WASHINGTON — President Joe Biden campaigned on a promise not to revolutionize the health care system, but to build on “Obamacare” through quiet, incremental change.
Tucked away in his $1.9 trillion coronavirus relief bill, which the House passed Wednesday and Biden is expected to sign Friday, is the first test of that strategy.
The massive spending package includes the largest expansion of access to health care since the Affordable Care Act became law 11 years ago. Yet the provision barely received mention from the White House in its push to get the bill passed through Congress. The .
That may become a signature tactic from the Biden administration on health care, focusing on low-profile advancements of the 2010 law that can achieve consensus among Democrats and be absorbed within larger bills, health care experts and allies of the president say.
It is a stark departure from the approach of previous presidents who have staked significant political capital on reimagining America’s health care system — often at great cost to their party in future elections.
Biden’s message during the 2020 presidential campaign was to build on — but not replace — the Affordable Care Act, signed into law by former President Barack Obama when Biden was vice president. His pledge stood in contrast of rivals who wanted to largely do away with private insurance.
Biden’s more subtle attempts to change health care policy carry big political implications, both for his relationship with his party’s restless left flank and the 2022 midterm elections.
Former presidents including Donald Trump, Bill Clinton and Obama have undertaken massive health care reform during their first two years in office. Only one, Obama, succeeded in having his bill passed into law, but each of them had heavy losses in their party’s subsequent midterm elections.
Biden has now included a provision in the American Rescue Plan that increases federal spending on subsidies for Americans purchasing coverage on the exchanges by nearly 30% — significant new funding that the nonpartisan Congressional Budget Office says will make it cheaper for some Americans buying health insurance on their own to afford it.
The health care provisions fit in the COVID-19 relief legislation, Democrats say. Individuals who pay for their own health insurance are typically between jobs, self-employed, or working at small businesses that don’t offer health coverage, and they have been disproportionately impacted by the pandemic economy.
Biden’s tactic — to bury the provision in larger legislation, which itself is being passed along party lines through budget reconciliation — may become standard practice for future health care initiatives.
Health care experts in touch with the Biden administration say they believe his next move will be to make the subsidies permanent in legislation later this year, leading to a likely contentious debate.
“I’ve heard it referred to as Reconciliation 2.0 later this year. It’s entirely possible that some of this might be packaged with, say, something on climate change. And one of those conversations might derail the other,” said Cynthia Cox, vice president at the Kaiser Family Foundation and director of its program on the Affordable Care Act.
“That’s the plan at this stage, but it’s entirely possible there will be deadlock about one issue or another, in a second attempt to implement Biden’s agenda, with less agreement among Democrats when we get there,” she said.
Biden pledged during the campaign to let individuals buy into a so-called public option, a government-backed insurance plan that anyone could access even if they weren’t enrolled in insurance exchanges. He also said he wanted to lower the eligibility age for Medicare from 65 to 60.
Republicans are unlikely to support a move to make the new subsidies permanent when they are already criticizing the current proposal for its cost burden on taxpayers. A Congressional Budget Office estimate found that the federal spending increase on subsidies included in the American Rescue Plan would cost $34.2 billion through the end of 2022.
Some progressive Democrats are expected to focus on the overall cost of health care, and Biden’s campaign call for a public option.
“If you’re going to make those premium subsidies permanent, then there’s probably going to be a need for Democrats to come up with a way to pay for it,” Cox said, “and a public option, depending on how it’s structured, could actually save the federal government money, which might help pay for these additional subsidies.”
Big changes to health care policy can upset voters more than other issues, say political strategists, because of how personally it affects them.
“You’re not going to see tens of thousands at a protest chanting over a marginal tax rate change,” said Matt Gorman, a Republican strategist. “You will see thousands of people at a rally over health care. And the stories are far more resonant. They lend themselves to advertisements far better than almost any issue.”
Gorman was communications director for the National Republican Congressional Committee in 2018, when the party’s House candidates were heavily criticized for backing Trump’s plan to repeal the ACA. House Republicans lost their majority that year after a barrage of attacks from Democrats that they didn’t support protections for people with pre-existing medical conditions, one of the provisions included in Obamacare.
Efforts to expand insurance coverage have proven just as politically fraught. Democrats suffered a historic rebuke in the 1994 midterms after Clinton’s failed attempt to remake the health system, and did so again in 2010 even after the ACA became law. Democrats lost 63 House seats in the 2010 midterms and were wiped out in many state legislative races across the country.
“You could probably make a reasonable argument that because of the way the politics of Obamacare were handled, Democrats lost at least a decade, if not more, of opportunities around the states,” said Chris Carney, a former Democratic congressman from Pennsylvania who lost his re-election race in 2010.
Carney said he thought Biden was cognizant of the cost of those defeats and as a result was taking a more careful approach to the issue now.
Biden still faces calls to expend some political energy on a push to improve the health care system, not only to chip away at the number of uninsured Americans, but to address the rising costs of health care for those who do receive coverage from their employers.
“Most people have coverage, and we have an important job to finish that up and get everyone covered. But it’s really about what people are paying for health care that’s concerning people. That’s the main worry that people have,” said David Kendall, senior fellow for health and fiscal policy at Third Way, a center-left leaning think tank.
“That will be the big thing to watch in the second reconciliation package, and it’ll be a big policy story, because we don’t really know how all these pieces come together,” he said.
A failure to push for more structural changes to health care, including lowering the Medicare eligibility age or implementing a public option, would frustrate progressive leaders, after some criticized the relief bill as not doing enough to address the health care system during an ongoing health crisis.
“If I were to do a pop quiz with anybody and ask them, ‘Hey, what’s the Democratic plan to address this massive amount of health suffering out there?’ I don’t think you’d get an adequate answer from most people,” said Faiz Shakir, who managed Sanders’s 2020 presidential campaign. “They have not seen it. We have not heard it.”
Shakir said that the Biden White House is likely aware that larger changes to the health care system don’t have enough support in the Senate or House, where Democrats have slim majorities. But he said he was still frustrated the president has not taken the pandemic as an opportunity to at least talk about the need for expanded health care coverage.
It’s a gap he predicted many progressive candidates will eagerly fill when they begin running their own campaigns.
“There is going to be the lingering and obvious kind of fallout of an unmet challenge from COVID,” Shakir said. “I do expect that you’ll see the political landscape to once again shift, and lots of progressive candidates will be pushing for bold solutions to this one.”
