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Biden’s most daunting challenges, according to public health experts

When President-elect Joe Biden takes the oath of office, the single biggest priority for his administration will be tackling the coronavirus pandemic. But even before COVID-19 killed hundreds of thousands of Americans, infected millions, and exposed structural weaknesses and inequities in health care, the country faced fierce debate over access to that care — a challenge Biden will also inherit.

Health policy experts expect him to tackle issues like Medicaid expansion and the future of the Affordable Care Act — a signature achievement of the Obama administration, which Biden served, and Republicans’ attempts to dismantle it — along with a weakened public health system pushed to the brink during a pandemic. When the dust of the pandemic settles, will the administration take a close look at questions like, who isn’t covered and why? How will it prioritize public health funding, or revamping the nation’s health infrastructure?

But until the virus is under control, “nothing works,” said Dr. Ashish Jha, dean of the Brown University School of Public Health. And urgency to regain the control over the pandemic is only mounting, with a new variant of the coronavirus confirmed in several places in the U.S. and in multiple countries after initially being identified in the United Kingdom.

Americans don’t know when life — schools, work, family and community — will ever return to what it was before. To rein in the virus, enough people in the U.S. need to get vaccinated to generate herd immunity. Already, states have been frustrated about bottlenecks in the distribution of doses, which has so far fallen short of Operation Warp Speed’s estimates.

Two run-off elections in Georgia on Tuesday will determine whether or not Republicans keep majority control of the Senate, which could influence the Biden administration’s ability to keep campaign promises, whether on coronavirus relief measures or expanding the ACA through a new public option.

The Biden team must accept that they “have to deal with the situation they have inherited,” Jha said, and quickly will be forced to own their response to the coronavirus pandemic, along with any successes (and failures).

Here’s what public health experts anticipate under a new administration.

The pandemic

One of Biden’s first actions after he was declared the winner in the presidential election was to form a COVID-19 advisory board. That board would weigh incoming data and research about how to implement the country’s COVID-19 response in order to chart a new course to get the country out of the pandemic. How should vaccine distribution be altered? Where is PPE most needed? How might wider usage of face masks alter transmission? And how might the new variant of the coronavirus throw what was understood about the virus so far into upheaval?

During the Trump administration, the White House Coronavirus Task Force gathered to tackle similar questions. But publicly, the task force often was sidelined by politics, with Trump making unproven claims about the benefits of hydroxychloroquine, while his chosen task force leader, neuroradiologist Scott Atlas (who had no experience managing responses to infectious diseases or epidemics), made false statements discouraging the use of face masks and advocated natural herd immunity before he resigned from his post in November.

Biden’s team is stacked with public health experts, including former U.S. Surgeon General Vivek Murthy (who is Biden’s nominee to again hold that same position).

READ MORE: What Biden can do to fight COVID-19 before Inauguration Day

Experts say the president-elect must address persistent problems in testing, left over from the Trump administration. Standing up a national COVID-19 testing strategy is vital to detecting outbreaks early and should be done within Biden’s first 100 days, said Dr. Leana Wen, an emergency physician and professor at George Washington University.

That includes the cost of getting tested for COVID-19, which may or may not be covered by health insurance, depending on the circumstances (like whether a doctor prescribed the test). If people aren’t sure they can afford the cost, they are less likely to get it when needed, and communities could be caught off-guard while an outbreak is already underway.

Biden and the Democratic Party have also criticized the Trump administration’s vaccine distribution campaign under Operation Warp Speed as “slow,” said Joe Antos, a health policy scholar at the American Enterprise Institute who worked at the Office of Management and Budget and the Department of Health and Human Services under the Reagan administration.For months, the Trump administration had pledged to have 20 million people vaccinated by Dec. 31. According to a newly launched database from the CDC that tracks progress in vaccinations, 17 million doses were distributed and 4.8 million people had been vaccinated for COVID-19 by Jan. 5. At the current rate of vaccination of about 1 million people per week, Wen said it will take roughly a decade for the U.S. to achieve herd immunity against COVID-19.

The practical problems of vaccine distribution, such as coordinating people to get shots in their arms, “aren’t going to go away just because Joe Biden is sworn into office on Jan. 20,” Antos said.

Jha called Biden’s assurance that he will get 100 million vaccine doses to Americans during the first 100 days of his presidency “ambitious.”

“If they can’t get to 100 million doses in 100 days, they can’t say that’s because of the Trump administration,” Jha said, because Trump will no longer be in the White House.

Antos said that what Biden says now could “come back to bite him” if he’s “living in the campaign world as opposed to the governing world.”

Wen also hopes that the Biden administration prioritizes something that has been a problem under multiple presidencies but brought into sharp focus by COVID-19 — the nation’s neglected public health infrastructure and a lack of funding for local health departments. In the past, investment in public health, especially in preparation for a pandemic, has been one of the first items cut whenever budgets need to be slashed. While some administrations have at least devoted some planning in the event of a pandemic, as was the case during the Obama administration, that is different from giving public health departments the resources and funding they need to be able to respond when outbreaks and community transmission spin out of control. Since 2010, per-capita spending had decreased 16 percent for state public health departments and 18 percent for local health departments, the Associated Press and Kaiser Health News reported in July.

Filling in those overlooked gaps would better position the country to identify, trace and isolate cases of infectious diseases, including the coronavirus, potentially preventing widespread outbreaks and massive disruptions to life and society. The nation’s ongoing opioid crisis is one example of how the country’s ability to respond to public health dilemmas has been compromised because of the pandemic, she said, pointing to a recent report from the CDC that showed a historic rise in drug overdose deaths between May 2019 and May 2020.

