and federal employees to wear masks.

Another likely potential action is leveraging the Defense Production Act to release more federal resources to ensure that hospitals around the country have enough PPE, ventilators and beds. Support for long-term contact tracing will be included as well, and the people hired to carry it out could form the basis of a new public health job corps that Biden has called for.

Biden may also choose to release federal funds to schools to enact measures to keep teachers and students safe—for example, by renting new buildings and hiring more instructors to spread pupils out. This would be doubly beneficial in that it would free up parents to go back to work. “State economies are contracting, so there’s less budget to throw at this problem,” Keller says. “Absent federal dollars to support such an effort, I can’t imagine that happening.”  

Vaccines will be another major focus. Mixed messaging about the testing and development process has eroded trust and confidence in the safety and efficacy of a future vaccine. “A lot of people are uncertain about the vaccine process with Trump, because they feel like it was being rushed,” says Paul Shafer, an assistant professor of health law, policy and management at Boston University. Consistent, accurate and honest communication from the Biden administration could help undo that. Putting the infrastructure in place to distribute a vaccine will also be a major undertaking that the administration will likely immediately start planning for, although some critics have pointed out that Biden’s currently named coronavirus task force is short on logistics experts. “That will be a significant area that will need attention and focus if you really want to have this distributed on a pretty big scale quickly,” says Gail Wilensky, an economist and senior fellow at Project Hope, an international health foundation, and the former director for Medicare and Medicaid under George H.W. Bush.

Finally, Biden will also reposition the U.S. as a global leader in the fight against the pandemic. He has announced that the U.S. will immediately rejoin the World Health Organization (WHO) and cooperate in the COVAX initiative, a global effort that aims to distribute 2 billion COVID-19 vaccine doses by the end of 2021. As Koh says, “If we just focus on the U.S. and not the rest of the world, that will assure us that this disease occurs over and over again.”  

ACA reform

Ultimately, the Biden administration’s goal is to make healthcare coverage as universal as possible, but “in terms of big-picture policy changes, there’s probably not a lot that’s going to happen right away,” Shafer says. That’s because new legislation takes time, and also because the pandemic will be taking up the administration’s bandwidth. Biden has articulated a few priorities, though, and these will likely be the things he pushes for in his early days in office.

Executive orders are one tool Biden will probably use to quickly launch into action on rebuilding certain aspects of the ACA. Primarily, this will entail reversing executive orders and rules that the Trump administration put in place, examples of which include extending the amount of time a person could be on a short-term limited-duration healthcare plan and decreasing funding for jobs and resources to help people navigate the healthcare marketplace. As Wilensky puts it, “What can be done with an executive order can be undone with an executive order.”

From the get-go, the Biden administration will also “bring back a lot of the old guard from the Obama administration” for top positions in health-related agencies, Shafer says. At the same time, they will probably step up advertising, outreach and enrollment assistance to get as many people signed up for healthcare coverage as possible.

Other leading Biden priorities will require congressional approval, though, including the creation of a public option to enable more Americans to access health insurance. “Basically, this would allow a segment of the population to buy a plan that is administered by the government itself,” Altman says. This would be quite a boon for the 27.5 million Americans who were uninsured as of 2018—a number that has surely gone up since the pandemic, especially in the 12 states that have not expanded Medicaid under the Affordable Care Act.

Other Biden priorities include creating new tax incentives that make health insurance more affordable, lowering the age of Medicare eligibility to 60 and reducing prescription drug prices by allowing Medicare to negotiate with pharmaceutical companies. Biden has additionally expressed interest in examining antitrust issues related to regions in which a single hospital or company has a monopoly and in tackling the issue of surprise billing for out-of-network services.  

It’s very difficult, though, to predict how far Biden will get on any of these goals in his first 100 days—or even in his entire presidency—if the Senate remains in Republican control. “What happens in the Senate, I just can’t emphasize how key that is,” Wilensky says. Although Biden and majority leader Mitch McConnell have cooperated at times in the past, the goodwill may no longer apply when Biden is president rather than a fellow senator. While it’s possible that Biden could persuade some moderate Republicans to break rank and support certain legislation, “McConnell has tended to rule the Senate with an iron fist, so that dissent seems unlikely,” Keller says. “Without Democrats in control of the Senate, I think Biden’s healthcare reform goals have a vanishingly small chance of being passed.”  

If the Democrats do take the Senate, though, then Biden can quickly get to work drafting and approving new legislation for stepping up the Affordable Care Act and more. As Koh says, “I’m really hoping that there’s going to be a national commitment to revitalizing and rebuilding public health at the federal, state and local level.”

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