By Sabrina Corlette, Kevin Lucia, and JoAnn Volk

The weekend brought the news that we will soon have a new President and with him, a new agenda for health care reform. President-elect Biden will be stepping into office amidst one of the worst health and economic crises in our lifetimes, one that has shone a spotlight on the deep inequities in our health care system and large gaps in our safety net. And, although we don’t yet know who the victors of the two runoff elections in Georgia will be, it is certain he will be governing with a deeply divided Congress. The Biden-Harris campaign platform included an ambitious health reform agenda, with proposals designed to expand insurance coverage and lower the cost of health care. As the dust settles on this contentious election, we at CHIR are considering what a Biden-Harris administration will mean for Americans’ ability to get and maintain affordable, high quality health insurance.

Fighting the COVID-19 Pandemic and Mitigating its Economic Fallout

The top priority of the Biden administration is – and needs to be – getting us quickly and safely to the other side of the COVID-19 pandemic. Thankfully, he has already laid the groundwork for this effort, and if his choice of advisors is any guide, we can breathe a sigh of relief that federal COVID-19 policy will soon be science-driven, consistent, and better coordinated.

A key element of any strategy to combat COVID-19 will be to ensure that no one, regardless of their insurance coverage status, fears getting tested, treated, or vaccinated due to cost. We expect a Biden administration will make early efforts to close loopholes in existing federal law that have led to many consumers facing high, unexpected bills for COVID-19-related services. The pandemic has also put tremendous strain on many businesses, with a projected 48 million people under age 65 living in families with a COVID-19-related job loss, and over 10 million of these individuals are projected to lose their health coverage at the same time. While the White House and Congress negotiate a relief package to mitigate these negative economic effects, the Biden administration is likely to take immediate steps to help people experiencing coverage disruptions due to COVID-19. These could include creating a COVID-19 “special enrollment period” for the federally facilitated marketplaces and investing in public awareness and consumer assistance to help people understand and navigate their options.

Reversing Trump Administration “Sabotage” of the Affordable Care Act

In 2016, President Trump promised to repeal the ACA. When Congress failed to do so in 2017, the administration began a series of administrative actions designed to weaken the law. These are too numerous to list here, but we can expect new leadership at the Departments of Health & Human Services (HHS), Treasury, and Labor to reverse and revise numerous rules and guidance issued these past four years. Likely candidates are Trump administration efforts to enable states to loosen ACA protections through 1332 waivers, expand insurance products and arrangements that do not meet ACA standards (such as short-term and association health plans), reduce ACA advertising and enrollment assistance, and end civil rights protections under section 1557. Also, the Department of Homeland Security under President Biden is likely to reverse the damaging “public charge” rule, which has caused many immigrant families to fear enrolling in insurance coverage they are entitled to.

The Trump administration has also joined with the plaintiffs in California v. Texas, now before the Supreme Court, to argue that the entire ACA should be struck down. Presumably a Biden Justice Department will reverse its current position and defend the law, although at this late date doing so would be largely symbolic. The administration could also work with Congress to enact a legislative fix that would effectively “moot” the litigation and leave the Supreme Court with nothing to decide. Even if Republicans maintain control of the Senate, the prospect that 21 million people could lose their coverage in the middle of a pandemic may provide an incentive to compromise.

Building on and Improving the Affordable Care Act

The ACA is by no means perfect, and even its staunchest advocates call for changes to improve the affordability of premiums, reduce enrollee cost-sharing, and ease administrative burdens on consumers. The Biden-Harris campaign has proposed several measures on this front, including the creation of a public option plan, lowering the Medicare eligibility age to 60, and enhancing premium and cost-sharing subsidies for ACA plans. Much of this will require congressional approval, but in the meantime there is a lot that can be done through executive branch action. Our colleagues at the Center for Children & Families would be the first to mention the need for HHS to encourage states that have not yet expanded Medicaid to do so. But with respect to private insurance, a Biden administration could help reduce the burden of high deductibles by creating standardized benefit designs for the federally run marketplace that provide first-dollar coverage for high-value services like primary care and generic drugs. A Biden Treasury Department could also effectively end the “family glitch,” which locks many low- and moderate-income families out of the ACA’s premium tax credits. We should also expect a Biden administration to prioritize reducing racial and ethnic disparities, by, for example, focusing on improving language access for those with limited English proficiency, targeting outreach and enrollment help to underserved communities, and defining network adequacy to include concepts such as cultural competency and language access.

Some Things May Remain the Same

There are few areas of agreement between the Trump and Biden administrations when it comes to health insurance policy. But we can think of two issues where there may be common ground. These include an interest in protecting patients from surprise out-of-network medical bills, and promoting greater transparency of health care costs and prices. On both issues, there has been a remarkable degree of bipartisan support.

As we look forward to a new day in health insurance policy, CHIR maintains its mission to improve access to affordable and adequate health insurance, and we will continue to pursue it by supporting policymaking with balanced, evidence-based research, analysis and strategic advice.