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What President Biden’s administration means for the health of the US

Healthcare is a core part of President-Elect Joe Biden’s political agenda. But with the second surge of Covid-19 raging across the US, and opposition to medical insurance reform still strong, his plans face significant obstacles. Bette Browne reports

Mr Joe Biden, America’s 46th President, has laid out a plan underpinned by “bedrock science” to get the coronavirus pandemic under control and in tandem has pledged to pursue a sweeping healthcare agenda.

But there is no question the pandemic is top of the list and will likely dominate much of his presidential term. As a seasoned Washington insider, the President-Elect also knows the road ahead will be mined with political obstacles.

Mr Joe Biden, then Vice President, speaking at the American Society of Clinical Oncology annual meeting in 2016

He will have to contend with a closely divided Congress, where he will face strong Republican opposition to many of his ambitions for advancing healthcare in America, including lowering the eligibility age for the government’s Medicare programme for older people from 65 to 60, expanding financial assistance for health insurance under the Affordable Care Act (ACA), known as ‘Obamacare’, and creating a “public option” government health insurance plan.

The total cost of the Biden plan is estimated to be $750 billion over the next 10 years, which would mostly be paid for by repealing former President Donald Trump’s tax cuts for very wealthy Americans. 

He plans to use a combination of executive orders to undo the changes the Trump administration introduced to weaken existing healthcare law. The years under President Trump saw increases in the number of children without health insurance. Today, more than four million American children have no health insurance and this occurred even before the huge job losses caused by the pandemic.

Other changes will need Congressional backing and this could ultimately force the new President to opt for incremental steps to improve access to quality care and insurance cover for millions of Americans rather than pushing for transformational healthcare reforms.

Covid-19

Nevertheless, he has moved quickly to begin implementing his priorities and targeting the pandemic, which has seen America, with only 4 per cent of the world’s population now suffering 25 per cent of the world’s cases and deaths. He pledged that every person who needs it would get free testing and treatment for the coronavirus.

Just days after his election, he said: “Dealing with the coronavirus pandemic is one of the most important battles our administration will face, and I will be informed by science and by experts.”

He then quickly named a high-ranking medical and scientific team, which is now helping him to manage the surge in infections and ensure that vaccines are safe and effective and are distributed efficiently and free to those in need.

“These leading scientists and public health experts will consult with state and local officials to determine the public health and economic steps necessary to get the virus under control, to deliver immediate relief to working families, to address ongoing racial and ethnic disparities, and to reopen our schools and businesses safely and effectively,” he emphasised.

Under Mr Biden, Americans will see a coordinated national strategy, involving increased Covid-19 testing, a national mask mandate, increasing use of the Defense Production Act to make more protective equipment available for frontline workers, and the likelihood of targeted lockdowns in the country.

“I would be prepared to do whatever it takes to save lives because we cannot get the country moving until we control the virus,” he said. “In order to keep the country running and moving and the economy growing, and people employed, you have to fix the virus.” On a mask mandate, he has said he would “go to every governor and urge them to mandate
mask wearing in their states”.

And if that doesn’t work, he said he would turn to mayors and county executives to institute local mandates.

WHO

On the global front, he also plans to repair the US relationship with the World Health Organisation and halt the President Trump-led process of severing US financial commitments to the global agency. “You can’t fight a global pandemic without a global approach and allies,” said Mr Ron Klain, who has now become Mr Biden’s Chief of Staff.

Every state has now submitted a plan to the Centres for Disease Control and Prevention (CDC) on how they intend to inoculate hundreds of millions of Americans against Covid-19.

Mr Biden’s plan suggests investing over $25 billion for vaccine development and distribution, guaranteeing “it gets to every American, cost-free”. The US would also call for the creation of a global health emergency board that would convene the leaders of the major countries in the G-7 industrial group and others in support of the WHO’s efforts to help offset the costs of vaccine deployment to developing countries.

These leading scientists and public health experts will consult with state and local officials to determine the public health and economic steps necessary to get the virus under control

Even with the power of the presidency, it will be a tough task. For a start, he will have to convince states, many of which supported his predecessor’s hands-off approach to the virus, to urgently implement key measures to control its spread and to support vaccination programmes across the country.

A Gallup poll at the end of November showed that more than 40 per cent of Americans still say they would not agree to get an FDA-approved vaccine to prevent coronavirus if it was available at no cost.

That was an improvement from October when only half of Americans said they would seek a vaccine, but it pointed to the strong vaccine scepticism in America that Biden will have to overcome. By contrast, a poll in Ireland, also in November, showed 76 per cent favoured taking a vaccine.

Still, Mr Biden’s hand was strengthened in a West Health-Gallup poll that found a majority of Americans (52 per cent) trust him over President Trump (39 per cent) to lead the US healthcare system.

It found that for 67 per cent said managing the pandemic was their top issue, while lowering the cost of healthcare came close behind (66 per cent), with 45 per cent supporting lower drug costs.

