Even before his inauguration day, President-elect Joe Biden was already walking along the perennial path tracking the divergence between soaring campaign rhetoric and policymaking reality.
Biden succeeded in making the 2020 presidential election a referendum on President Donald Trump. While over 80 million Americans voted for Biden—the most-ever for a presidential candidate—almost 74 million voted for Trump, 4.5 million more than the previous vote-total record garnered by Barack Obama in 2008. More important, according to a Morning Consult Poll conducted on the morning of Election Day, Nov. 3, 2020, 44% of Biden voters surveyed said their vote was “more of a vote against Donald Trump” rather than a vote for Biden.a
There are two main scenarios that the Biden administration could achieve in the realm of health policy.
The aggressive scenario
Realizing the boldest health policy changes touted by Biden during the election campaign would certainly please the self-described “progressive” wing of the Democratic party. These reforms include a public option plan, expanding Medicaid, enhancing the Affordable Care Act’s health insurance marketplaces, lowering the Medicare eligibility age to 60 and promoting unionization and collective bargaining for healthcare workers.
However, the path to effecting those policy changes is extremely narrow, requiring successful execution of domestic realpolitik, or “power politics.”
Biden has been helped significantly bv the victories of the Democrats Jon Ossoff and Raphael Warnock in Georgia’s two U.S. Senate runoff elections on Jan. 5, 2021, over incumbent Republican senators, David Perdue and Kelly Loeffler. As a result, the Democrats gained a 50-50 split in the Senate, which translates into a majority, because Vice President-elect Kamala Harris holds the tie-breaking vote in the chamber.
In this scenario, a simple majority of the Senate would need to vote to eliminate the filibuster at the beginning of the 117th United States Congress in January 2021. The filibuster enables a united minority to prevent a Senate vote on a bill and requires a three-fifths vote of the Senate to end a filibuster and enable passage of legislation.
While Obama has voiced his support for eliminating the filibuster and Biden has said he is open to eliminating it, Sen. Joe Manchin (D-W.Va.) recently stated, “I will not vote to end the filibuster.”b In addition, Sen. Dianne Feinstein (D-Calif.) says that eliminating the filibuster would only deepen the polarization in Washington — which Biden has pledged to lessen as part of his quest to heal the nation’s divide.c
Thus, the aggressive scenario remains highly unlikely, although no doubt the progressive wing of the Democratic party will continue to push its more liberal agenda.
The moderate scenario
While Biden is expected undo many measures his predecessor put in place, such as imposition of Medicaid work requirements, expansion of short-term health plans and various measures to curtail enrollment in the ACA health insurance marketplaces, the retention of the filibuster would lead the Biden administration to pursue less-ambitious health reforms that have bipartisan support. The least controversial of these would include supporting telehealth, ending surprise medical billing, promoting value-based care and alternative payment models and increasing price transparency.
Tackling prescription drug prices is an area where there is both public support — polls consistently show that high drug costs are the top healthcare issue — and considerable bipartisan support in Congress. However, the devil has been in the details, precluding passage of substantive legislation.
Ironically, the Trump administration may have done the Biden administration a favor by issuing on Nov. 20, 2020, an interim final rule for the Most Favored Nation (MFN) Model that would lower prescription drug costs by paying no more for Medicare Part B drugs and biologicals than the lowest price that drug manufacturers receive in 25 other industrialized countries, normalized by GDP per capita.
Although the MFN Model is only a proposal and is unlikely to be implemented due to procedural missteps, it does pave the way for the Biden administration to advocate variations on this theme, including allowing Medicare to negotiate drug prices, limiting launch prices for drugs, capping annual drug price increases to inflation, allowing consumers to buy drugs from other countries, and increasing the supply of generic drugs.
A note of caution
Some pundits say that Biden should push for his most aggressive policy changes during his “honeymoon” period, the first few months after the inauguration. But that would run counter to his promise to be a uniter and may risk taking his administration’s eyes off job one in 2021: the efficient and broad distribution of a COVID-19 vaccine. The Biden administration has the opportunity to reap the harvest of Trump’s Operation Warp Speed, which clearly accelerated the development of multiple successful vaccines. If the vaccine distribution goes poorly, many more lives will be lost to the novel coronavirus, and the U.S. economy will remain in or dip into a recession, rendering discussion of many of the aforementioned policy changes relatively moot.
a Aldridge, B., “Nearly half of Biden voters say they voted against Trump, not for Biden, exit poll finds,” Nov. 3, 2020.
b Lesniewski, N., “Joe Manchin kills dreams of expanding Supreme Court, eliminating the filibuster,” Roll Call, Nov. 9, 2020.
c Haberkorn, J., “Q&A: The century-old filibuster may end. Here’s why it matters,” The Los Angeles Times, Oct. 2, 2020.