READ MORE: What’s behind the historic spike in drug overdose deaths under COVID-19

“There are all these ongoing health issues that have not gone away with the coronavirus, and if anything, many of these issues were exacerbated because of coronavirus,” Wen said. “We just don’t have the bandwidth to address them.”

Investing more in public health will also help address critical disparities in communities of color and low-income households that have been disproportionately rocked by the pandemic. Starting in mid-March, Biden campaigned for a COVID-19 renewable fund for states, tribes and local governments that would “provide sorely under-resourced public health departments the support they need to stop new outbreaks.” People of color have long been more likely to be uninsured than white people. Many either work in essential jobs that required them showing up in-person, or lost their jobs when the economy buckled last year. Despite funding cuts, public health departments have been critical to extending health care to these communities, but the pandemic has overstretched their resources.

Strengthening access to health care

The percentage of uninsured Americans rose in 2017, 2018 and 2019, after hitting a historic low in 2016, according to the Kaiser Family Foundation.

Linda Blumberg, a fellow at the Urban Institute’s Health Policy Center said some weakened care or gaps in coverage are a result of the Trump administration’s strategies to gut the ACA.

Those measures included Trump’s executive orders that lifted restrictions on short-term plans. These health insurance policies typically cost less because they did not have to cover all essential benefits as mandated under the Affordable Care Act, such as hospitalization, emergency and preventative services and prescription drugs. Without these ACA guidelines, insurers could reject a person’s application or charge higher premiums based on medical history. The Trump administration also cut staffing and funds for outreach, such as advertising, for the Obamacare marketplace insurance plans, which experts say made it harder for Americans to navigate or complete enrollment.

Trump’s moves “have all weakened the adequacy of coverage for a lot of people,” Blumberg said, adding they must be addressed to ensure people have access to health care in the middle of a pandemic. Ramping up outreach around enrollment could be as simple as the flip of a policy switch to free up some money, Blumberg said, but some steps would require more effort and funding.

Before the election, the Trump administration, along with several Republican state attorneys general, stoked a massive legal fight over the constitutionality of the Affordable Care Act itself after a Republican-led Congress stripped the individual mandate from the health care law. The case, which threatened to fully wipe out the mandate, escalated to the Supreme Court. But the federal-level support for that case is expected to atrophy when Biden takes office, said Joan Alker, who directs Georgetown University’s Center for Children and Families.

One of Trump’s lingering legacies that may not be so easy to undo is his administration’s public charge rule, Alker said. The federal regulation had the effect of scaling back access to public benefits that are critical for health for many immigrants who live in the U.S., no matter what their legal status, by making it harder for them to gain a green card if they are enrolled in programs such as Medicaid.

READ MORE: How U.S. citizens’ health could suffer under Trump’s new rule aimed at immigrants

Touted by Ken Cuccinelli, acting director of U.S. Citizenship and Immigration Services, as encouraging “self-reliance and self-sufficiency,” Alker said the move was “part of an agenda that’s very hostile to immigrant families.”

As a result of the rule, she said, “we have lots of children who are citizens, and their immigrant parents are scared now to enroll their children into Medicaid or CHIP [the Children’s Health Insurance Program].” Between 2017 and 2019, Alker said more than 726,000 children have become uninsured, and she fully expects that the pandemic will drive those numbers beyond 1 million kids when 2020 data is available.

While Alker anticipates that the Biden administration will quickly undo that regulation, it will take time to regain people’s trust.

“To have an administration that wants people to be covered will be a giant step forward,” Alker said.

In order to grow the ranks of the insured after a few years of reductions, Biden has said he wants to offer more subsidies to allow people to buy health insurance plans on the marketplace established under Obamacare. Another option, health policy experts suggest, would extend Medicaid coverage to people who live in states that haven’t expanded coverage under the ACA.

Many progressive Democrats have wanted to see a grander version of the ACA than what was initially forged during the Obama administration — something more akin to universal health coverage. But over the course of a decade, Republicans have pushed back against the ACA, saying it surrenders too much control to the government and doesn’t do enough to contain spiraling health care costs, which make up roughly a fifth of the U.S. gross domestic product. For Republicans, the prospect of restarting talks over the ACA activates political muscle memory from the Obama administration, Antos said. For years, some conservative politicians have staked their campaigns on talking points of dismantling the ACA, and many constituents signaled their approval by voting those people into office, he said.

“It’s not politicians but voters in a lot of districts in a lot of states” who want to get rid of the ACA, Antos said.So far, 38 states plus the District of Columbia have adopted expanded Medicaid coverage through Obamacare. And Biden could consider incentives for Medicaid expansion, such as legislation that offers states more benefits or updating state waivers to encourage greater Medicaid coverage. That may appeal to more states, said Matthew Fiedler, an economics fellow with the Brookings Institution and a chief economist on the Council of Economic Advisers during the Obama administration. That could include expanding tax credits to help individuals and households afford more comprehensive health care plans.

READ MORE: COVID-19 has eroded confidence in the U.S. health care system

Even if Democrats win a narrow Senate majority after the Georgia runoff election, Fiedler said he still thinks it would be difficult for the Biden administration to secure enough votes to successfully pursue a public option. Fiedler expects “intense” resistance to a public option from health care providers. That’s due to the fact that the U.S. health care system is built to financially incentivize reactive care rather than preventative care.

The pandemic seems to have increased Americans’ interest in universal health care coverage. That may be influenced in part by how countries with such coverage have been able to respond to and contain the virus. In a Sept. 1 poll from the PBS NewsHour and Marist, 55 percent of Americans said they had a favorable impression of universal health care coverage, which the U.S. does not have. That’s up slightly from 52 percent in February before the coronavirus and the threat it carried were fully recognized in the U.S.