What's in the Biden/Harris Health Care Reform Platform?

Maintaining and Enhancing the ACA

Joe Biden speaking about health care reform at a campaign event.

Joshua Roberts / Stringer/Getty Images 

It's been more than a decade since the Affordable Care Act (ACA, also known as Obamacare) was enacted, but the issue of health care reform has remained contentious and near the top of many Americans' list of most important issues.

Health care reform is one of the top issues in the 2020 presidential campaign. This is especially true as a result of the COVID-19 pandemic—which has highlighted many of the shortcomings in our current system—and the pending lawsuit that aims to overturn the Affordable Care Act.

The case is scheduled to be heard by the Supreme Court in November 2020. The court vacancy left by the death of Justice Ruth Bader Ginsburg has added an additional sense urgency to the future of health care reform in the United States.

Biden Health Care Platform Overview

The health insurance portion of Democratic presidential nominee Joe Biden's health care reform platform is focused on enhancing the Affordable Care Act so that it can provide better coverage to more Americans. Biden also has proposals to address surprise balance billing and the affordability of prescription drugs.

And although a public option was essentially dead on arrival when the ACA was being debated in 2009, public opinion on this issue has shifted considerably over the last decade and a public option is now a pillar of Biden's health care reform proposal.

Biden's campaign website notes that he "believes that every American—regardless of gender, race, income, sexual orientation, or zip code—should have access to affordable and quality health care."

In other words, health care is a right, not a privilege. So his proposals generally focus on ways to expand access to high-quality health coverage, while also taking steps to make that coverage affordable.

Contrast With Trump

This is in contrast with the Trump administration's efforts to expand access to short-term health insurance plans, which are not considered minimum essential coverage. Although short-term plans do tend to have much lower monthly premiums (and are thus naturally more affordable, even without government subsidies), the coverage they provide is much less robust than ACA-compliant health plans.

Short-term plans generally exclude all pre-existing health conditions, which means that they're really only suitable for healthy enrollees, and to address unexpected medical costs.

They also tend to have gaping holes in the coverage. Short-term plans virtually never include maternity coverage, most do not include prescription drug coverage, and mental health/substance abuse coverage is also rare.

So while these plans can be adequate for a healthy person who is experiencing a short gap in other coverage, expanding them as a general health coverage strategy leaves many consumers under-insured and without adequate coverage.

Biden's proposals would increase the number of Americans with comprehensive health insurance coverage. As of 2019, the U.S. Census Bureau determined that 92% of Americans had health insurance for at least part of the year. Biden's proposals would increase that to about 97%.

That will come with a price tag, of course, but the Biden campaign notes that they "will make health care a right by getting rid of capital gains tax loopholes for the super-wealthy."

Challenges in Approval

As is always the case with a presidential candidate's platform, many of the proposals would require legislative approval, and others would likely face challenges in the court system.

Enhancing and building on the ACA could end up being next to impossible if the Senate remains under Republican control, as GOP lawmakers have been loath to agree to any proposals over the years that called for any sort of improvement to the ACA.

But there are numerous changes that a Biden administration could implement without legislative action—just as we've seen from the Trump administration since sweeping legislation to repeal the ACA failed in 2017.

With that in mind, let's take a look at the changes the Biden/Harris campaign is proposing, and how they would affect health coverage and access to affordable health care:

A Public Option

Biden's proposals are more progressive than the ACA, but less ambitious than some Democrats' proposals for a transition to a single-payer system. Biden wants to keep private health insurance, but introduce a public option that would compete with private insurers and serve as an alternative plan choice.

The public option would be expected to offer more affordable premiums than similar private coverage, due to a substantial enrollment that would allow the program to negotiate lower payment rates with health care providers.

The public option plan would be available for free to people who have income below 138% of the poverty level but live in one of the 14 states that have refused to implement the ACA's expansion of Medicaid (note that two of those states—Oklahoma and Missouri—will implement Medicaid expansion by mid-2021 under the terms of ballot initiatives that voters passed in 2020).

This would eliminate the current coverage gap in those states and would provide free health benefits to an estimated 4.9 million people (some are currently in the coverage gap; others are enrolled in subsidized plans in the exchange but with much higher out-of-pocket costs than they would have under the public option—or under Medicaid, if their states were to accept the ACA's expansion of the program).

More Substantial Premium Subsidies

For most people who buy their own health insurance, the ACA's premium subsidies (premium tax credits) make the coverage much more affordable than it would otherwise be. As of 2020, there are 9.2 million people receiving premium subsidies, amounting to 86% of the people enrolled through the health insurance exchanges nationwide.

But there have long been criticisms that the subsidies need to be more robust and more widely available, and Biden has proposed some significant changes to address those issues.

Eliminating Income Cap on Premium Subsidy Eligibility

Under the ACA's rules, premium subsidies are only available to households with an ACA-specific modified adjusted gross income that doesn't exceed 400% of the poverty level.

