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During the 2020 campaign, former Vice President Joseph R. Biden Jr. has outlined major health policy legislative goals for his potential presidency, which includes expanding the Affordable Care Act, lowering the age of Medicare eligibility, and passing prescription drug pricing reform. Those larger policy goals, of course, will have to include addressing COVID-19 during Biden’s first year in office.  

“Any element of health care reform is going to have to fit into the larger context and the larger context is that COVID is undoubtedly the dominant issue going forward. And on January 20, it’s going to be how do I get vaccines out as rapidly as possible?” said Ezekiel Emanuel, MD, Vice Provost for Global Initiatives, Co-Director, Healthcare Transformation Institute, University of Pennsylvania.  

Creating a centralized, federal response to COVID, distributing a vaccine, and managing supply chain issues, Emanuel said, would be the major focus of a Biden administration in year one. But the Biden administration would also be dealing with other pressing issues outside of health care.  

“Besides COVID, we’ve got climate change, we’ve got challenges with the economy and jobs that needs to be attended to, and we have a very volatile situation with China. All of that means major focus on health care reform, at least in the first year, is probably going to be regulatory, rather than legislative, just given a bandwidth issue,” said Emanuel, who is on Biden’s COVID-19 task force.  

Emanuel was joined by former Senator Tom Daschle, Founder & CEO of The Daschle Group, in the Health Evolution Executive Briefing webcast, Biden’s Health Care Policy – How Big Is the Aperture for Change? Kavita Patel, MD, Nonresident Fellow, The Brookings Institution and a Venture Partner at New Enterprise Associates, lead the discussion.  

“Vice President Biden has a clear point of view on health care and his approach is very different from President Trump’s,” Patel said. “But that point of view also has to be executed.” 

The three experts discussed the impact of the Supreme Court’s decision on the ACA, whether a public option is viable, the future of value-based care and more.  

ACA and the Supreme Court 

On the campaign trail, Biden has made it clear he would like to improve upon the ACA in a number of ways, rather than go for Medicare for All. Experts agree that the future of the ACA comes down to two things: Congressional makeup and the Supreme Court. A week after the election, the Supreme Court is ruling on the fate of the ACA in a case called, “Texas vs. Azar.” The result of that ruling won’t be known until mid-2021 but it’s certainly a factor going forward.   

If the Court rules the ACA unconstitutional, it will mean Biden and Congress would have to start over with a wholesale replacement. If it works out a compromise or gets saved in some capacity, as both Emanuel and Daschle predicted, any additions to the ACA can be made in concert with Congress. In both cases, whatever happens to the ACA—whether its replaced or expanded on—will completely depend on what Congress looks like in 2021.  

“Will it be Democratic? That’s one question. The other is what will the Senate do to change its rules? Will it follow recent precedent and completely eliminate the filibuster? For over 200 years, the Senate has depended on bipartisanship to work well, but it’s become deeply polarized and deeply dysfunctional today. There were 37 filibusters in the first 50 years after cloture was created. There were 239 in the last two years alone,” said Sen. Daschle. 

With that in mind, the easiest way for Biden and Democrats to pass ACA legislation would be to eliminate the filibuster on all legislation if they controlled the Senate. If that happens and they control the House and White House, Daschle predicted they would try to rebuild the ACA and improve upon it.  

“They’d repeal the waivers, the short-term junk plans that the Trump administration has offered. They’d press for Medicaid expansion for the remaining 14 states. I think they’d lift the cap of the tax credit eligibility. They would do a lot of aggressive marketing and outreach to expand enrollment,” Daschle said.  

Public option and more plans for the uninsured 

Emanuel, who was an architect of the ACA, agrees with Daschle’s predictions that Biden’s administration would try to get rid of the Trump administration’s short-term health plans, derided by critics as junk plans. He said they don’t offer patients real protection. He also sees an expansion of the ACA tax subsidies to reach more people, as well as lowering the age of Medicare eligibility and a potential public option to be a four-legged stool to expand health coverage to patients.  

“If I had to push them for a fifth stool, I would say we’d need some auto enrollment program into Medicaid. Because there is no way getting to 100% coverage or even 97% coverage without some auto enrollment program,” Emanuel said.  

The idea of adding a public option may be a little more difficult than the other proposed changes mentioned by Daschle and Emanuel. Patel said that the public option was part of the original ACA plans before getting removed for numerous political and financial reasons. The challenges that derailed it the first time may come to a forefront again.