When ACP released its Vision for a Better US Health Care System in January, we could not have anticipated that a global pandemic would soon reach our country, and 10 months later, be responsible for deaths of more than 240,000 Americans, many millions more being sickened, and hospital beds and clinical staff again in short supply because of another dangerous surge in cases.
But it turns out that ACP’s vision was prescient in identifying
fundamental deficiencies in US health that have worsened the toll from
COVID-19. Losing your insurance because you lost your
job. Living in a state that has not expanded Medicaid. Being
faced with high deductibles and excessive prices even if insured.
Discrimination and racism that contributes to poor health. Living in
communities that are underserved, neglected, and poor. A failure by
the US to invest and support public health and primary care. These
are all risk factors for getting sick and dying from COVID-19, just like being
old and having chronic conditions like diabetes and heart disease.
You might even say that the United States itself has multiple
chronic diseases of its health care system, making it far more vulnerable to
COVID-19 than many other countries.
While many issues influenced how Americans cast their votes on
November 3, the performance of President Trump and his administration on
COVID-19 certainly was one of them. By electing Joseph R. Biden as the next
president, and Kamala D. Harris as the next Vice President, voters elected the
candidates who promised a major shift in how the US government addresses health
care. Voters may have hedged their bets, though, by maintaining GOP control of
the Senate, depending on the outcome of two special elections in
Georgia. Democrats have to win both Senate seats up for grab in
Georgia on January 5 to split the Senate 50-50, with Vice President Harris
being available to cast tie-breaking votes. Should the Republican candidate win
either or both, Senator Mitch McConnell (R-KY) will remain the Senate’s
Majority Leader and be able to impede much of a Biden administration’s
legislative agenda. The filibuster will still require 60 Senate
votes on most legislation. The House of Representatives will remain under
Democratic control, but with a smaller majority.
The Biden transition website, Build
Back Better, lists COVID-19, racial equity, and climate change, and
economic recovery, as the top 4 initial priorities for the new administration.
Getting Congress to enact legislation to advance policies in these and other
areas will be difficult. Still, there is a lot a Biden
administration can do to make health care better, even without Congress:
COVID-19: President-elect Biden
already is charting a different course on COVID-19 than President Trump,
announcing a COVID-19 Task Force composed
of physicians and other health experts, co-chaired by former Surgeon General
and ACP member Vivek Murthy. He is expected to seek a national
mandate to wear masks, using the administration’s regulatory authorities to
require it in federal facilities and contractors and in public transportation,
while seeking support from the states’ governors for a broader
mandate. He pledges to have science and scientists lead the public
health response, rejoin the World Health Organization as recommended by
ACP, address lack of supply of personal protective equipment, and expand
testing and tracing.
Coverage and cost: A Biden
administration can use its executive authority to expand coverage under the
ACA, in ways recommended by ACP in its New Vision papers and other policy
statements. It can begin to reverse Trump administration rules that allow sale
of plans that do not cover the 10 categories of essential benefits required of
other ACA-compliant plans. It can increase funding and support for ACA outreach
and enrollment and stop states from imposing work requirements as a condition
for Medicaid coverage.
President-elect Biden’s more ambitious plans to
move the country closer to universal coverage will face an uphill battle.
Congress would need to enact legislation to expand Medicare to persons aged 50
through 64, create a public option available to everyone, automatically enroll
people in non-Medicaid expansion states in the public option, and lift the
income caps on federal subsidies to buy health insurance
coverage. Of these, lifting the income caps might be more likely to
command bipartisan support, because it would extend subsidies to people with
incomes over 400% of the Federal Poverty Level, many of whom have been priced
out of coverage. A Biden administration will seek to rein in
prescription drug prices, but Congress is unlikely to allow the federal
government to negotiate Medicare Rx prices, or eliminate the tax deductibility
for direct-to-consumer advertising.
Immigration: As President Trump has
shown, presidents have a lot of power to shape immigration policy, without
needing to go through Congress, and the courts generally defer to the executive
branch. The Biden administration will begin reversing immigration
policies that have an adverse impact on health, one of ACP’s top priorities. President-elect
Biden has promised that on the first day of his administration, he will
terminate the Trump administration’s ban on travel from 7 majority-Muslim countries,
restore the DACA program to protect “Dreamers” from deportation, end the
practice of separating children from their parents at the border, and appoint a
federal task force to re-unite immigrant children who were separated—all
actions strongly supported by ACP.