For a family of four buying coverage for 2021 in the continental U.S., that amounts to $104,800 in annual income (the poverty level numbers are higher in Alaska and Hawaii). That's a lot of money in some parts of the country, but not in others.

And even in areas where the overall cost of living is moderate, health insurance premiums can be particularly high and can amount to a substantial percentage of a household's income if they're just above the subsidy eligibility cut off.

Wyoming is an example of this, with average pre-subsidy health insurance premiums of $957/month in 2020. This is also true for older enrollees since the ACA allows premiums for a 64-year-old to be three times as high as the premiums for a 21-year-old.

So Biden's plan is to eliminate the income cap for premium subsidy eligibility. Instead of a subsidy cliff at 400% of the poverty level, households would qualify for a premium subsidy if their premiums would amount to more than 8.5% of their income.

Premium subsidies wouldn't be available for people earning seven-figure incomes, because health insurance premiums simply wouldn't eat up more than 8.5% of their income.

But many households with income just a little over 400% of the poverty level would go from having to pay full-price for their coverage (which can amount to more than a quarter of their income, depending on where they live and how old they are) to receiving a premium subsidy that would make their coverage affordable.

Reducing Percentage of Income Paid for Insurance

The 8.5% of income threshold would also be a modification. This was set at 9.5% under the ACA, and is indexed each year. It's currently 9.78% in 2020, and will increase to 9.83% in 2021 (these are for people with income on the higher end of the subsidy-eligibility scale; lower-income enrollees pay a smaller percentage of their income for their health insurance, and this would continue to be the case under Biden's plan).

So instead of ensuring that people don't have to pay more than 9.5% (indexed) of their income for health insurance premiums, the Biden plan would ensure that people don't have to pay more than 8.5% of their income for health insurance premiums. This would result in more people qualifying for premium subsidies, and larger subsidies across the board.

A Gold (Instead of Silver) Benchmark Plan

Another very significant part of the proposal would be a shift to a gold benchmark plan, instead of a silver benchmark plan (gold plans provide more robust benefits).

The benchmark plan is currently defined as the second-lowest-cost silver plan in each area, and premium subsidy amounts for everyone in that area are based on the cost of that benchmark plan.

The subsidies are designed to keep the cost of that plan at an affordable level (based on the percentages of income described above), although they can be applied to the cost of any metal-level plan.

Because gold plans tend to be more expensive than silver plans, Biden's proposal to switch to a gold benchmark plan would result in larger premium subsidies (although not as dramatically as it would have been without the rule change that has resulted in much higher silver plan premiums in recent years) and better access to more robust health coverage.

Medicare at 60

Biden announced a proposal earlier this year to lower the Medicare eligibility age from 65 to 60, with enrollment optional for people who are 60-64 (they could enroll in a private plan, the public option, or an employer's plan instead).

Medicare is not free—there are premiums for Part B, Part D, Medigap, and most Medicare Advantage plans. But Medicare Part A (hospital insurance) is premium-free for most enrollees once they turn 65, and that would be the case starting at 60—for people who opt into Medicare at that point—if Biden is able to implement this part of his health care reform proposal.

Non-Discrimination in Health Care

Biden would reverse the Trump administration's rule that allows discrimination in health care based on gender identity, sexual orientation, and sex stereotyping. The rule, which was finalized in 2020, also reverts to a binary definition of sex as being either male or female.

The Trump administration's rule eliminated many of the nondiscrimination provisions that the Obama administration had finalized in 2016 in order to implement Section 1557 of the ACA. Under a Biden administration, the rules would be revised again and would end up being much closer to the broad non-discrimination protections that were implemented in 2016.

A Ban on Surprise Balance Billing

When medical providers are part of a patient's health insurance network, they have to agree to accept the insurer's payment (plus the patient's cost-sharing) as payment in full, and write off any charges above that amount. But out-of-network providers do not have this obligation, and can bill the patient for the excess amount.

This is known as balance billing, and it's considered "surprise" balance billing in situations where the person didn't have a choice or didn't realize the provider was out-of-network (as opposed to actively choosing to see an out-of-network provider, despite the cost).

Surprise balance billing happens in emergency situations, and in situations where a person goes to an in-network medical facility but doesn't realize that some of the providers may not be in-network—including providers that the patient may not even realize are part of their care team, such as assistant surgeons and durable medical equipment vendors.

Surprise balance billing is nearly universally considered unfair to patients. Both political parties agree that patients should not be stuck with the bill in these circumstances, although there is disagreement over how the solution should be crafted (i.e., should the provider have to reduce their rates, or should the insurer have to pay more).

More than half of the states have enacted laws to protect patients from surprise balance billing. But state laws do not apply to self-insured health plans, which cover the majority of people who have employer-sponsored health insurance (self-insured plans are regulated by the federal government instead).

Biden's platform calls for prohibiting "health care providers from charging patients out-of-network rates when the patient doesn’t have control over which provider the patient sees." Federal legislation has been considered in recent years to address surprise balance billing, but none of the bills have been enacted.

