Biden's fragile legacy on health care
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President Biden at a White House event last year marking the first anniversary of the Inflation Reduction Act. Photo: Win McNamee/Getty Images
President Biden — who was propelled into office in no small part by his health care agenda — realized Democrats' decades-long dream of allowing Medicare to negotiate prescription drug prices, and came closer to achieving his party's equally elusive goal of universal health coverage than any other Democratic president before him.
Why it matters: As history-making as those achievements were, his health care legacy is a fragile one that could be undone by future administrations, congresses or court decisions, and in some ways is already being overshadowed by rising medical costs that top many Americans' financial concerns.
Driving the news: Biden put lowering prescription drug costs for seniors and expanding coverage to a record number of Americans among his top accomplishments in the letter announcing his decision to bow out of the presidential race on Sunday.
The big picture: Biden's presidency was shaped by huge health care decisions, beginning with a COVID-19 response that brought mass vaccinations and scaled-up testing, but also controversial mandates on masking and vaccines and flawed public health messaging.
- He revived the cancer "moonshot" he first spearheaded as vice president, launched a multibillion-dollar science agency aimed at curing major diseases and took steps to close gender gaps in medical research.
- He issued executive orders to protect abortion access after the Supreme Court overturned Roe v. Wade and took further steps early this year to expand access to contraception, abortion pills and emergency abortion care. Yet many of those moves could be reversed by a future Republican administration.
- The same goes for the Medicaid demonstration waivers that gave states a way to test new approaches in the safety net program, including eligibility and benefit expansions.
Between the lines: Biden's biggest health accomplishment may have been in dramatically expanding health coverage and getting the nation close to a goal that Democratic presidents starting with Harry S. Truman embraced.
- Following up on campaign pledges to protect the Affordable Care Act, he pushed through Congress the enhanced subsidies for marketplace coverage that drove record sign-ups at little or no cost for some low-income customers, especially in states that haven't expanded Medicaid.
- While that helped drive the national uninsured rate to record lows, the subsidies expire next year and are likely to not be renewed if Republicans sweep the November elections.
- And the ranks of the uninsured are certain to tick up again as states continue to pare their Medicaid rolls post-pandemic.
Biden also made good on enacting Medicare drug price negotiations via the Inflation Reduction Act — an idea that Democrats pushed for almost 20 years against fierce drug industry resistance.
- While the negotiated prices will initially cover just 10 prescription drugs starting in 2026, talks will expand to more drugs in the following years and could include blockbuster GLP-1 weight-loss treatments.
- And yet the drug pricing plan is facing a barrage of legal challenges from drug manufacturers and their allies, who contend it's government overreach that will squelch investment in medical research. So far, the administration has prevailed in three cases, giving proponents hope they can build on the plan and even extend discounts to private health plans.
The IRA brought other reforms, including a redesign of Medicare's Part D that capped seniors' drug costs and prescription drug inflation rebates.
- But Biden wasn't able to deliver on his campaign plan to lower Medicare's eligibility age from 65 to 60 or to create a new public option available in the individual market or with employer coverage.
What we're watching: Democrats settled their internal debate over Medicare for All when Biden won the party's nomination in 2020, and the push for such a large expansion of the program has largely receded.
- But Biden's withdrawal opens the door for a renewed attempt to expand public insurance options, should his successor choose to move to his left — which most of the 2020 primary field did.
- On the other hand, the health care landscape has changed dramatically since 2020, with abortion becoming a much more urgent issue for the party after the fall of Roe, and the appetite for reigniting a coverage debate may not be there.
