Early acts by president presage bigger health care changes

From the first day of his presidency, President Joe Biden made it clear that shaking up the health care status quo is of paramount importance to him. Many of his early actions are aligned with ACP policies and its vision for U.S. health care, “Better Is Possible: ACP's Vision for the U.S. Health Care System,” which was released in January 2020 and is even more relevant in the era of COVID-19. Yet much more will be needed to create a better health care system that is accessible to all.

Elevating response to COVID-19

President Biden initiated a series of actions to improve the nation's response to COVID-19, many of which had previously been recommended by ACP. He directed agencies to address racial disparities in infections and recovery; increase production, supply, and distribution of personal protective equipment, vaccines, and tests; increase testing; and strengthen U.S. relationships internationally, including rejoining the World Health Organization. Agencies were told to prioritize high-risk populations in long-term care facilities, encourage new therapies, ensure treatments are available and affordable, create a sustainable public health supply chain, protect worker health and safety, and ensure a data-driven response to COVID-19 and future public health threats.

The president ordered agencies to implement evidence-based practices to limit spread of COVID-19, including requiring federal employees, federal contractors, and visitors in federal facilities and on federal land to wear a face mask, practice social distancing, and adhere to other CDC recommendations. Mandates were issued to require the wearing of masks on public transportation, including trains, airplanes, buses, and subways, and at any transportation hub that provides transportation within the United States.

Ensuring equity for immigrants

President Biden reversed the previous administration's ban on travel from seven majority-Muslim countries, consistent with ACP policy on the value of allowing legal entry to the United States, including by physicians and other scientists, for study, research, work, and other purposes subject to applicable U.S. visa requirements, without regard to country of origin. Other ACP-supported actions seek to reunite children detained and separated from their families at the border, reverse the “public charge” rule that puts legal immigrants at risk of deportation if they get benefits from Medicaid or other public programs, and streamline the naturalization process for legal immigrants, including for international medical graduates residing and practicing in the U.S.

The administration restored and pledged to strengthen the Deferred Action for Childhood Arrivals (DACA) program. ACP has long supported the DACA program and finding a pathway to citizenship for individuals in the program, including for DACA-eligible medical students, physicians-in-training, and physicians in teaching and practice.

Prioritizing nondiscrimination, health equity

Federal agencies were directed to assess systemic barriers in accessing benefits and opportunities for marginalized and underserved communities; consider whether new regulations may be needed to advance equity in these programs; and direct resources toward underserved communities. As previously called for by ACP, the administration reversed a prohibition on federal agencies and contractors offering or supporting certain forms of implicit bias training. Agencies were told to address housing inequities, which are associated with poorer health outcomes, and strengthen relationships with American Indian and Alaska Native tribes.

Another order supported by ACP directs federal agencies to fully enforce laws prohibiting discrimination, address overlapping forms of discrimination, and determine whether further action or new regulations are needed.

Promoting environmental health, scientific integrity

The president ordered federal agencies to protect public health and the environment and restore science to tackle the climate crisis and announced the U.S. would rejoin the Paris Agreement. ACP believes that efforts to reduce greenhouse gas emissions are crucial to mitigating the impact of climate change on human health. The president directed agencies to prioritize science and integrity in policymaking and protect government scientists from political interference.

Easing student loan repayment

The president extended a pause on federal student loan payments and collections through Sept. 30, 2021, and kept the interest rate at 0%. This is especially important for physicians who may be experiencing a reduced salary while also helping the health care system cope with COVID-19.

Improving access to care

ACP supports the administration's decisions to create a new Affordable Care Act open enrollment period for people affected by COVID-19; require agencies to review policies that undermine coverage, including sales of plans that do not cover needed care; reduce barriers to Medicaid enrollment and eligibility; and expand access to reproductive health care services.

What to expect next

As significant as these initial steps have been, many of them only start the process of changing health care policy. Requiring agencies to review rules that create barriers to care and coverage, for example, does not necessarily mean they can unilaterally change them. Many rules finalized by the previous administration likely will need to go through another round of rulemaking with public notice and comment. While the administration's approach to COVID-19 seems promising, it will be judged by how effective it really is at turning the tide against this pandemic.

Much will be determined about the willingness of Congress to put dollars and policies behind the administration's aspirational goals, since legislation in the Senate will require 60 votes to overcome a filibuster, and the Democrats only have 51 if Vice President Kamala Harris casts a tie-breaking vote. With significant GOP opposition in the Senate to the scope and cost of the administration's plans, legislation would need to be passed by using the cumbersome budget reconciliation process, which requires only 51 votes; by ending the filibuster, which is unlikely, although it could be curtailed; or finding an approach that at least 10 Republican senators would support. So far, the administration and Democratic congressional leadership are moving forward on using reconciliation rather than accepting a scaled-back version of legislation to win GOP support.

Then there are whole host of issues important to ACP that were addressed only partially or not at all by the Biden administration's early actions, including needed reforms in payment policies to support the value of care provided by internal medicine physician specialists, prioritizing collaboration with primary care physicians in vaccine distribution, addressing student loan debt, training more internal medicine physicians, and building on the Trump administration's efforts to put patients over paperwork and advance telehealth, among many others.

That the new president wants to shake up health care policy in a direction that ACP has long called for on many issues is welcome. What happens next, especially with Congress, will determine whether grander and bigger changes to make U.S. health care better, as ACP called for in its new vision for health care, come to fruition.