Biden presses to expand health insurance on uncertain congressional terrain

Biden spoke Tuesday afternoon about his aspirations to “work quickly with the Congress to dramatically ramp up health care protections, get Americans universal coverage, lower health care costs as soon as humanly possible.”

Standing in front of a blue backdrop with white letters saying, “Protect and build on the Affordable Care Act,” the president-elect vowed without details, “We’re going to build a health care system that puts you and your families first and that every American can be proud of.”

Yet with the Senate majority in limbo until a pair of Georgia runoff elections in January, a Biden campaign official acknowledged, “I’m not going to sit here and say it’s not going to be a whole lot harder to get it done if the Republicans win those seats.” But the official, speaking on the condition of anonymity because the person was not authorized to discuss internal strategy publicly, said the president-elect has shown in the past that he “is quite adept at going to the Hill and getting the votes he needed.”

According to several longtime health policy experts, including ones close to Biden’s team, the most politically divisive part of the president-elect’s health-care plan is his goal to offer a public alternative alongside the private health plans sold through the ACA’s insurance marketplaces for people who cannot get affordable coverage through their jobs.

Even if Democrats were to eke out control of the Senate to join the party’s House majority, creating such a new form of coverage would broaden the government’s involvement in insurance more than some Democratic lawmakers accepted when the ACA was created a decade ago. And it would almost certainly stoke widespread opposition from the health-care industry, the analysts noted.

“Public option, I think, becomes exceedingly difficult in this climate,” said Dan Mendelson, founder of Avalere, a health-care consulting firm, who worked on health-care budget issues in the Clinton White House.

Even if the new president faced a GOP Senate majority, the campaign official said, “I don’t think we would view [the] public option as off the table. We would view it more as a dial than a light switch.”

Such optimism reflects Biden’s portrayal of himself as a seasoned hand at bipartisanship from his eight years as President Barack Obama’s vice president and three dozen years as a senator, forging compromises at times with members of the opposing party. That optimism also minimizes the fervent Republican opposition to the ACA, including by President Trump, since the statute — expanding insurance coverage and altering large swaths of the health-care system — was pressed into law by a Democratic Congress in 2010.

Other parts of Biden’s health-care agenda would embroider on the ACA, too. The president-elect wants to expand federal subsidies for health plans bought in the insurance marketplaces to help more middle-class families. He also wants to change the rules for the maximum percentage of income families are required to pay in premiums for marketplace health plans — lowering it from nearly 10 percent to 8.5 percent. And his plan would provide such health plans to low-income people who would qualify for the law’s expansion of Medicaid except for people living in one of a dozen states that have balked at expanding the safety-net insurance program.

Another aspect of the Biden agenda would lower from 65 to 60 the age at which people could join Medicare, an idea Democrats have considered for years to help an age group in which unemployment runs high and insurance premiums tend to be expensive.

The president-elect’s eagerness to use the ACA as a basis for expanding affordable health coverage stands in contrast to Trump’s posture. The outgoing administration has taken many steps to weaken the law — such as slashing federal support to encourage people to buy ACA health plans and broadening access to skimpy health plans that do not contain all the benefits the law requires. The Trump administration also is siding with Republican attorneys general asking the Supreme Court to strike down the law.

More than 10 million Americans have private health plans through the ACA marketplaces, and about 12 million have gotten coverage through Medicaid’s expansion.

Outside health policy advisers suggest that Biden might consider adapting the idea of a public option to a more private-sector approach. They say it could be similar to Medicare Advantage, part of the vast federal insurance program for older Americans that operates through private health plans. The GOP has long favored the arrangement.

The campaign official said Biden’s team is not considering stepping away from his goals in such a way.

Mendelson said, “Once [Biden] is seated, there’s got to be a legislative agenda that is feasible and realistic, and works within in the context of the Senate he has, not the Senate he wanted.”

Senate Republicans — absorbing Trump’s loss of the presidential election — are not sounding hospitable to far-reaching Democratic health-care ideas.

“Depends on what it looks like,” said Sen. John Cornyn (Tex.), a senior Republican who just won reelection. “If it’s Medicare-for-all, I don’t think there’s much chance,” he said in an interview Monday, referring to a broader government role in health care than Biden favors.

Cornyn did not specifically address the president-elect’s plan, but said that if the Democrats end up barely in control of the Senate, with a 50-50 split among senators and a Democratic Vice President-elect Kamala D. Harris in a position to break ties, “we’re obviously going to have to work together to do things.” He added: “It’s probably going to be frustrating to the progressives, because they’re not going to be able to get everything they want.”

Even in a Senate barely in Democratic control, some of Biden’s health-care proposals might face impediments, outside experts said. Although Democrats tend to favor allowing more consumers to get federal insurance subsidies, “the Achilles’ heel for improving the subsidies is how to pay for it,” said Robert Laszewski, a longtime health-care adviser with clients across the industry.

Despite Biden’s pledge Tuesday to move quickly, it remains uncertain for now how soon congressional Democrats — or his administration, once it begins on Jan. 20 — will want to take up the health-care changes he espouses.

When Obama assumed office in 2009, with Biden as his vice president, he announced before a joint session of Congress in February that he would start collaborating with Capitol Hill on major health-care changes. Congressional Democrats began working within a few months on bills that evolved into the ACA.

During Biden’s campaign, his plan to enlarge upon the ACA was a major theme, and it placed him in contrast with primary opponents to his left, such as Sen. Bernie Sanders (I-Vt.), who favor sharper changes such as a single-payer health-care system. Improving the nation’s health care ranked as the top priority among voters in polling for much of the long campaign, until the issue was eclipsed by the novel coronavirus and the economic damage the pandemic has wrought.

Biden does not include health-care coverage among his four main priorities on his new transition website. In addition to covid-19, the disease caused by the virus, those priorities are economic recovery, racial equity and climate change.

The president-elect has made it clear that he regards efforts to control the pandemic as his first priority. On Monday, he named a coronavirus advisory board. And he has indicated that he may take an uncommonly active role as president-elect to nudge Congress to adopt another coronavirus relief package — the first since the spring — before the end of the year.

According to a senior House Democratic aide, speaking on the condition of anonymity to discuss internal deliberations, the timing of broader health-care proposals will depend on how much Congress accomplishes on pandemic legislation before this session ends. If lawmakers in the new Congress continue to wrangle early next year about how much help to provide to cope with the virus, the aide said, other priorities will be deferred — health system changes among them.

However, the campaign official said the pandemic, combined with the fact that the Supreme Court is hearing a third case seeking to overturn the ACA, “deepened President-elect Biden’s commitment to deliver on additional health-care reform. It only emboldened him to get it done.”

“Those two things align for a President Biden to execute on his health-care agenda. . . . It furthers public understanding of the importance of health insurance among the general public, which helps builds consensus.”

And in his remarks Tuesday, the president-elect expressed equanimity about the possibility Republicans will continue to dominate the Senate.

“I’m sworn in to be able to get things done,” Biden said. “I can’t imagine there not being a willingness on the part of Republicans. They’re going to be [under] significant pressure to deal with health care.”

Rachael Bade contributed to this report.