When millions of people lost their jobs this spring, many of them could turn to the law’s insurance marketplaces, where they could purchase coverage with the help of premium tax subsidies created by the law. Others qualified for Medicaid in the states that have chosen to expand the program through the law. The Affordable Care Act created a new safety net, and it was there for people in a crisis.
But not for everybody. The law is flawed, and it has been weakened by Republican obstruction. More than 2 million people remain uninsured because the state they live in has refused Medicaid expansion. Some people who lost their jobs in the coronavirus crisis won’t be eligible for health benefits because of it. The Trump administration refused to reopen Obamacare enrollment in the spring, leaving the uninsured with no options in the middle of the worst infectious disease outbreak in a century.
The ACA had brought the uninsured rate to historic lows by the end of the Obama presidency — but the US still had a much higher share of people without basic medical coverage than any other developed economy. Then Donald Trump entered the White House, tried to repeal the law completely, and, when he failed, weakened it through administrative action. Then the coronavirus pandemic hit, with a damaged safety net capable of partially, but not totally, protecting Americans from the worst economic crisis since the 1930s.
US health care has demonstrably improved since Joe Biden last co-headlined a Democratic National Convention in 2012. But the ACA’s aspirations — to make health care coverage a right — have not been fully realized. There is still work to be done.
If Biden beats Trump in the November election and becomes president in January 2021, he will be charged with finishing the project of universal health care started under President Obama. He will likely assume office in the right moment to make big changes — not unlike when he was sworn in as vice president in 2009.
The question will be whether he has the will and opportunity to do it.
How Joe Biden’s health care plan builds on Obamacare
Obamacare’s successes are self-evident. The US cut its uninsured rate roughly in half, from about 16 percent in 2010 when the law was passed to about 8 percent when Obama and Biden left office, according to Census Bureau data. About 11.4 million people enrolled in coverage through the law’s marketplaces for 2020, the vast majority of them eligible for the tax subsidies created by the law, and 12.5 million people qualified for Medicaid expansion in the nearly 40 states that extended eligibility to childless adults with incomes near or below the federal poverty level. Several million more young people under age 26 have been able to stay on their parents’ health insurance under the law.
The ACA’s political resilience is best attested by the failures of Trump and congressional Republicans to repeal it in 2017. The rules that banned insurers from discriminating against people with preexisting conditions and required plans to cover certain essential health benefits like prescription drugs, maternity care, and mental health treatment proved to be too popular to undo. So was the requirement that insurers cover preventive services, including birth control, at no cost. Cutting Medicaid was indefensible with millions more Americans relying on its benefits.
But Obamacare has not delivered universal health care in America. Medicaid remains only partially expanded; 12 states are still holding out because of Republican opposition to the law. Many people signing up for ACA marketplace plans still have significant deductibles, which means they could end up paying thousands of dollars out of pocket every year on health care. For many of the Americans who make too much money to qualify for the ACA’s tax credits, premiums are unaffordable. The US uninsured rate ticked up to 8.5 percent in 2017, the last year for which census data is available, meaning 27.5 million people still don’t have coverage.
Biden’s health care agenda is very intentionally designed to patch up those holes. The law’s underlying structure is sound, he argues, and it established the foundation for more reform.
“The quickest, fastest way to do it is build on Obamacare,” Biden said at the first debate of the Democratic Party, back in June 2019. “To build on what we did.”
He would create a new government insurance plan to be sold on the ACA markets. The 2 million or so people currently stuck in the Medicaid expansion gap would be automatically enrolled, for free. Obamacare’s tax credits would be enhanced, pegged to more generous insurance, and eligibility for government assistance would be available to anybody. Nobody would pay more than 8.5 percent of their income on insurance premiums.
Obamacare was supposed to help sever the link between health insurance and work, making it easier for people to change jobs or start their own business because they could buy insurance on the marketplace. There are anecdotes of people taking advantage of that opportunity, but restrictions written into the law on who qualified for coverage and financial assistance slowed down any large-scale shift. Biden’s public option would be available to the 150 million people who get insurance from their job, potentially opening the door for millions of Americans to join a government health program of their own volition, another step toward realizing the law’s vision.
“Extending a public option and premium subsidies to people with employer coverage is possibly the most powerful and underappreciated part of Biden’s plan,” Larry Levitt, executive vice president at the Kaiser Family Foundation, told me. “The largest number of Americans get their health insurance through an employer, and this starts to address their affordability concerns in a way the ACA never has.”
Biden could also reverse the administrative actions taken by Trump — cutting outreach programs, loosening regulations where possible — that have undermined the ACA and likely contributed to the recent uptick in the uninsured rate.