Reduce the Cost of Prescription Drugs

Biden's health care platform includes extensive reforms to address the spiraling cost of prescription drugs. Prescription drug costs are a significant factor in health insurance premiums, so the high cost of medications in the U.S. is borne by those who pay for their own drugs as well as those who purchase health coverage, including Medicare and commercial health plans.

Allowing Medicare to Negotiate Drug Prices

Under current law, Medicare is not allowed to negotiate prices with the pharmaceutical industry. This provision was part of the 2003 law that created Medicare Part D, and it keeps prescription prices for Medicare beneficiaries higher than they would otherwise be.

Limiting the Price of New Specialty Drugs

When a new drug is launched without competition, Biden's plan calls for an independent review board to determine the value and fair pricing, which will be used by Medicare and the public option, and by private insurers if they choose to do so.

In the current environment, there is no such pricing oversight, which means that pharmaceutical companies can launch drugs at prices that are unjustifiably high, knowing that patients and insurers will have little choice but to comply with the pricing since there is no competition.

Limiting Drug Price Increases

Biden's plan calls for limitations on how much pharmaceutical companies would be able to increase their prices from one year to the next, with limits based on the general inflation rate for insurers that participate in Medicare and the public option. The proposal would apply to all "brand, biotech, and abusively priced generic drugs."

A recent analysis of 460 drugs found that their prices increased by more than double the inflation rate in 2020. Biden's proposal is an effort to curb these year-over-year increases in prescription drug prices that make mediations increasingly out-of-reach for consumers.

Allowing Americans to Buy Foreign Drugs

As long as the Department of Health and Human Services agrees that the imported drugs are safe, Biden's proposal calls for allowing Americans to purchase their medications from outside the U.S.

In most circumstances, it's currently illegal for Americans to obtain their prescription drugs from other countries, but Biden's proposal calls for those rules to be relaxed or eliminated.

Ending the Tax-Deductibility of Drug Advertising

Pharmaceutical advertising costs are currently tax-deductible, which incentivizes pharmaceutical companies to spend an inordinate amount of money on advertising.

The American Medical Association has called for a ban on direct-to-consumer pharmaceutical advertising, noting that it "is driving demand for expensive treatments despite the clinical effectiveness of less costly alternatives."

It's notable that the U.S. is also one of only two countries in the world that allow direct-to-consumer pharmaceutical advertising, and it's a multi-billion dollar industry in the U.S. Not surprisingly, the Association of National Advertisers disagrees with the AMA, and feels that direct-to-consumer pharmaceutical advertising should continue.

Expediting the Availability of Generic Drugs

There are widely used strategies that allow the pharmaceutical industry to delay the introduction of generic drugs to the market, even after patents have expired.

The FDA has described drug industry tactics—including withholding samples of their drugs from generic drug manufacturers—as "shenanigans" and legislation to ensure that drug companies provide samples to generic manufacturers has broad bipartisan support in Congress.

General Improvements in Health Care Access

Biden's platform also includes a wide range of proposals for expanding access to health care.

This includes doubling federal funding for community health centers, which serve populations that would otherwise have limited access to affordable health care.

It also includes better access to reproductive health care by eliminating the Hyde Amendment, codifying Roe v. Wade, and restoring federal funding for Planned Parenthood. [The Trump administration issued a rule in 2019 that prohibits Title X funding for an organization that performs abortions or refers patients for abortions, resulting in Planned Parenthood leaving the Title X program.]

Biden's plan also calls for reducing America's maternal mortality rate, which is currently worse than all other similarly wealthy countries. The plan calls for a nationwide approach that mirrors what California has done, cutting its maternal mortality rate in half since 2006 by "linking public health surveillance to actions, mobilizing a broad range of public and private partners, developing a rapid-cycle Maternal Data Center to support and sustain quality improvement initiatives, and implementing a series of data-driven large-scale quality improvement projects."

A Word From Verywell

Biden's health care platform serves as a roadmap for where he would like to take the country in terms of health care reform, but full implementation would require a willing Congress and court system. So it's more likely that we'd see some of these proposals brought to fruition, while others might be held up in the legislative or judicial system.

In general, the Biden Plan can be thought of as ACA 2.0: Building on what works in the ACA and modifying existing laws and regulations to expand access to affordable health coverage and health care to more people.

Many of the provisions in Biden's proposal are also reflected in the Democratic Party's 2020 Health Care Platform, indicating that Democrats are likely to stand behind Biden in his efforts to reform the American health care system.

The party platform calls for a strong public option, aggressively addressing the cost of prescription drugs, eliminating the income cap on premium subsidies, and reducing, to 8.5%, the amount of household income that people have to pay for self-purchased health insurance.

It also calls for improving access to mental health care, reproductive health care, and maternal health care, among many other potential improvements that would expand access to affordable, comprehensive health care in the U.S.

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