The new administration can take action to address the backlog in
visas for international medical graduates (IMGs) seeking permanent residency
status, and to ensure the effective and efficient processing of visas for IMGs
seeking to enter the United States. It can also begin the process of
reversing the public charge rule, which denies residency to legal immigrants if
they are likely to use public programs like Medicaid, which ACP has said is a
major barrier to
legal immigrants getting the health care they need.
Women and LGBQT health: The Biden administration
is expected to begin to reverse restrictions on federal funding for Planned
Parenthood and on physicians who counsel women on abortion or provide abortion
services themselves—as called for by
ACP. It may seek to expand the ACA’s essential benefit requirements
to ensure coverage for the full range of women’s health, and roll back
so-called employer conscience exemptions that allow them to exclude
contraception from coverage, although a Supreme Court decision
may stand in their way. President-elect Biden pledged to codify Roe
v. Wade into federal law, as a hedge against future Supreme Court decisions to
overturn or curtail the constitutional right to abortion; this though would
require that such legislation pass both the House and Senate, which is very
unlikely. Similarly, the Senate would likely reject his call for
Congress to end the Hyde rule, with prohibits federal funding for
abortion. As ACP and other organizations representing frontline
physicians have advocated, the new administration is expected to reverse
federal regulations and executive actions that weaken protections
for LGBQT persons
Climate change: As called for by ACP, President-elect Biden
has promised to rejoin the Paris Accord on the first day of his administration,
which would recommit the United States to specified targets for reducing carbon
emissions. He can begin the process of reversing Trump
administration regulations that eased restrictions on carbon emissions and
opened up more federal lands to drilling for oil. His more ambitious
plans to promote green technologies and achieve a carbon-free power sector by
2035 likely will be stymied by the Senate, although the new administration can
be aggressive in using its executive authority to achieve as much of this
agenda as it can.
Racism and health: There are
many things a Biden administration can do to address racism, discrimination,
and related health disparities, only some of which require legislation from
Congress. It can reverse a Trump administration Executive Order that
prohibits implicit bias training for federal employees and contractors as called
for by ACP and AAMC,
redirect federal funding and priorities to addressing social drivers of health,
prioritize persons that are at the greatest risk of COVID-19 because of where
they live and their race or ethnicity, have the Department of Justice address
inequities in sentencing and legal representation particularly for capital
offenses, and seek bipartisan solutions to system racism in law enforcement,
although much of the latter likely will require legislation at the state and
federal levels. As important as specific policies are,
President Biden and Vice President Harris can speak to the need for the United
States to extend justice, fairness, diversity, equity, and inclusion to all and
support Black Lives Matter, rather than seeking to undermine such goals. ACP
welcomes the opportunity to advocate for policies to address the impact of racism and discrimination on health
care.
Rolling back regulations that have been finalized by the
previous administration won’t happen overnight, since by law they have to go
through an entirely new round of agency rulemaking with public comment; many
could remain in effect in the meantime.
The Biden team, to be sure, will be exploring ways to halt, delay or
modify implementation of rules it seeks to reverse or modify, as quickly as
possible. Executive orders that have not
been finalized as regulations likely can be reversed with the stroke of a pen
of the new president, and new policy directions for federal agencies can be
created by new Biden executive orders.
There are initiatives from the Trump administration that ACP
will urge the Biden administration to continue, or even expand, including
implementing higher Medicare payments for office visits, putting patients over
paperwork, easing documentation and reporting requirements, and expanding
coverage and payment for telehealth visits and phone calls.
In Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians, we wrote that “U.S. health care costs too much; leaves too many behind without affordable coverage; creates incentives that are misaligned with patients' interests; undervalues primary care and public health; spends too much on administration at the expense of patient care; fails to invest and support public health approaches to reduce preventable injuries, deaths, diseases, and suffering; and fosters barriers to care for and discrimination against vulnerable individuals.” [Disclosure, I was the lead author for this Call to Action]. COVID-19 has shown us how true this is. President-elect Biden now has the opportunity to advance polices to make health care better, and ACP stands ready to assist him, no matter how difficult it may seem.
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