Quick fixes? What Biden can do to improve health care system now

Fewer people likely would have died from COVID-19 if everyone in the United States had access to health care. But a system of universal health care coverage is not coming to this country any time soon. 

The public option, a Medicare-style plan that people could choose to buy into that has been the centerpiece of President Biden’s health care plan, is not likely either. Unless the U.S. Senate does away with the filibuster, Biden won’t have the 60 votes in the Senate that he would need to pass major health reform.

The U.S. spends more on health care than peer countries, and yet has higher rates of people uninsured, more chronic disease and lower life expectancy.

But even without Medicare for All or a public option, the administration can get us closer to quality, affordable health care. These solutions are consistent with the preference of the majority of Americans for incremental change. 

There are two major ways that the current system falls short of universal health care: over 30 million people do not have any coverage at all for health care expenses, and more than 43 percent do have coverage but still cannot afford the care they need. 

To get more people covered, the government should expand subsidies and broaden access to Medicaid.

One of the key reforms of the Affordable Care Act (ACA) was the creation of state marketplaces. The idea, while imperfect, is one-stop shopping for health insurance policies for those who can’t get a policy elsewhere.

The marketplaces were also designed to address the number one reason people give for not having insurance: affordability. Low-income Americans — not the poorest Americans who typically qualify for Medicaid but those who make between 100 percent and 400 percent of the federal poverty level, or roughly $17,000-$51,000 per year for a one-person household — qualify for lower premium rates. The federal government pays part of the cost of their marketplace plans to make coverage more affordable.

The subsidies have worked. Around 10 million people got marketplace coverage in 2014 because of ACA reforms like the subsidies. Of those who purchase policies through the marketplace, 86 percent do so with the help of subsidies.

Still, the marketplaces are only enrolling about a third of potential enrollees while millions of Americans continue to be uninsured and the number keeps growing. 

Biden has proposed widening eligibility for subsidies and increasing the generosity of the amount awarded. A new analysis finds that expanding access to subsidies would lower the cost of coverage for almost all marketplace enrollees. More affordable coverage means higher enrollment rates.

More good news is that increasing subsidies is something that can almost certainly be done through the budget reconciliation process. It will only require a majority of votes in both houses of Congress, votes that Biden should be able to get.

Additionally, Biden has proposed building on the success of the ACA’s Medicaid expansion. Prior to the ACA, Medicaid coverage was mostly reserved for the “deserving poor.” In other words, you had to be a child, the caretaker of a child, a pregnant woman or in some other covered category. Just being too poor to afford coverage was not enough. 

The ACA gave federal funding to incentivize states to expand eligibility for Medicaid coverage — to cover all poor people, whether or not they were in a special category. Most states took it. Only 12 did not. But those states — which include Texas and Florida — have the highest uninsured rates in the country.

While states cannot be forced to expand Medicaid eligibility, the federal government can make the funding too good to pass up. If the remaining 12 states agree to take federal money for Medicaid expansion, over 4 million Americans would become eligible for coverage. 

Promising generous funding for Medicaid expansion is also something that could be accomplished through the budget reconciliation process. 

And expanding Medicaid serves the companion goal of improving affordability. Most services for Medicaid enrollees are paid for in full, with no out-of-pocket contribution required. 

In general, reducing out-of-pocket costs is difficult without major legislation. For example, proposed reforms to combat the high price of prescription drugs, just like the public option, will prove difficult to get through Congress. 

Some progress, however, can be made through executive and administrative action. A small but nevertheless impactful reform would be to do away with a 2017 rule that allowed plans to charge higher deductibles and copays. 

Even without sweeping change, Congress can move the United States closer to the ultimate goal of universal and affordable health coverage. As close to 1 million Americans continue to contract COVID-19 every day, change that results in more people having access to health care will save lives in the weeks and months ahead.

Wendy Netter Epstein is professor of law; faculty director, Mary and Michael Jaharis Health Law Institute at DePaul University and a Public Voices Fellow of The OpEd Project.