Health Policy Journal Club, January 2020
Biden’s Health Care Plans

 

Readings

Biden's plans for health care 

1. Biden's health care plans as described on his campaign website and the Biden-Sanders Unity Task Force for Health Care Recommendations.
2. Keith K. What Biden's election would mean for the Affordable Care Act. Health Affairs blog. November 5, 2020. 
3. Wynne B, Zatorski D, Cowey T, Llamas A, LaRosa J, Testa L. What's next for health care policy under a Biden Administration. California Health Care Foundation Issue Brief. 

Biden's plans to combat the COVID-19 pandemic

1. The Biden plan to combat coronavirus (COVID-19) pandemic and prepare for future global health threats and summarized 7 point plan as described on his campaign website. 
2. Members of President-elect Biden's coronavirus task force. Associated Press. November 9, 2020.
3. Biden lays out plan to combat covid in first 100 days, including requiring masks on interstate buses, trains. December 8, 2020. The Washington Post.

Key takeaways from the readings

 

President-elect Biden plans to protect and build on the Affordable Care Act.

 

One of President-elect Biden’s primary health care aims is to give every American affordable access to health insurance. Expansion of health care coverage would be achieved through a few strategies (Biden’s campaign website, Biden-Sanders Unity Task Force):

• Establish a public insurance option like Medicare that includes coverage of primary care without copays.
  • Grant premium-free access to the public option for those who are Medicaid-eligible. 
  • Automatically enroll eligible individuals in the public option through programs like SNAP. 
• Increase the value of tax credits to decrease premiums and extend coverage.
  • Eliminate the income cap on tax credit eligibility (currently 400% of the federal poverty level).
  • Lower the limit on cost of coverage from 9.8% to 8.5% of income.
  • Calculate the size of tax credits based on a gold rather than silver plan.
• Lower the Medicare eligibility age to 60.

Several changes made during the Trump Administration weakened the ACA and will likely be targets of early executive action. Reversals of such policies may include (Keith, 2020):

• Roll back access to short term, limited duration plans
• Extend open enrollment period back to 90 days
• Undo other changes in the ‘market stabilization’ rule
• Promote access to and increase funding for non-profit navigators
• Curb state options for selecting a new essential health benefits package
• Address broad exemptions to the contraceptive mandate
• Revise rules on Section 1557 to provider conscience protections
• Eliminate “double billing rule” for abortion services
• Roll back prior guidance on Section 1332 waivers
• Reverse premium adjustment percentage methodology

 

Biden’s health care agenda would be funded by getting rid of capital gains tax loopholes and rolling back Trump tax cuts for the very wealthy (those with over $400,000 annual income).

 

Comments from discussion participants:

• Biden’s campaign is one of restoration and filling the gaps of the ACA not looking to build new things. What about opening up to innovative change from a whole person/whole health perspective that uses an infrastructure grounded in communities for better success?  

 

Additional health care priorities for the Biden Administration include controlling health care costs, addressing health inequities, and achieving mental health parity.

 

In addition to ensuring access to health insurance coverage for all Americans, Biden’s campaign website lists several other aims related to health care: 

