“The administration’s struggles to enact a broader reform agenda
reflects the daunting political restraints that limit U.S. health care policy.
Congress continues to be be riven by hyper partisanship”.
– Jonathan Oberlander, Ph. D, Department of Social Medicine,
University of North Carolina; (1)
Biden’s campaign promises:
1. expand coverage under ACA (Affordable Care Act, aka Obamacare)
2. control prescription drug prices
Accomplishments so far:
1. removed the barrier preventing legal immigrants from receiving Medicaid or CHIP (Children’s Health Insurance Program) health insurance benefits. (Executive Order February 2021)
2. withdrew federal waivers allowing some states to set work requirements for Medicaid enrollees. (EO)
3. revoked permission for some states to increase premiums for Medicaid enrollees.(EO)
4. reopened ACA health insurance marketplaces and created a special enrollment period for low income (below 150% federal poverty level) people. (EO)
5. secured Congressional enactment of the American Rescue Plan (ARPA) – (first ACA revision since 2010)
a. increased premium subsidy for low income people to purchase private health insurance.
b. extended premium subsidy to people with income above 400% of federal poverty level.
c. new financial incentives to states to expand their Medicaid coverage.
d. improved affordability of insurance for all low income people
e. expanded postpartum coverage from 60 days to 12 months for low income women.
1. lowering Medicare eligibility from 65 yrs. to 60 years.
2. enacting a new “public option” Medicare-like program as an alternative to purchasing private health insurance.
3. Build Back Better Act (BBBA) with 6 health care insurance provisions has been passed in the House and is stalled in the Senate by two Democrats. Provisions include:
a. increased premium subsidy for low income people to purchase private health insurance
b. extend premium subsidies for ACA,
c. add full premium marketplace subsidy in states that have not expanded Medicaid and make CHIP funding permanent,
d. add hearing services coverage to Medicare,
e. improve Medicare prescription drug coverage,
f. implement several policies to “slow the growth” of prescription drug prices.
“This important incremental progress in expanding access to affordable health insurance reflects the sobering reality that there has been no discernible movement toward universal coverage or comprehensive reform of our non-system.” (1)
“Meanwhile”, as Stephen Colbert says, as of March 2020 the ACA has resulted in:
1. expansion of health insurance to 20 million previously uninsured people (11.5 million through the health insurance marketplaces),
2. the outlawing of premium surcharge or outright denial for 135 million Americans with pre-existing conditions,
3. pumping of $135 billion (“B”) into state coffers of the 36 states willing to expand Medicaid,
4. prohibition of the 50% premium surcharge of private health insurance for women (known as “gender rating”),
5. reducing the Medicare “donut hole” of prescription drugs cost to Medicare participants by $20 billion (“B”),
6. and allowing disabled people to return to work without losing their Medicaid health benefits.
This expansion of health insurance benefits is financed in part by an estimated tax levy of $46,000 on millionaires.
We have clearly had “hyper partisanship” before: President Truman vs. General MacArthur , Senator McCarthy vs U.S. Army and Joseph Welch (“At long last have you no sense of decency”), and President Lincoln vs. the South , etc.. Those past periods also had strong forces against “changing a profitable status quo”, but this time it is within the context of close to 1,000,000 American deaths from the pandemic. “Some analysts previously speculated that it would take a crisis for the U.S. to embrace universal health insurance; that crisis is here, but major reform is not.” (1)
An apparent consequence of our current hyper partisanship is a growth of “government by executive order“. President Trump issued a total of 894 executive actions, of which 220 were Executive Orders (EOs) during his one term (519 other actions were “presidential proclamations” as in presidential memos, presidential notices, presidential determinations, etc.), George W. Bush issued 290 EOs in 8 years, Obama 275 EOs in 8 years, and Biden has issued 87 EOs in one year.
Sen. Charles E. Grassley (R-Iowa), one of the most vocal opponents of the ACA law, said this week that Republicans will not try to repeal the Affordable Care Act if they retake the Senate in November’s midterm elections. “Chuck Grassley has voted to roll it back TWELVE times — and even voted to take away coverage for folks with pre-existing conditions. This could be the latest signal that the GOP is abandoning its long-running effort to scrap the health-care law also known as Obamacare which is viewed favorably by 55 percent of Americans”.
1. Health Care Reform Under the Biden Administration, NEJM 386;19, May 12, 2022