While control of the White House and Congress dominated the November election, other health policy issues were also on the ballot in a number of states. In six states, voters were deciding the legality of marijuana in one form or another. Montana, Arizona and New Jersey opted to join the 11 states that allow recreational use of the drug.

Mississippi voters agreed to legalise medical marijuana and South Dakota approved legalising both recreational and medical marijuana.

Also approved was a separate ballot question in Oregon to decriminalise possession of small amounts of hard drugs, including heroin, cocaine and methamphetamine, and a mandate establishing addiction recovery centers partially funded by using some tax proceeds from marijuana sales.

In California, for the second time in two years, the state’s profitable kidney dialysis industry was challenged at the ballot box. A union-sponsored initiative would have required dialysis companies to employ a doctor at every clinic and submit infection reports to the state. But the industry spent $105 million to successfully fight against the measure, which ultimately failed.

Mr Biden will also have to battle for more congressional funds for hospitals, which after years of underfunding are sounding the alarm not just about the lack of beds for patients, but the lack of doctors and nurses and respiratory specialists and other medical personnel.

Non-Covid healthcare

Apart from the thousands of Covid-19 patients who are hospitalised, people in America, as in Ireland, are still suffering heart attacks, being diagnosed with cancer and other life-threatening conditions.

According to a recent survey, hospitals in at least 25 of the 50 US states are critically short of professional staff, with patients being transferred not just to other hospitals, but also to other states.

A Medicare-like public option would likely be substantially less expensive than current private insurance plans

States that sent doctors and nurses to hotspots like New York at the beginning of the pandemic are now hotspots themselves, but have nowhere to turn to get extra help because the virus is still surging everywhere. The situation has become so dire in North Dakota, for example, that hospital workers who have tested positive for Covid-19, but don’t have symptoms, have been told to continue working. 

Rural hospitals that are ill-equipped to treat certain illnesses or trauma and would normally transfer those patients to larger, better-equipped facilities are now having to try to treat those conditions because the larger hospitals do not have sufficient facilities, space or staff. Even worse, doctors, nurses and other frontline staff are getting sick themselves and, tragically, many have died due to coronavirus.

The CDC said in an update in November that at least 232,497 healthcare workers have now been infected and at least 836 have died.
On the plus side, Mr Biden begins his term just as a number of new vaccines and therapies are showing promising results. He said he wants to ensure that consumers are not “price gouged” as new drugs and therapies come on the market.

He has also warned about the need to prepare for the possibility of simultaneous outbreaks of flu and Covid-19 “that could overwhelm our public health system and confound our efforts to fight Covid-19”.

He also released a statement cautioning that widespread vaccination is months away and that “Americans will have to rely on masking, distancing, contact tracing, hand washing, and other measures to keep themselves safe well into next year”.

But, as Mr Biden is painfully aware from his eight-year term as Barack Obama’s Vice President, the power of the presidency tends to be limited, especially by the make-up of Congress, where healthcare legislation can be slowed, stymied or even binned altogether.

Obamacare

That’s why he called the passage 10 years ago of Obama’s Affordable Care Act, which he helped to shepherd through Congress, “a big deal” for Americans because “it was the conclusion of a tough fight that required taking on Republicans, special interests, and the status quo to do what’s right”.

Obamacare may not seem revolutionary by European standards, but it certainly was “a big deal” in America where well-funded and powerful industry lobbyists and their equally powerful political supporters have combined to block or challenge almost every measure of healthcare progress over many decades.

The primary achievement of the Affordable Care Act was that it provided insurance for over 20 million more people and banned insurance companies from denying coverage or charging higher premiums to people because they have a pre-existing condition. Now Mr Biden wants to build and expand on that by giving Americans more choices and reducing healthcare costs.

But he will have to try to bring hostile Republicans along with him in the House of Representatives and the Senate.

While the new administration can achieve a number of advances on its own through regulations and other administrative actions to strengthen the Affordable Care Act, other moves will require bipartisan cooperation. He can lower the uninsured rate, for example, by ordering an expansion of enrollment periods for the ACA.

“Dozens more seemingly small technical changes to regulations can cumulatively have a considerable impact,” according to Prof Simon F Haeder (PhD), Assistant Professor of Public Policy at Pennsylvania State University.

As well as boosting ACA, the President-Elect also wants to work with Congress to create a Medicare-like public insurance plan that anyone can buy into.

Such an insurance programme would be administered by the federal government, as is Medicare, but would be available to people of any age and would compete against private insurance plans in the marketplace. This idea was part of the original ACA but did not make it into the final law in 2010.

“A Medicare-like public option would likely be substantially less expensive than current private insurance plans,” according to Mr Larry Levitt, Executive Vice President for health policy at the non-profit Kaiser Family Foundation. “That’s because of the leverage the government would have to drive down the prices of doctor visits and hospital care.”

One example of how this works is in payment rates for doctors and other providers. “Medicare pays hospitals about half of what private insurance companies pay, so a Medicare-like public option at Medicare prices would be much less expensive than private insurance plans,” Mr Levitt pointed out.

