Joe Biden takes office as president of the United States in the midst of a global pandemic, immense economic and social dislocation, recurrent reminders of racial injustice, acrimonious partisan divisions, and disquieting threats to American democracy. After the tumult of the Trump years, Biden will try to restore normalcy to Washington. But he comes to the presidency at a time that is anything but normal, with myriad challenges that will immediately confront his administration.
Health policy will be central to the new administration. As Biden takes office, the staggering case count and death toll from COVID-19 continue to mount. The administration must figure out how to ramp up an unprecedented program of mass vaccination against COVID-19 while encouraging the maintenance of social distancing and other public health measures in a nation that is politically divided and fatigued by the pandemic. It also needs to develop a coordinated national COVID-19 strategy that overcomes the fragmentation of American federalism. And it must prepare for the next pandemic.
Yet the COVID-19 public health emergency is only one issue on the administration's health policy agenda. The pandemic has once again exposed the cavernous holes in America's byzantine, illogical, expensive, and inequitable health insurance arrangements. The uninsured population is on the rise again, driven upward by Trump administration policies that eroded access to insurance and the economic fallout of COVID-19 that buffeted employer-sponsored insurance. The Affordable Care Act (ACA), now more than a decade old, is sorely in need of repairs to make insurance more affordable, while many reformers clamor for more ambitious changes, from a public option to Medicare for All, that aim to cover the uninsured, remedy the growing problem of underinsurance, and control health care spending.
Public support for legislation to curb the costs of prescription drugs is high, but Congress, riven by partisan divisions, has been unable to agree on reforms. Medicare, meanwhile, faces a looming trust fund “crisis” and must reckon with the evolution of payment and delivery reforms that have often not fulfilled their initial promise. While any concern for budget deficits was suspended during the Trump years, eventually deficit politics may create renewed pressures to restrain growth in Medicare spending. On Medicaid, the Biden administration will look to reverse Trump administration policies that enabled states to impose barriers to enrollment, while enticing more states to expand Medicaid eligibility under the ACA. The Biden administration could additionally use the waiver process to encourage states that wish to pursue innovative health reforms. If congressional divisions cannot be surmounted, then the states could emerge as a locus of action in health care policy.
The administration also will confront an opioid epidemic that, even as its terrible toll has been obscured by COVID-19, continues to rage across the US. And it must grapple with the intersections between racism and health that are evident not only in the COVID-19 pandemic's unequal impacts but also in persistent racial and ethnic health disparities, the concentration of continued opposition to Medicaid expansion in former states of the Confederacy in the South, and the everyday experiences of Blacks, Latinos, and other Americans who have been marginalized.
The articles in this special issue explore what the Biden administration can and should do to meet these daunting health policy challenges. There is no shortage of obstacles to Joe Biden's fulfilling this ambitious agenda. Presidents' plans often flounder in Congress from partisan resistance or intraparty divisions, fade in the face of public opposition, are rejected by the courts, or are weakened by American federalism as they cross the states. And health policies must compete with other issues for presidential and congressional attention. Still, the end of the Trump administration opens up the possibilities of change. The next chapter in US health policy is here, and JHPPL will be on hand to chart its unfolding.
