In his 28 April speech to Congress marking his first hundred days in office, Joe Biden declared that healthcare should be “a right not a privilege” for all Americans. The declaration came as no surprise: the Build Back Better program he took to last year’s election had at its heart a rebuilt and expanded version of the Affordable Care Act, the country’s most sweeping healthcare reform since Medicare and Medicaid were introduced more than half a century ago.
Despite its flaws, and despite a decade of attacks by congressional Republicans, the ACA — or Obamacare, as it is often called — is more popular than ever. A February poll showed support at 54 per cent, with many of those saying they oppose Obamacare supporting its provisions when they are spelt out. But that popularity seems only to have hardened Republicans’ resolve to fight its expansion.
On his first day in office Biden use presidential authority to rescind an array of healthcare-related executive orders made by his predecessor and implement his own policies. He appointed a new Covid-19 response coordination team. He withdrew Donald Trump’s Medicaid waiver, which allowed states to restrict eligibility using work requirements. He rolled back restrictions on reproductive health and the use of foetal tissue n research. He revived US membership of the World Health Organization and the Paris climate accord.
Biden also restored science and scientific expertise’s central role in health-related policymaking, reinstated workplace and environmental protections, and reversing the Trump administration’s hostile stance on gay rights and racial justice — all decisions just as important for Americans’ health as expanded health insurance coverage and improved access to healthcare services. (Kaiser Health News keeps a list, aptly titled The Great Undoing, of his ongoing efforts to undo Trump’s health policies.)
But the real work of restoring and expanding Obamacare involves writing the detailed legislation that must then pass Congress. With a Democratic majority of only six votes in the House of Representatives and just one (the vice-president’s) in the Senate, and with little or no chance of Republican support, that will be an enormous challenge.
Biden signalled where he was heading early. The US$1.9 trillion American Rescue Plan Act, the first of three bills that make up the Build Back Better plan, was made public before he took the oath of office. It focuses on pandemic relief, rescuing the American economy, opening schools, scaling up vaccination, and in other ways controlling the pandemic.
Aside from one-off payments to all Americans and increases in tax credits — measures that will temporarily lift many children out of poverty — short-term funding was also provided to lower the cost of health insurance premiums and pay the private health insurance of laid-off workers. Unemployment, nutritional assistance, rental and mortgage assistance benefits were boosted; Native American communities received US$8.3 billion for health, housing and education programs; and new financial incentives were introduced to encourage the twelve remaining states (led by Republicans, mainly southern and poor) to take up Obamacare’s expansion of Medicaid.
Biden’s time in the Obama administration had brought home to him the hazards of endless and ultimately fruitless negotiations with Republicans. He knew that bill must be passed in full, and quickly.
The American Rescue Plan Act was signed into law on 11 March, having passed through Congress without attracting a single Republican vote. As a result, Biden could mark his first hundred days in office with most Americans having received their promised relief payments, some 200 million Covid-19 vaccinations having been carried, out and many other achievements. The economy is roaring back, if unevenly, and the White House is characterised by action, transparency and an air of normality. Polling shows Americans are the most optimistic they’ve been about the nation’s direction in nearly fifteen years.
This gives the president the political capital to proceed with the two other parts of his Build Back Better agenda — US$2.3 trillion over the next eight years for the American Jobs Plan and $1.8 trillion for the American Families Plan — both of which include health and healthcare provisions.
Although the American Jobs Plan is primarily about rebuilding America’s rundown infrastructure, investing in green energy and creating jobs, it will also provide funding for the social supports that advance equity and aid access to healthcare. These include investments in broadband access, public transport, affordable housing and safe drinking water, all of which will especially benefit low-income and minority communities.
One of the package’s ground-breaking initiatives is the US$400 billion allocated to expand and upgrade community-based care for the elderly and people with disabilities, and an almost doubling of current spending under Medicaid. Although these funds seem unlikely to meet demand — especially given fears about the safety of residential care in the wake of Covid-19’s toll — they could dramatically improve the lives of those in home care and their carers. The latter are mainly immigrant women, often living below the poverty line without health insurance, whose median hourly wage is only US$12.60. During his election campaign, Biden spoke out about the need for this important part of the healthcare workforce to be given pay raises, workplace protections, paid family and medical leave, job training programs and collective bargaining rights.
The third component of Build Back Better, the American Families Plan, covers education, childcare, paid family leave and healthcare. It expands the American Rescue Plan’s premium tax credits for health insurance and provides US$2 billion to train skilled healthcare workers. It also tackles the social determinants of health by providing free meals to children in areas of high poverty and creating a healthy foods incentive program.
Education is directly linked to self-rated health, infant mortality, life expectancy and compliance with medical advice. Programs that close gaps in educational outcomes between low-income or racial and ethnic minority populations and higher-income or majority populations are essential to achieving health equity.
Congressional Republicans are predictably outraged by these US$6 trillion spending plans. They have accused Biden of pursuing a radical agenda that will turn the United States into a failed socialist state, and reject even job creation and infrastructure initiatives they (and Trump) once supported. They don’t see broadband or the removal of lead pipes carrying drinking water as infrastructure, and they claim that home care services were “shoehorned” into the plan.
Senate minority leader Mitch McConnell declared that the Biden administration “wants to jack up taxes in order to nudge families toward the kinds of jobs Democrats want them to have, in the kinds of industries Democrats want to exist, with the kinds of cars Democrats want them to drive, using the kinds of childcare arrangements that Democrats want them to pursue.”
