Biden’s healthcare reforms in the balance

This is shaping up to be a make-or-break year for US President Joe Biden’s ambitious plans for healthcare, with the Covid-19 pandemic still dominating the agenda. Bette Browne reports 

US President Joe Biden begins his second year in office fighting for the survival of his healthcare agenda in a deeply divided Congress and with time running out before congressional elections make the task even tougher.

The President’s Democratic party now holds a slim majority in both the House of Representatives and the Senate, but if Republicans win back control of both chambers in congressional elections in November, then Biden’s agenda will be stalled, or even doomed. Democrats are also nervous about the trends of political history when it comes to midterm elections, which are held two years after the presidential election.

Historically, the party that controls the White House frequently loses seats in Congress in the midterm election. It happened during the recent presidencies of Donald Trump, Barack Obama, and Bill Clinton. Therefore 2022 is shaping up to be a make-or-break year for Biden’s healthcare agenda.

Build Back Better

The healthcare changes the President wants Congress to enact are largely contained in his ‘Build Back Better’ Bill. Its provisions, which were passed in the House of Representatives late last year but remain stalled in the Senate, would herald sweeping advances in healthcare and social policies and propel the country closer than ever before to the goal of universal health coverage.

The plan is replete with measures that appeal to most Americans, according to polls. In one survey, 66 per cent of respondents including 61 per cent of independents and 39 per cent of Republicans said they supported the Build Back Better plan. However, at the end of 2021, another poll found support had dipped along with the President’s popularity, as the Covid-19 pandemic showed little sign of ending.

Politicised pandemic

Legal and political setbacks in his battle against Covid are seen as impacting the President’s wider healthcare agenda and weakening his political clout in pushing it through Congress. Indeed, some Democrats contend that for many Republicans this is part of their motivation for opposing the President’s push to get more Americans vaccinated.

Such politicisation of the pandemic was evident back in the summer of last year at a Conservative Political Action Conference in Texas, when supporters of President Biden’s predecessor, Donald Trump, cheered when a speaker said the Biden administration had failed to reach its target of getting 90 per cent of the country vaccinated.

Since then, however, Trump has urged the unvaccinated to take the jab, although his exhortations were often met with jeers from his supporters. Meanwhile, in this increasingly toxic atmosphere, the country’s death toll from the disease stood at over 850,000 people on the first anniversary of President Biden’s election.

This has left the President fighting a two-pronged battle – one against Covid and the other against opponents of his Build Back Better Bill. Its provisions would make health insurance more affordable for adults, expand healthcare access for children and improve benefits for older people and those with disabilities. It includes an expanded child tax credit that would give parents up to $300 (€260) per child per month.

The provisions, which would also boost investment in housing  ing and implement measures to combat climate change, may not seem particularly radical. However, they would represent major advances, building on President Obama’s Affordable Care Act (ACA) a decade ago that insured millions.

The Biden plan would reduce premiums for more than nine million Americans who buy insurance through the Affordable Care Act by an average of $600 (€525) per person per year. For example, a family of four earning $80,000 (€70,000) per year would save nearly $3,000 (€2,270) per year on insurance premiums. Experts predict that more than three million people who would otherwise be uninsured will gain health coverage under the President’s plan.

In addition to investing in protecting Americans from future pandemics, the Build Back Better framework will expand access to affordable coverage “While the historic Affordable Care Act reduced the number of uninsured Americans by more than 20 million, extended critical consumer protections to more than 100 million people, and strengthened and improved the nation’s healthcare system, too many Americans continue to struggle to afford care,” according to a White House briefing.

“About 30 million people were uninsured in 2019 before President Biden took office, and coverage under the ACA (even with the premium subsidies) was too expensive for many families. In addition to investing in protecting Americans from future pandemics, the Build Back Better framework will expand access to affordable coverage. In all, the  framework will be the largest expansion of healthcare coverage since the Affordable Care Act.” 

The administration said the plan would save most families more than half of their spending on childcare, deliver two years of free preschool for every three- and four-year-old, give more than 35 million families a major tax cut by extending the expanded Child Tax Credit, and expand access to homecare for older Americans and people with disabilities.

Costs

Yet for all its popularity among voters, a tug of war over its provisions has ensued in Congress, with opposition Republicans opposed to its $1.75 trillion price tag. Many are the same Republicans who enthusiastically backed tax cuts for the very wealthy in 2017 during Trump’s presidency, but are not happy this time because Biden wants to pay for his plan by increasing taxes on the largest corporations and the wealthiest Americans.

The administration stresses, however, that only those making over $400,000 (€350,000) would have to pay more taxes if the plan is passed. President Biden had hoped to pass the Bill in the Senate before Christmas, but failed to do so when Democratic Senator Joe Manchin dramatically withdrew his support at the last minute and demanded changes to the plan. Voting was then postponed.