• Provide the peace of mind of affordable, quality health care and a less complex healthcare system.
  • Stop surprise billing (no out of network rates in situations where a patient does not have control over who they see).
  • Tackle market consolidation with antitrust authority.
  • Partner with the healthcare workforce to accelerate testing and deployment of innovative solutions.
• Stand up to abuse of power by prescription drug corporations.
  • Repeal the prohibition on Medicare negotiating prices with drug companies.
  • Limit launch prices for drugs that do not have competition by establishing an independent review board to use external reference pricing (if released in other countries already) or their own evaluation.
  • Limit price increases for brand and biotech drugs to no more than inflation in Medicare and the public option.
  • Allow consumers to buy prescription drugs from other countries.
  • End tax breaks for advertising by pharmaceutical companies.
  • Improve the supply of quality generics.
• Ensure health care is a right for all, not just a privilege for a few.
  • Expand access to contraception and protect the constitutional right to an abortion (including coverage in the public option).
    • Repeal the Hyde Amendment.
    • Codify Roe v. Wade and try to stop state laws against abortion.
    • Restore federal funding for Planned Parenthood.
    • Re-rescind the Mexico City Policy (global gag rule) barring support to global health programs if they also offer information on abortion services.
  • Decrease the unacceptably high maternal mortality rate, especially for people of color. They cite a successful strategy created in California that mitigated the disparity; expand it nationwide.
  • Defend health care protections for all regardless of gender, gender identity, and sexual orientation.
  • Double investment in community health centers.
  • Achieve mental health parity and expand access to mental health care by ensuring enforcement of parity laws and expanding funding for services.

 

Comments from discussion participants:

• There is limited discussion of child health. Child health receives less attention because Medicaid is smaller than Medicare, and within Medicaid children account for less of the health care spending than adults. The White House could consider convening the next conference on child health – this was last held in 1929 and resulted in the creation of the Maternal and Child Health Bureau.)
• The Mental Health Parity and Addiction Act of 2008 made mental health parity the law; this was reinforced in the ACA. However, it lacks the infrastructure or teeth necessary for enforcement.

 

Lack of a Senate supermajority may lead to more action at the regulatory rather than legislative, and state rather than federal, levels.

 

The Senate requires a supermajority of 60 votes to end a filibuster and vote on final passage of a bill. Pathways to achieve Biden’s health care agenda without a supermajority include (Wynne et al.):

• Budget reconciliation
• Executive orders
• Regulatory actions

 

Budget reconciliation can be used to pass legislation related to spending, revenue or debt limits and only requires a simple majority. The Byrd Rule mandates that this legislation cannot include “extraneous matters.”

 

The California Health Care Foundation Issue Brief includes a table that reviews the specific regulatory and legislative pathways to achieve different aspects of the Biden health care agenda. Select examples are included below:

• Bolstering the ACA: At the regulatory/executive level, the Biden Administration could make changes to enrollment periods and outreach. Legislation, on the other hand, would be required for the proposed changes to premium subsidies.
• Public option: The Biden Administration could develop guidance to support states in developing their own public option. Legislation would be required to implement a nationwide public option.
• Behavioral health: The Biden Administration could enforce existing mental health parity laws. Legislation would be required for additional federal funding to increase the mental health workforce.

 

Comments from discussion participants:

• Agencies will need rebuilding after the loss of many mid-level staff.

 

Biden has announced COVID-19 Advisory Board and other key nominees and a plan for responding to COVID-19 within the first 100 days of his presidency.

 

Biden’s COVID-19 Advisory Board has three co-chairs (Associated Press):

• Dr. David Kessler, professor of pediatrics and epidemiology and biostatistics at the University of California, San Francisco (former head of FDA)
• Dr. Vivek Murthy, US Surgeon General from 2014-2017
• Dr. Marcella Nunez-Smith, associate professor of internal medicine, public health and management at Yale University

 

Dr. Nunez-Smith was subsequently selected to another role leading a health equity task force focused on the pandemic.  Dr. Murthy has also been nominated to again serve as Surgeon General.

 

Biden’s COVID-19 response goals for the first 100 days of his presidency include (Washington Post):

• Deliver 100 million vaccine shots
• Open most K-8 schools
• Ask all Americans to wear masks

 

While the Biden Administration would not have authority to mandate masks nationally other than on federal grounds and in interstate travel, it would work with state and local jurisdictions to support mask mandates across the country.

 

Comments from discussion participants:

• The advisory board appointees are notable in that they are scientists, not politicians, and not family members of the President.
• The advisory board initially lacked someone with rural health experience, later a public health professional from the Navajo Nation was added. 20% of Americans live in rural areas.