Last night, President Biden delivered his first joint address to Congress, during which he highlighted several of the actions his administration has taken in the first 100 days and laid out his vision for the future.
Unsurprisingly, the administration's response to the Covid-19 pandemic was front and center. But Biden also briefly mentioned future health policy goals: permanently lowering premiums for coverage purchased on the Affordable Care Act's exchanges, giving Medicare the power to negotiate prescription drug prices, and bolstering the Medicaid-covered home care workforce.
We'll explore each of those in a moment. But before we dive into the policies the Biden administration hopes to achieve, we'd like to take you back to the original predictions we made on Biden's inauguration day. Which predictions came true, which did not, and what are their chances of moving forward during the rest of Biden's presidency?
5 predictions for Biden's first 100 days, revisited
Prediction 1: More centralized control over the Covid response—but probably not as much you might think
How we fared: Mostly accurate
When Biden took office, the nation had two authorized Covid-19 vaccines. Biden set—and ultimately doubled—an initial goal of administering 100 million shots in the first 100 days. But while the Biden administration made changes to the distribution process and communication channels, it's worth noting that before Biden took office, the nation was already on track to administer 100 million vaccines by the 100-day mark.
So, what exactly did the Biden administration do when it took office? First, they increased transparency. Biden appointed Jeff Zients as his "Covid- czar," and Zients has been very consistent in his messaging and public appearances. Zients also reportedly brought back the weekly calls with governors. He reopened communication about the vaccine pipeline and what states could expect (at a time when states were voicing their frustrations over the opacity of the vaccine distribution process). Second, the administration secured additional funding through the American Rescue Plan to help sustain existing and create new vaccination sites.
But in our original post we also posited that the Biden administration would issue stronger mask-wearing guidance and social distancing guidelines, and that they would lean heavily on states to issue their own mandates. This didn't happen. While Biden did issue executive orders to require mask wearing on federal properties and during interstate travel, the administration was less successful in getting states to adopt their own mandates. And now, even CDC is beginning to walk back mask-wearing guidelines as more Americans get vaccinated.
Prediction 2: Boost federal funding for the health care industry, individuals, and vaccine rollout
How we fared: Mostly accurate
While Biden missed his goal of signing a new Covid-19 relief bill by January 30, Congress did ultimately pass a $1.9 trillion Covid-19 package on March 10—but the health care industry was not the main beneficiary of that bill.
The package, called the American Rescue Plan, provided $1,400 stimulus checks to millions of Americans, extended unemployment insurance through September 6, provided full coverage of COBRA insurance premiums through September for those who were laid off amid the pandemic, and increased the child tax credit.
The plan also included billions of dollars to expand vaccinations; $360 billion in emergency funding for state, local, and tribal governments; and a Medicaid FMAP bump to fully cover vaccine administration costs.
But despite our predictions that Democrats could use their House and Senate majorities to include additional Provider Relief Funds (PRF) in the package, those were ultimately left out of the bill. Some Democrats noted that there was still funding in the PRF (though the exact amount has been debated) and were unwilling to divert funds from other areas to put more funding into the PRF. Instead, they included $8.5 billion to help rural providers or suppliers cover health care expenses and lost revenues related to the pandemic.
Prediction 3: First restore then expand access to ACA-compliant health coverage
How we fared: Accurate
As we predicted, Biden rescinded a 2017 executive order that directs federal agencies to consider changes that would loosen federal requirements on association and short-term health plans, which do not have to comply with the ACA's essential health benefits.
One thing has become very clear during Biden's first 100 days: The Affordable Care Act (ACA) is his vehicle of choice for expanding access to health coverage. HHS used its authority under the Public Health Emergency to launch a special open enrollment period for people who lost their employer-sponsored coverage to purchase subsidized coverage on the exchanges. And subsidies available to exchange customers recently became more generous, at least temporarily. Biden is now pushing for Congress to make the subsidy changes permanent as part of his newly proposed $1.8 trillion American Families Plan, which he pitched to Congress during his joint address Wednesday evening.
HHS on April 21 also announced CMS will allocate $80 million for ACA navigators as well as outreach and education efforts for the 2022 open enrollment period. This marks the highest amount allocated for exchange open enrollment assistance and promotion to date.
Prediction 4: Take action to halt Medicaid work requirements—and block grants
How we fared: Mostly accurate
Back in January, we posited that CMS could roll back the Trump-era Medicaid work requirements. In February, the agency signaled it would use its authority to revoke the previously approved letters.
Since then, the agency has formally rescinded waiver approvals in Arkansas, New Hampshire, Michigan, and Wisconsin. States have the option to challenge the decision, but so far none have opted to do so. Instead, Arkansas is continuing to pursue a case pending before the Supreme Court. It's also planning to submit a new waiver to CMS that would allow the state to offer financial incentives for Medicaid beneficiaries in the state's expansion population to participate in a work or education program. We'll be watching closely to see whether CMS approves such a waiver, as that could open the door for other states to offer their own incentive programs.
While we still expect CMS to take action on a first-of-its kind Medicaid block grant waiver for Tennessee, the agency has not yet addressed the waiver. A group of Tennesseans have sued the federal government to halt the waiver from taking effect, and it's possible the Biden administration could decline to defend the case in court.
Prediction 5: Focus on health equity and restore health care protections for LGBTQ+ individuals
How we fared: Mostly accurate
We predicted that HHS under Biden would quickly move to reinstate Obama-era protections that the Trump administration rolled back, such as reversing Section 1557 waivers that permit providers to discriminate against patients on the basis of gender identity, sex-stereotyping, and sexual orientation. While HHS has not yet issued regulations undoing the Trump-era changes, Biden on January 21 signed an executive order that directs federal agencies to review existing policies and expand discrimination protections for LGBTQ+ individuals under federal law.
HHS also has strongly signaled its intent to deliver on Biden's order to close the gap in health equity through policy solutions. CMS earlier this month began issuing annual payment regulations. Each proposed rule (including those for skilled nursing facilities, inpatient rehabilitation facilities, inpatient psychiatric facilities, and the Inpatient Prospective Payment System) included a request for information on ways to close the health equity gap.
While this is not the first time CMS has proposed new ways to account for health disparities, the agency's past efforts have largely focused on social risk. CMS' inclusion of risk factors related to race and ethnicity, as well as a push for hospitals to collect more detailed demographic data, signals a commitment to health equity that we have not seen in the past.
Beyond 100 days
While the Covid-19 pandemic will continue to consume a lot of the Biden administration's time and resources, we expect to see more non-Covid policy movement as more Americans get vaccinated and Biden's health care team is confirmed by the Senate.
Biden teed up a few of his top health care priorities during his joint address to Congress on Wednesday. We expect to see debate in the near term on making the American Rescue Plan's subsidy changes permanent. In the medium term, Congress appears poised for another debate on broader drug pricing reforms, including giving Medicare the power to negotiate prescription drug prices. And in the long term, looking ahead to after the next mid-term elections, Congress will likely have to tackle the looming Medicare Trust Fund insolvency, which will open debate on ways to find additional cost savings and new revenues.