President-elect Joe Biden has an ambitious plan to build upon the Affordable Care Act, in effect evolving “Obamacare” into “Bidencare.”
But depending on the outcome of the two Georgia Senate run-offs, Biden either will face a Republican-controlled Senate or a tied Senate in which Vice President Kamala Harris can cast a tie-breaking vote. On some issues, the Democrats might pick up a few Republicans, and on others, they could lose a few votes from their side.
Any health proposals from the new administration will come amid a shadow of uncertainty from the latest GOP challenge to the ACA now before the Supreme Court. Oral arguments were on Nov. 10, and a ruling probably is at least several months away.
So even though Biden moved several degrees to the left on health care reform over the past few months, getting his plan enacted in Congress as-is will be unlikely. Even with a Democratic majority, the health industry lobbies would put up a fierce fight. But Biden does have the ability to reshape aspects of the ACA via executive actions. (We’ll look at that possibility in a future post.)
The president-elect’s health care plan during the campaign had three significant elements. First, Biden wanted to create a public option to compete with private insurance. This feature was included in the original ACA legislation back in 2009 but didn’t receive enough congressional support. Biden expanded the reach of his public option proposal after the primary season as he moved closer to the Medicare-for-all wing of the Democratic party, though never totally embracing that approach.
The public option, a federally run health plan that would compete with private insurers, would have solved the Medicaid gap problem created when the Supreme Court made Medicaid expansion optional for states in 2012. In other words, low-income people in states that did not expand Medicaid would be enrolled in the public option. They would finally be covered – and not have to pay any premiums if they were below the income threshold. Other states also could shift the Medicaid expansion population to the public option, as long as the states pay their current share.
The public option wouldn’t only be for Medicaid-eligible people. It would become the default coverage plan for people who lose their job (and their insurance) during the pandemic and beyond. It also would be an option for those who preferred the public option to the health insurance choices available at work or through the ACA.
“A Medicare-like public option would likely be substantially less expensive than current private insurance plans,” Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation, told NPR. “That’s because of the leverage the government would have to drive down the prices of doctor visits and hospital care.”
Biden’s second big plank was lowering the age of Medicare eligibility. This should not be confused with other proposals floated over the years to create a Medicare buy-in program. Biden would extend the current Medicare program to people starting at age 60, not age 65. It would be optional, so people who preferred other coverage through the ACA or an employer would not have to change. But it potentially could cover up to 23 million people in that 60-to-65 age bracket, Avalere estimated.
Biden has noted that older workers have been particularly vulnerable to job loss during the pandemic-driven economic crash and that the damage may be enduring. His Medicare proposal “reflects the reality that, even after the current crisis ends, older Americans are likely to find it difficult to secure jobs,” Biden wrote earlier this year in introducing the idea.
Biden also wanted to restructure the ACA insurance subsidies and make them more generous –a proposal that the health sector, by and large, does not oppose because it expands their market. Under current law, subsidies are available to individuals or families earning up to 400% of the federal poverty level. But there’s a lot of geographic variation in what’s affordable on the local insurance market and how much of a family’s budget it can eat up. Biden instead would set a ceiling of what percentage of income people would have to devote to buying health insurance, with subsidies available above that amount. It would be 8.5% – and the subsidy or tax credits would be more generous because the benchmark would be the current gold-tiered plans in the ACA exchanges. That means more coverage, with lower out-of-pocket costs. But here, too, the odds of Republicans going along are slim at this point.