Progressive Democrats oppose any further changes to the Bill, citing Congressional Budget Office estimates that even if the Bill is passed, more than 27 million people would still remain uninsured including many undocumented immigrants.

The stalemate is causing President Biden problems on two fronts. It is highlighting his inability – so far at least – to get all the members of his party on board, thus weakening his authority in Congress and threatening passage of his agenda. Indeed, Senate Democrats are now beginning to realise they may have to accept a smaller list of accomplishments than what they hoped for at the start of last year when President Biden took office.

Voters are also increasingly questioning the President’s lack of progress. A University of Massachusetts Amherst/YouGov poll on 11 January, a week before the anniversary of his first year in office, indicated that 55 per cent of adults felt he had “fallen short of expectations”.  Yet the hard reality for Democrats is that they have the narrowest of majorities in the Senate – 50-50 with the Vice President breaking ties in favour of Democrats – so the battle to improve access to healthcare and implement social reforms was always going to be tough for President Biden.

Sweeping changes usually only get passed through Congress when a President has big numbers in both chambers. President Biden also faces another major challenge. The toxic political climate in America in 2022 makes change even tougher than for any previous President in modern times. For a start, he was the first President to be inaugurated after a coup attempt by his predecessor’s supporters who tried to prevent Congress from ratifying the election two weeks before he was due to assume office.

At a rally before the attack on Congress, Trump told his supporters that the election had been “stolen” from him and declared: “We fight like hell. And if you don’t fight like hell, you’re not going to have a country anymore.” A week after the riot, the House of Representatives impeached Trump for incitement of insurrection. The 6 January coup attempt was widely seen as one of the most dangerous threats ever faced by America’s democracy and it was in this political cauldron that Biden began his presidency just a year ago.

Covid-19 measures 

At the same time, America, like the rest of the world, was also reeling from the Covid-19 pandemic. President Biden made the fight against the disease his top priority when he took office. “(This is) the worst pandemic in a century,” the President said in his first address to a joint session in April 2021. “The worst economic crisis since the Great Depression. The worst attack on our democracy since the Civil War.” But within months the battle against the disease had become politicised and Biden soon began to face political and legal challenges to his plans to fight the disease.

Still, he notched a number of impressive early wins. In his first days in office he signed a series of executive orders, including measures to ramp up vaccine manufacturing and distribution. At his urging, Congress poured tens of billions of dollars into state and local public health departments in response to the pandemic, paying for masks, contact tracers, and education campaigns to persuade people to get vaccinated. 

He then pushed for immediate coronavirus legislation on a Covid relief package. This $1.9 trillion (€1.6 trillion) relief Bill, which was subsequently passed in Congress, provided for direct payments to support Americans hit by the effects of the pandemic, and also enhanced unemployment benefits and rental assistance. 

It was the biggest piece of social and economic legislation since the 1960s and was widely seen as the major achievement for the President during his first 100 days. An NBC poll around that time showed 81 per cent of independents approved of how President Biden was handling the pandemic. But alarm bells were already ringing because the Bill was passed without a single Republican voting in favour. 

Soon vaccine hesitancy, especially in Republican-controlled states, became a huge problem. Millions refused to get vaccinated or wear masks. Vaccine mandates were challenged by Republican governors in many states and legal challenges followed in the courts. 

This year began with a major setback for President Biden’s plan to boost the number of people vaccinated when the Supreme Court ruled on 13 January against vaccine-or-test rules for businesses. This means that private businesses can now decide for themselves whether to impose a mandate. But without the legal cover, it is unlikely that many will do so, especially in Republican-led states that have made mandates illegal. A federal ruling would have overridden state policies allowing businesses to keep their mandates in place. 

Republicans hailed the ruling. Louisiana Congressman Steve Scalise, in a tweet, congratulated the Supreme Court for blocking “Biden’s authoritarian vaccine mandate for businesses. But let’s be clear: This doesn’t go far enough. Healthcare workers should not be subjected to this tyrannical mandate either.”  Health experts in the US, however, argue that mandates work in getting more people vaccinated.

They fear that without one for some 80 million workers, more people will be at risk of getting hospitalised and dying.  “It is now highly unlikely that the US will hit the 85-to-90 per cent of Americans vaccinated to get to the other side of the pandemic,” tweeted Dr Celine Gounder, an infectious disease specialist and former member of the Biden administration’s team. 

President Biden has also indicated he is running out of patience with Americans who refuse to get vaccinated, even when offered inducements including cash giveaways and sweepstake prizes like cruises.  In remarks at the White House on 13 January, he again stressed that this was now a pandemic of the unvaccinated.

“Right now, both vaccinated and unvaccinated people are testing positive, but what happens after that could not be more different,” he warned.  Mr Lawrence Gostin, a Public Health Law Professor at Georgetown University, said President Biden should mandate Covid vaccines for domestic travel.  According to the US publication, The Hill, Mr Gostin said: “He has wide authority over regulating the travel industry, and he’s already lawfully required masks in airports and on planes.