Plus, he says, “the government-sponsored insurance plan also wouldn’t have a profit margin like private insurers have, which would also help lower premiums.”

Medicaid for poorer Americans and the Medicare plan for the elderly together provide coverage to about 15 million people and Mr Biden has signalled he wants to expand eligibility for these programmes and in particular he wants to lower the age of enrolment from 65 to 60 and include dental, vision and hearing coverage.

At present, most Medicare beneficiaries have to buy a supplemental policy to add on those benefits. Tackling the raging opioid epidemic is another priority for Mr Biden and to do this he will also have to work with Congress to secure additional funding.

The crisis has worsened because of Covid-19. The CDC stated 130 people are now dying every day from an opioid overdose. From 1999–2018, almost 450,000 people died from an overdose involving any opioid, including prescription and illicit opioids.

Another area the administration will focus on is organ transplantation. The US has suffered a severe shortage of available organs for decades. Every day, 13 Americans die waiting for a kidney, and four more die waiting for other organs. Covid-19 has further worsened this shortage.

The Trump administration did make some advances on this issue through regulations, including increasing support for living organ donors. Mr Biden will aim to build on this progress. He could also change the current approach to donations, which now relies solely on altruism, by increasing financial support for donors.

Reining in prescription drug prices will be another major goal for the new administration. The US pays substantially higher prices than the rest of the developed world for prescription drugs. This is primarily due to limited competition among drug companies, while the US regulatory apparatus has focused largely on drug safety while de-emphasising cost-effectiveness for new and existing drugs.

While pharmaceutical companies will vigorously fight to maintain their profits, growing anger over surging drug prices may fuel bipartisan action to finally address the issue.

Mr Biden may also move to reverse the executive actions Trump took to limit healthcare options for immigrants. This is “one of the areas where Biden could do a lot administratively without Congress,” Mr Levitt said. That may include reversing the “public charge” rule, which was aimed at denying green cards to some immigrants who had to use food stamps or other public benefits.

The president has also said he wants to expand coverage to DACA (Deferred Action for Childhood Arrivals) immigrants who are now adults, but who were brought into the country as children.

On reproductive health, Mr Biden is likely to reverse Trump’s restrictions on federal funding for agencies that provide abortion counseling, such as Planned Parenthood. He also supports the 1973 Roe v Wade ruling that legalised abortion in the United States and has said he wants to codify its protections in law.

His administration would likely also introduce measures to allow more federal funding for abortion and to ensure no-cost contraception coverage for more employees.

Mr Biden “is very aware that there are pieces of his agenda that certain interests may be opposed to, maybe because it cuts into their profit margins”, according to former Surgeon General Dr Vivek Murthy, now a leading advisor to the President-Elect. “He’s clear on the fact that it’s going to require fights, in some cases,” Dr Murthy said.

“He’s prepared to do that. He is not deterred by political pressure or industry opposition.”

But implementing his healthcare agenda will not just involve battling Republican opposition. He will also have to face down those in the Democratic party who want to push him in a more radical direction towards universal healthcare.

He has not endorsed these more ambitious ideas. But public opinion in the wake of the brutal Covid-19 pandemic has been shifting leftward, and Mr Biden’s thinking appears to some extent to have shifted with it, creating an agenda to which progressives have so far favourably responded.

It’s “the most progressive platform of any Democratic nominee in the modern history of the party”, according to Mr Waleed Shahid, Communications Director for the leftist Justice Democrats group.

Inequities

The administration is also acutely conscious of the fact that Covid-19 has sharply highlighted the existing inequities in the US healthcare system and has also exacerbated them.

A survey by the Commonwealth Fund, which promotes access to quality healthcare and health insurance, showed that the black and Latino population, women, and people with low incomes are being hit hardest by the pandemic. Unemployment has soared and more than 50 million Americans could face food insecurity by the end of the year, including 17 million children, according to the Feeding America charity.

The Feeding America organisation operates a nationwide network of more than 200 food banks catering to the needs of more than 45 million people through food pantries, soup kitchens and shelters. Many households that experience food insecurity do not qualify for federal nutrition programmes and have to rely on help from their local food banks and other hunger relief organisations.

The Biden administration will also seek to tackle this shameful crisis of hunger in America. President Trump’s four-year term as President was marked by cuts in federal investment in a range of healthcare areas, not least food security, which has now reached appalling levels for such a wealthy country.

Mr Biden built his presidential campaign as “a battle for the soul of America”. But now he faces another battle, this one for the soul of Congress and that may be the toughest battle of all in Washington. Moderate Republicans like the late Senator John McCain, whose single vote made Obamacare possible 10 years ago, are now rare.

Trumpism may be over in America, but it will cast a long shadow over the political agenda of Congress for years to come. How Mr Biden manages to navigate around the political landmines ahead will decide the success – or failure – of his healthcare agenda.

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