Just as anathema to the Republicans are the increases in corporate taxes and taxes on individuals earning more than US$400,000 needed to pay for these bills, measures designed to avoid boosting an already huge federal deficit. Unsurprisingly, the Republicans’ appetite for remaking the economy is small, as evidenced by their US$568 billion infrastructure counter-proposal, which deals narrowly with roads, bridges and other transport infrastructure and ignores the economic possibilities of green jobs and clean energy.
Biden recognises that he has a unique opportunity to make what he has called a “once in a generation series of federal investments in our nation’s future.” With the pandemic having highlighted the consequences of relying on the market to deliver affordable and accessible services, a majority of Americans now supports a single-payer health insurance system and 69 per cent favour a public option that would compete with private health insurance.
Recognition is also growing that the much-touted American exceptionalism involves lower life expectancy, higher suicide rates and higher rates of avoidable deaths than in comparable countries. Many Americans now see the consequences of what happens when healthcare is neither universal nor affordable and paid family leave isn’t guaranteed.
Joe Biden is acutely aware of the Democrats’ narrow majorities in the current House and Senate and the distinct possibility these could be overturned in the next election cycle. His response is to go big, go fast and go partisan to get his plans in place before the 2022 elections.
The president has found considerable bipartisan support for his proposals in the community. Indeed, his ideas are often more popular than he is (his approval rating is currently around 54 per cent) and in most polls that support also comes from many Republicans. An ABC News/Washington Post poll conducted on 18–21 April found that 65 per cent of Americans support the now-enacted coronavirus relief package. Several different polls indicate that a majority of voters want Congress to pass the American Jobs Plan, and the more people know about it the more they approve. Polling also shows strong approval of the care-giving provisions, with a Morning Consult/Politico poll showing 76 per cent support (including 64 per cent among Republican voters). A Monmouth poll shows widespread enthusiasm for the American Families Plan, with 64 per cent support and 34 per cent opposition.
Nor are American voters particularly fazed by the price tag, or the increased taxes needed to pay it. A CBS News/YouGov poll, for example, found that Americans support raising taxes — on individuals earning more than US$400,000 a year and on corporations — by the same wide margin of 71 per cent to 29 per cent. A Monmouth poll found support for higher corporate taxes at 64 per cent and for raising taxes on those earning more than US$400,000 at 65 per cent. Some Republican lawmakers have even been touting the benefits Biden’s Covid-19 relief plan has delivered to their districts.
The president’s problems with Congress are not confined to managing the Republicans; there is obstinacy and dissent among the Democrats, especially those on the left who want more, and want it quicker. Biden campaigned on giving Americans universal healthcare coverage, and that is still a long way off. Estimates put the percentage of uninsured Americans at 12.5 (rising to an average of 15.5 per cent in states that have not expanded Medicaid): that’s twenty-nine million people, mostly low-income and people of colour, with another 21.3 per cent under-insured.
To reduce those figures significantly, two things need to happen: the cost of health insurance purchased privately and through the Obamacare exchanges needs to fall, and the recalcitrant states need to expand Medicaid. Biden is already tackling these issues, but more needs to be done. The new supplements for purchasing health insurance run for only for two years, and twelve states (with some four million eligible people) have yet to expand Medicaid.
In the absence of universal healthcare, Medicaid is an important, if shaky and uncertain, safety net. It provides mental health and substance abuse treatment for millions and covers almost half of all births. The states holding out against expansion are losing money they can ill afford, especially as coronavirus infections continue. Just last month, the Texas State House rejected Medicaid expansion because of continuing opposition from Republicans. Expansion would have enabled some 954,000 adults to receive healthcare coverage (about 75 per cent of whom are people of colour) and brought the state US$5.4 billion in federal dollars to pay for it.
Rather than funding expanded health insurance coverage through private insurers, progressive Democrats and some policy experts argue for a public option (as originally proposed in Obamacare) and/or for people aged fifty-five or sixty qualify for Medicare (an idea that was championed by Hillary Clinton in her 2016 presidential race).
Congressional Democrats led by Senator Bernie Sanders and the Congressional Progressive Caucus are pushing to have Medicare expansion included in the American Families Plan. They see this as a precursor to an eventual Medicare-for-All program. A broader group of Democrats is pushing for the American Families Plan to allow Medicare to negotiate prescription drug prices. Biden has endorsed these, and the public option, in the past.
In his speech to the Congress Biden promised that he would strive “this year” to lower insurance premiums, reduce drug costs and pursue other reforms to Obamacare. Presumably he feels that including these provisions in the American Families Plan would draw fire from the powerful health insurance, hospital and pharmaceutical corporations, making its passage through Congress even more difficult.
Sometime between now and 1 October the administration and Democrats must also confront the decision of the US Supreme Court in the California v Texas, a case brought by Republican state attorneys- general and supported by the Trump administration. The decision will essentially decide the fate of Obamacare and the survival of the entire Affordable Care Act. Analysis shows that it would adversely affect the lives of almost all Americans.
Should the worst happen, re-enacting a version of the Affordable Care Act in today’s political climate would be almost impossible, even as more Americans than ever are signing up for the health insurance coverage provided by the federal Obamacare exchange. It would be a dreadful irony if Trump’s legacy, delivered after he left office, was — finally — the end of Obamacare.
For this reason alone, but for so many others besides, Biden’s efforts to provide the United States with the kinds of government services that other wealthy, democracies already take for granted and to build voter support for a stronger social safety net are a national imperative. •