President Biden's Healthcare Policy Agenda

This week, as Joe Biden takes the oath of office to become the 46th President of the United States, many in the healthcare industry are wondering what impact the new President will have on the pandemic and broader healthcare reform initiatives.  

Although much is still unknown and broader political dynamics will play a big part in shaping the timing and exact content of the Biden Administration’s healthcare policy agenda, here is what we know today…

Key Nominees and Appointees

As is true with every new Administration, big pieces of Biden’s healthcare agenda are likely to be implemented through regulatory and executive actions. Thus, it is important to know who President Biden has appointed to the top healthcare positions in his Administration.

At the top of the list is Department of Health and Human Services (HHS) Secretary nominee Xavier Becerra, who is the current Attorney General of California and a former member of the U.S. House of Representatives from California. Other key nominees and appointees include:

• Andrea Palm, Deputy Secretary of Health and Human Services (Wisconsin Secretary of Health, former Obama Administration HHS official)
• Dr. Rachel Levine, Assistant Secretary for Health at the Department of Health and Human Services (Pennsylvania Secretary of Health)
• Dr. Vivek Murphy, Surgeon General (former Obama Administration Surgeon General)
• Dr. Rochelle Walensky, Director of the Centers for Disease Control and Prevention (Chief of Infectious Diseases at Massachusetts General Hospital) 
• Dr. Marcella Nunez-Smith, COVID-19 Equity Task Force Chair (Associate Dean for Health Equity Research at the Yale School of Medicine)
• Dr. Anthony Fauci, Chief Medical Adviser on COVID-19 to the President (I think we all know Dr. Fauci by now…)

Biden has not yet announced his pick to lead the Centers for Medicare and Medicaid Services (CMS). Nominees for CMS Administrator and other top CMS positions will be important to watch since these officials will play a key role in shaping policies for Medicare, Medicaid, and the Affordable Care Act (ACA) individual market exchanges, including those related to value-based payment models within those programs.

The Senate will have to confirm most of these nominees and the timing of those confirmations could delay certain healthcare policy actions. Regardless, from day one of the Biden Administration onward, we should expect a heavy use of regulatory and executive actions, especially considering the narrow margins in Congress. Speaking of Congress…

117th Congress

The prospects of President Biden getting his healthcare agenda through Congress improved dramatically following the Democrats victory in the January 5th Georgia Senate runoff elections.  With both Democratic candidates (Raphael Warnock and Jon Ossoff) defeating their Republican opponents, the U.S. Senate will be split evenly with 50 Democrats and 50 Republicans. This means that Vice President Kamala Harris can break any 50-50 tie for the Democrats by casting the 51st vote as President of the Senate, handing majority control of the Senate to the Democrats.  

As a result of the November elections, Democrats also maintained control of the House, but had their majority reduced to a margin of 222-211 (the slimmest majority for either controlling party since 2003.)  Still, healthcare legislation will likely have a more difficult time passing the Senate since ordinary legislation requires 60 votes to escape a filibuster. To pass any piece of legislation that cannot gain 60 votes in the Senate, Democrats will have to use the budget reconciliation process, which only requires 51 votes but carries with it several key limitations.

Nonetheless, with 51 votes, this opens the door for the Biden Administration and Democratic Congress to pursue partisan healthcare policies including potentially expanding the ACA, Medicaid, and/or Medicare. 

Key Healthcare Policy Proposals

Over the next several weeks, the Biden Administration and Democratic-led Congress are expected to focus heavily on the COVID-19 pandemic.  During the transition, Biden outlined a “seven-point plan to beat COVID-19”. Biden's COVID plan calls for revising existing policies on testing, personal protective equipment (PPE), vaccines, reopening businesses, and implementing a nationwide mask mandate by working with governors and mayors.  

Last week, Biden took it one step further and outlined his vaccine plan and set a goal of administering 100 million shots by the end of his first 100 days. Biden’s plan calls for the federal government to play a more central role in the vaccination process, in large part by helping to add more vaccination sites across the country.

In terms of economic relief from COVID, last week Biden also unveiled his $1.9 trillion “American Rescue Plan” that would provide billions for vaccinations, businesses, families, state and local governments, and communities. The plan would require congressional approval, which could be challenging in the Senate, since it will either require (a) 10 Republican votes to clear the 60-vote filibuster threshold or (b) use of the complex and time-consuming budget reconciliation process.

Beyond the pandemic, the Biden Administration is expected to focus on protecting and expanding the Affordable Care Act (ACA), expanding access to health insurance coverage, and reducing disparities.  While some progress on these issues will likely come through regulatory action, most of the policies Biden campaigned for will require legislative approval, including: increasing the value of ACA individual market tax credits; adding a public health insurance option for the ACA individual market; creating a premium-free public option for Medicaid expansion eligible population in states that have not expanded Medicaid; and allowing those between the ages of 60 and 64 to buy into Medicare.  

Holding razor-thin majorities in the House and Senate, the Democrats would need to hold the support of every one of its moderate and liberal members to pass such major legislation. With the Democratic caucus including over 100 supporters of Medicare for All in the House and Joe Manchin of West Virginia (where President Trump defeated Biden 69 percent to 30 percent) in the Senate, at this point it is unclear what legislation will meet this test.

What to Expect

It is clear that the pandemic response will initially be the biggest focus of the Biden Administration and 117th Congress. Some changes, such as those to the vaccine rollout plan, will probably occur quickly through regulatory and administrative actions.  Whether with 60 or 51 votes, it is also likely that the Democratic-led Congress will pass another COVID-19 aid bill in February or March.  And then another a month or two after that.

From there, how the pandemic plays out in addition to broader political dynamics will have a major impact on other potential health reform efforts. Biden’s coverage expansion proposals could be attached to COVID-19 aid or infrastructure legislation, as opposed to being passed as a stand-alone healthcare bill. If such legislation passes into law, healthcare providers would likely see a gradual decrease in uninsured patients and a gradual shift in payer mix towards government programs.

Regulatory actions on the ACA and health equity are likely, while tweaks to existing value-based care programs and payment models (such as ACOs) are inevitable as CMS (under the Biden Administration) begins its annual rulemaking process this spring and summer. Regulatory waivers, delayed or extended deadlines, and temporary policies in effect during the pandemic (such as those related to Medicare telehealth services) will also need to be dealt with this year.  

Overall, we should expect the fight against COVID-19 and the transition to value-based care to continue under the Biden Administration. And if we learned anything from 2020, we should also expect something unexpected.