Joe Biden’s pitch to voters is that he is the bearer of President Barack Obama’s increasingly marginalized legacy. This is more obvious than ever reading through the Vice President’s new health care plan, released today by his campaign. It’s one of Biden’s first major policy releases, a culmination of his longstanding opposition to the Medicare for All proposals touted by his rivals, and one of the more detailed health care plans put out by a moderate Democrat this cycle. It is also a policy deeply defined by its reverence for the Affordable Care Act; much of its goals involve rolling back Trump’s assaults on Obamacare and nearly all of it is based in strengthening the frameworks enacted in 2010.
The result is a plan that appears to be deeply considered and beneficial to many left behind by the Affordable Care Act’s advances, yet one that does far too little to address the numerous structural failings of America’s health care system. Perhaps even more disappointing is that, in a primary campaign defined by aspiration and reinvention, these shortcomings appear to be by design, a misguided attempt to capitalize on Obama’s legacy and maintain the status quo.
A series of smart, obvious additions to the ACA
The biggest addition in the Biden Plan is the creation of a public option in the insurance marketplace. This plan would be run by the government in a way similar to Medicare and Medicaid. It would lower health care costs by negotiating directly with hospitals. This is something Medicare already does, and a theoretical Medicare for All plan would do as well. Critics of that approach say that lower health care costs for everyone as a result of these negotiations would financially threaten hospitals and doctors. Assumably since the public option in the Biden plan would not cover every American, only those who want the public option, this would not be an issue. But since the Biden public option will cover primary care without co-payments—a very generous amount of coverage that many plans lack—it’s likely that a large amount of Americans would switch to the public option. Biden does not address what impact this may have on hospitals or doctors.
The Biden plan would universalize the tax credit Americans receive to pay for health insurance on the individual market. Currently, anyone making between 100% and 400% of the federal poverty line receives a tax credit calculated with the goal of ensuring they do not need to pay more than 9.86% of their income towards a silver-level plan. This has been a dumb part of Obamacare for years now; the federal poverty line is a poor way to gauge the need for financial assistance nationally (since a middle-class income in one state or area could be low-income in another). Biden’s plan removes the 400% income cap, making the credit available to anyone, and lowers the percentage of income to 8.5%. Additionally, the tax credit will be calculated based on a gold plan as opposed to a silver one, meaning Americans will be able to get higher-quality health insurance for less than before. For a family of four with an income of $110,000 a year that buys insurance on the individual marketplace (as opposed to through their employers), Biden’s campaign says his plan will cut health care costs down by $750 a month.
Between the more generous tax credits and the creation of a public option, Biden says his plan will allow every American the access to affordable health coverage. His health care plan will also be more aggressive in insuring the uninsured than the ACA currently is; anyone making below 138% of the federal poverty line will be automatically enrolled into the public option when interacting with public institutions like school or when applying for welfare programs. A public option, theoretically, would also allow lower-income people living in states that have opted out of Medicaid expansion to receive coverage. There is, however, no word on whether or not the plan will automatically enroll newborns—as other incrementalist plans have proposed—or if Biden’s plan will lead to the return of the individual mandate (although Biden has previously pledged to do so.)
The Obama legacy
There are a number of more aspirational proposals laid out in Biden’s plan: closing loopholes that allow perscpriton drug companies to avoid negotiating with Medicare, limiting prices on new drugs with specific use cases that don’t face competition, allowing Americans to import perception drugs from other countries, and working to increase access to mental health care in rural communities. But most of these policies are not very detailed and appear to be incidental to the campaign’s messaging around health care. Fundnementially, the Biden plan is an attempt to plug the gaps in the Affordable Care Act that allow people to go uninsured or underinsured, and to address the concerns with expensive plans on the individual market. It does little or nothing to deal the issue of medical debt, bloated administration costs, or high co-pays for people who get insurance through their employers. It is not a complete reimagining of America’s costly, inefficient health care system that other, more progressive candidates are proposing. A according to the Biden campaign, this is intentional; Biden views improvements to the ACA as the best and most viable path to universal access to healthcare. The messaging around this plan is another example of Biden’s longstanding goal of tying himself to the Obama administration, with facts and nauance occasionally taking second place to rhetoric.
The first thing you see when you view the campaign’s page explaining the new plan is a YouTube video where Biden says that “I understand the appeal of Medicare for All but folks should be clear that it means getting rid of Obamacare”. As many other campaigns have pointed out, this is a silly argument, since debating a Medicare for All bill in Congress has no effect on current laws and because every serious Medicare for All plan currently circulating includes a years-long transition process specifically to create an orderly bridge between systems. The second thing you see is a paragraph describing how the “Obama-Biden administration” passed the Affordable Care Act, which led to the uninsured number of Americans dropping in half. Again, this something of a fallacy; most accounts of the Obama administration say Biden was against Obama’s decision to make health care reform a priority in his first year. While he got behind passing the law as the administration moved forward, most of the more radical policies in early iterations (including a public option) were rejected by more moderate Democrats, a group Biden belonged to as a Senator.
By tying himself to the Affordable Care Act and limiting his policy thinking to incrementally improving a system that already exists, Biden seems to be trading an opportunity to help more people for very little political benefit. Efforts to defend Obamacare have increased its public popularity, but it is still a deeply unpopular plan that is facing numerous legal challenges. It is unclear whether modest increases to the ACA would drive turnout in what will likely be an incredibly close election, or create the kind of public support required to pass the plan in a divided Senate.
Biden is promoting this plan as a safer route to universal healthcare, a pathway that runs through already existing markets as opposed to a more fundemential rethinking of the American health care system. There are benefits to this approach; passing this plan may be less politically intensive than Medicare for All. Biden says he’ll pay for this plan by repelling Trump’s tax cuts and by levying a modest tax on capital for America’s highest earners, which is a more straightforward funding approach than other proposals.
But there is only so much that can be done with a system that many regard as fundamentally broken. Regardless of your opinions on the ACA, many Americans are still deeply unsatisfied with their health care, and the US falls behind developed countries in health care costs, access to doctors, and medical debt. As the torturous fight to pass Obamacare showed, whatever healthcare plan Democrats push (including Biden’s) will be met with near universal opposition by Republicans, both in terms of rehtoric and potientially fatal legal challenges. This is the moment for the creation of a truly just, less wasteful and exploitive American health care plan, a proposition that Biden seems unwilling or unable to grapple with. While his plan includes smart reforms that would help many, it does not do enough for the millions of American facing medical debt or high costs under employer insurance. In trying to create something attainable, Biden’s plan simply does too little.