He could do the same thing with vaccines, just like he requires it for international travellers.”  But airlines and other business groups oppose any vaccine and testing requirement for domestic air travel.  According to data from the Centres for Disease Control and Prevention (CDC), about 67 per cent of the eligible US population is fully vaccinated. The remaining group of unvaccinated holdouts is in large part fuelling the more than 1,700 deaths a day from Covid-19.

As the Omicron variant has ripped through the country, healthcare professionals say hospitals and health systems have been overwhelmed in many places because of unvaccinated patients.  An analysis by the Kaiser Family Foundation (KFF) found there were 690,000 vaccine-preventable Covid-19 hospitalisations from June to November 2021 and the cost of treating these patients over that six-month period was $13.8 billion (€12 billion).

“That [cost] could have been prevented if people had chosen to get vaccinated. It’s hard to project how the pandemic sort of plays out. But prevention measures do reduce longer-term costs. These are preventable deaths and hospitalisations,” said Ms Krutika Amin, a KFF Associate Director. 

The administration is fighting back against some states. On 14 January, for example, it threatened to withdraw federal Covid-19 relief funding from Arizona unless the state stops directing the money to schools without mask mandates. 

State programmes, funded with payments from the Coronavirus State and Local Fiscal Recovery Funds, impose conditions that discourage compliance with wearing masks in schools, contradicting guidance from the CDC on how to reduce Covid-19 transmission. 

The funds are intended “to mitigate the fiscal effects stemming from the Covid-19 public health emergency, including by supporting efforts to stop the spread of the virus”, the Treasury department stressed in a letter to Arizona state authorities. According to the administration, a recipient may not use the federal money for any programme or service that includes a term or condition that undermines efforts to stop the spread of Covid-19. 

Arizona’s Republican Governor Doug Ducey will now have 60 days to redirect federal funds to eligible users or change the state programmes so they are in compliance.  If not, the federal government said it will move to recover the relief money. In a statement posted on Twitter, Governor Ducey countered by accusing the President of being “out of touch with the American people”. 

He wrote: “When it comes to education, President Biden wants to continue focusing on masks. In Arizona, we’re going to focus on math and getting kids caught up after a year of learning loss.”  Meanwhile, amid this increasingly toxic atmosphere, the country’s death toll from the disease has continued to soar in many states, not least Arizona where it is on track to be the leading cause of death in the state. The Arizona Department of Health Services reported an unofficial total of 24,229 Covid deaths as of 31 December 2021, in the state of seven million people. The surging numbers are a change from 2020, when the virus was the third-leading cause of death behind heart disease and cancer. 

Unexpected medical charges 

But the New Year also saw some positive healthcare news for President Biden when a ban on unexpected medical charges went into effect. The ‘No Surprises’ Act will apply to about 10 million such charges a year, according to federal estimates.  The new law protects patients when they receive emergency care or scheduled treatment from doctors and hospitals that are not in their insurance networks and that they did not choose.

Consumers would be responsible only for their in-network cost-sharing in these situations.  Two-in-three adults say they worry about unexpected charges, according to the KFF. About one-in-five emergency room visits and up to one-in-six in-network hospitalisations include at least one surprise out-of-network bill. Patients can be hit with more than $1,200 (€1,000), on average, for anaesthesiologists’ services and $2,600 (€2,272) for surgical assistants, according to a report by the Department of Health and Human Services. 

The Biden administration is also in the process of implementing a plan to make 400 million N95 masks available to Americans for free in its latest effort to try to halt the deadly Covid surge.  But the President needs much more to show for his healthcare agenda. Unless he can sort out differences among his party’s senators to ensure passage of his Build Back Better Bill in the coming weeks and months his agenda may well be doomed after the November congressional elections. 

Still, Biden can take some heart from a poll on 14 January from FiveThirtyEight that put his average approval rating at 42.2 per cent. But it remains to be seen if this will translate into boosting support for his Build Back Better Bill.  If his sweeping plan does fail to pass, some Democrats believe that all will not be lost. Senator Tim Kaine of Virginia has said that while he fears the $1.75 trillion Bill may be “dead”, core elements will probably still pass. “The most recent version of it is not going to happen,” Senator Kaine said on the CBS network on 16 January. He added that the Democrats will “find the core of the Bill – like education, reduced childcare costs, and healthcare support – and pass it”. 

The President accepted as much at a news conference marking the anniversary of his first year in office. “It’s clear to me that we are going to have to probably break it up,” he said of his Build Back Better Bill.  But he emphasised the fight for those goals was not over. Instead, he said he would move on and try to achieve the objectives incrementally. “I think we can break the package up, get as much as we can now and come back and fight for the rest later.” 

While some healthcare reform is better than none in this political climate, it seems Americans will again have to settle for incremental changes rather than the transformative advances proposed by the President.