His plan still wouldn’t quite achieve universal coverage, by the Biden campaign’s own admission. Undocumented people living in the US would be left out, for starters, and some people who likely find health insurance to still be unaffordable. But the campaign estimates 97 percent of Americans would have health insurance under those reforms.
In the primary campaign, that would have been an opening for attack; Sen. Bernie Sanders (I-VT) repeated over and over again during the campaign that his single-payer Medicare-for-all plan would cover every single person and almost completely eliminate out-of-pocket costs. Biden’s plan fell short of those maximalist ambitions.
But now we’re heading into the general election, where the alternative is Donald Trump, whose Justice Department is suing to overturn Obamacare entirely. It felt like an important moment for party unity when Sanders, in his remarks on the Democratic National Convention’s opening night, extended some warm words for Biden’s health care plan.
“As you know, we are the only industrialized nation not to guarantee health care for all people,” Sanders said. “While Joe and I disagree on the best path to get universal coverage, he has a plan that will greatly expand health care and cut the cost of prescription drugs.”
Democrats want to run on health care in 2020. Midway through the second hour of the party convention’s second night, actor Jeff Bridges narrated an extended video on Biden’s commitment to health care. The nominee himself spoke via video call with several patients about their medical experiences.
ALS activist Ady Barkan, an outspoken advocate for single-payer health care, punctuated the primetime package.
“We must elect Joe Biden,” Barkan said, through a computer because the disease has taken his natural voice. “Each of us must be a hero for the community. For our country. And then with the compassionate and intelligent president, we must act together and put on his desk a bill that guarantees us all the health care we deserve.”
Biden will have to prioritize health care — and he’ll need Democratic majorities in Congress
Biden’s promise, the contrast he drew with Sanders in the final days of the Democratic primary campaign, was he could get a health care reform bill passed through Congress.
“We can do that now. I can get that passed. I can get that done, if I’m president of the United States of America,” he said at the last primary debate in March, facing Sanders one on one. “That will be a fundamental change, and it happens now.”
January 2021, after a year of unprecedented turmoil from compounding medical and economic crises, would provide an opportunity for a President Biden to pursue aggressive reforms. As Vox’s Ella Nilsen reported, the Biden campaign has concluded that a return to normal is no longer sufficient after the Covid-19 pandemic. A sweeping agenda is needed in this moment.
The evolving politics of health care could make the public more receptive to new reforms. This summer, voters in Republican-led states like Missouri and Oklahoma have elected to expand Medicaid coverage through the ACA. The law’s net approval rating (+15 in the latest Kaiser Family Foundation poll) is near its all-time high.
“Many of the biggest coverage expansions both in the US and in similar countries happened in the context of wars and social upheavals, as well as financial crises. One theory is that those circumstances redefine social solidarity, thus expanding views of the role of government,” Cynthia Cox, director of the Peterson-Kaiser Health System Tracker, told me earlier this year. “I think one factor that will determine the permanency of these changes is how long this disruption continues. The longer this goes on, the more likely this social solidarity becomes ingrained.”
This has been a consistent finding in social science for decades. Jacob Hacker, a Yale University political scientist, and his colleagues found this to be true in research they conducted after the Great Recession. Personal experiences with economic insecurity during that crisis led to a shift in policy attitudes of a magnitude that they said “rivals partisanship and ideology.” People who experienced more profound personal shocks ended up supporting a bigger government role in mitigating their economic risks.
As Hacker put it: “The middle and working classes lose their lives, the rich and business at least have to lose their money.”
But even if Biden is thinking bigger now, he’ll need a Democratic Congress to pass most of his health care agenda. Democrats would have to hold on to the House and flip at least three Republican-held Senate seats to take control of that chamber.
And that’s when the really difficult work would commence.
As president, Biden and congressional Democrats would first have to decide whether to eliminate the Senate filibuster or try to pass a health care bill through the self-limiting process of budget reconciliation. As Vox’s Ezra Klein reported a year ago, after interviews with influential Senate Democrats, that is far from a settled question within the caucus.
Then the party would have to agree on the legislation itself. As the Hill reported recently, the existing disagreements could lead to Democrats starting small on health care reform — even leaving out Biden’s public option at first and sticking strictly to some smaller improvements to the ACA. Key Senate Democrats sounded on board with an expansion of Medicare eligibility and a public option in their interviews with Klein, but there are a lot of details still to be worked. out. And anything short of a significant expansion of public health insurance would surely be a tough sell for progressive Democrats who already believe Biden’s plan doesn’t do enough.
This is where Biden’s self-professed prowess as a congressional dealmaker would come into play. He would have to decide how hard to push.
But it all starts with Biden beating Trump in November, to give himself the opportunity to build on the Obama-Biden administration’s health care legacy.
“What happens in November?” Hacker said. “The answer to that question is going to influence what’s possible in terms of large-scale health policy changes as much as anything else.”
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