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How the congressional balance of power limits Biden on health care

The Affordable Care Act allows young adults to stay on their parents’ insurance for several years, prohibits insurance companies from refusing to cover pre-existing medical conditions and enables roughly 12 million Americans to receive Medicaid. But without congressional support, could President-elect Biden still expand it? William Brangham talks to The Washington Post’s Paige Winfield Cunningham.

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  • William Brangham:

    The Affordable Care Act is deeply woven into the fabric of American life, more than many people realize. It allows young adults to stay on their parents' insurance plans for several years.

    And, as John reported, it prohibits insurance companies from refusing to cover preexisting conditions. And millions of Americans get Medicaid through it, roughly 12 million people, in fact.

    During the campaign, president-elect Biden laid out a number of proposals to expand coverage. But it's not clear if he will have the votes in Congress to do so.

    So, what could a health care administration under the Biden administration actually look like? And how tied is it to the fate of the Affordable Care Act?

    Paige Winfield Cunningham covers health care policy for The Washington Post. And she joins me now.

    Welcome back to the "NewsHour."

    The Affordable Care Act is, as many people who looked at this case as it was heard today, may survive this legal fight.

    But just could you please remind us what would happen if the ACA were cut totally?

  • Paige Winfield Cunningham:


    Well, as you noted earlier, there would be, indeed, a huge effect, not only on the people who got coverage through in the marketplaces in Medicaid expansion, but also the people who are protected because of the preexisting condition.

    The law is really huge and sweeping. And it's certainly hard to imagine and hard to overstate the impact if the law were to be struck down.

    I would like to say, though, if that should happen next spring, there is recourse for Congress. Congress could actually pass a bill which would render the lawsuit moot, essentially, by making clear that it's absolutely clear, once and for all, that it's fine with the law remaining on the books even without the mandate.

    If that were to happen, I think this would be a real sweet spot for president-elect Joe Biden, who, of course, spent many years in the Senate and is skilled at negotiating with the other side.

    And it would be interesting to see how all of this would play out and whether he would be able to persuade Congress then to pass a law making sure that the ACA were preserved.

  • William Brangham:

    As we heard earlier, president-elect Biden gave a speech today about the Affordable Care Act, and he laid out a series of goals for his administration, increased access, lowering costs, increasing coverage.

    But you have been reporting that, even if the Democrats were to win these two Senate run-off seats in Georgia, that the Biden administration might still face real headwinds trying to pass substantive health care improvements. Why is that?

  • Paige Winfield Cunningham:

    Well, right.

    So, when we look at even the best-case scenario for Democrats in the Senate at this point if they win those two seats in Georgia, then they're at 50/50, with the vice president, Kamala Harris, being the tiebreaker.

    In that scenario, take Biden's core health proposal, which is to pass a public government option, adding that to the marketplaces as a cheaper option for people. That's an idea Republicans have made very clear they're not on board with.

    So, were Democrats to try to push that through the Senate, they couldn't afford to lose a single vote. And when you look at some of the more conservative senators — I'm thinking of Joe Manchin in West Virginia — it seems highly unlikely that he would be on board with something like that.

    So we're really looking at smaller-bore things. And probably most of the ways that the Biden administration can put its mark on the Affordable Care Act is by things that can do through executive action and rule-making.

    A big thing we're looking at the administration doing very early on is restoring advertising for the marketplaces, and probably opening up a special enrollment period, really trying to spread the word about the law, and sort of reverse a downward trend in enrollment in the marketplaces and really get enrollment back up.

  • William Brangham:

    Another thing that the Biden has said that he wants to do is to try to get the federal government to have the ability to negotiate drug prices. It's a huge buyer of drugs in the marketplace.

    And he argues, why not let the federal government negotiate with the companies? Does that have any prospects for passing?

  • Paige Winfield Cunningham:

    I'd really put that in the same basket as the public option.

    This is something that — negotiating was included in a bill House Democrats passed a year ago. Then it got stuck. We have even seen smaller-bore bills that would not go nearly as far. Even those really struggled to gain a lot of traction last year.

    So, I could see some smaller things happening, depending on how negotiations go between Biden and Senate Majority Leader Mitch McConnell, if indeed he remains the majority leader. But I would be really, really doubtful if you would see something as progressive as allowing for direct negotiation.

  • William Brangham:

    Assuming this current political storm passes, Biden will be assuming office in January, the middle of winter.

    Unless we reverse course on how we have been dealing with this pandemic, cases are likely to be up, hospitalizations and deaths, plus this — just the economic agony of this pandemic.

    Do you think that any of that has a force that would help push for health care reform?

  • Paige Winfield Cunningham:

    Yes, I know, in talking to people, they have sort of brought up the idea of being able to get different initiatives into some kind of COVID relief bill. And there certainly seems that there will be steam behind passing that.

    And when we're talking about too the effort to expand health insurance and lower health care prices, I think, because of the environment, we're in the pandemic environment, that's got to be the number one focus for the new administration.

    So, you probably will see a bit of a longer timeline in terms of trying to accomplish any other health care priorities. It's really hard to say at this point how a COVID relief bill will shake out. But we definitely know from Biden's comments today that he wants to keep health insurance and health costs front and center in his new administration.

  • William Brangham:

    All right, Paige Winfield Cunningham of The Washington Post, thank you very, very much.

  • Paige Winfield Cunningham:

    Thank you.

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