Biden deserves credit for some key healthcare accomplishments
Today is Inauguration Day and the torch is being passed from President Biden to President-elect Donald Trump. Many have argued that Joe Biden’s presidency will be remembered as less than stellar, but I wanted to take this chance today as a Republican to reflect on some of Joe Biden’s healthcare accomplishments as he leaves office.
My views on healthcare are somewhat unique as a Republican
I am a Republican, but I always tell you that I am a maverick one on healthcare.
Part of my college discipline was in economics. As such I studied how the market works, consumer behavior, and micro and macro trends. I was also in politics before making my leap to healthcare. As a state budget director, I was known as a fiscal disciplinarian, who always sought low taxes and a balanced budget. At the state level, we did not have the ability to deliberately deficit spend. Even then, though, I was always on the lookout for good investments in healthcare, whether children’s healthcare, long-term care, supportive housing, or HIV/AIDS investments.
After leaving government and entering the world of healthcare, I came to the ultimate conclusion that affordable universal access makes sense for the nation. It is both a moral and economic imperative.
On the moral issue — if healthcare is not an absolute right, it is darn well close to it.
On the economic issue, America has a terribly bad deal. There is little value unless you are among the well-heeled or strongly insured who can leverage what is admittedly a strong technology-driven, on-demand American healthcare system –if you can afford it. But from the viewpoint of the vast majority of Americans, we spend the most of any developed nation and have the worst outcomes.
We have a broken price system. Because of the broken price system and obscene costs, health plans have traditionally focused on how to limit services, whether through prior authorization or claims denials.
Due to the obsession with utilization management, little attention has been paid to primary care, health and wellness, and disease and care management. A lack of investment and market forces in healthcare have virtually crippled primary care in America.
Lastly, America has fundamentally missed on the issue of affordable universal access. With the passage of the Affordable Care Act (ACA), there was some hope that America would make inroads here and it has helped a bit. But we still have a rough 8% to 10% uninsured rate in America – tens of millions of people. What’s more, we continue to have a nation of underinsured, too. High prices and admittedly overly rich benefit designs have conspired together to create a category of people who technically have insurance but cannot afford to use it most of the time. Taken together, we have perhaps 85 million who are disenfranchised by being uninsured or underinsured – about one quarter of the population.
In short, investing in and reforming healthcare could mean huge economic dividends. Over time it would lower healthcare costs and improve outcomes.
To learn more about my views on what needs to be done to reform healthcare, see the healthcare reform series I did at the links at tne end of the blog. The series is based on a much broader look at healthcare reform in my book, The Healthcare Labyrinth (available at this site and at leading bookseller sites).
Biden’s two key healthcare accomplishments
I have painted a very dreary picture of healthcare. But it would be wrong not to recognize some of the progress President Biden made on the problems we see in healthcare. To his credit, Biden had healthcare accomplishments on many fronts. I want to focus on two of them and they tie back to the three main problems I raised – price, primary care and care management, and insurance access.
Coverage Expansion: While President Obama deserves the most credit for the ACA, Joe Biden was his partner and Biden continued to make critical investments in the program when he became president. He endorsed the twin pillars of the ACA’s coverage whenever he could – Medicaid expansion and Exchange enrollment. Ironically, many red, reddish, and purple states expanded Medicaid under Trump’s first term. Biden continued to encourage state expansions and a few states converted during his tenure as well. (We still have ten holdout states.) As well, Biden worked with states to expand Medicaid coverage and tenure and streamline eligibility for certain populations.
While Trump 45 worked to limit enrollment in the Exchanges, Biden undid many of the misguided policies of the first Trump administration. He lengthened the open enrollment period, expanded special enrollment periods, invested in marketing and outreach, and touted the program whenever he could. Biden’s policies had a positive impact on premiums, enrollment, financial stability, plan participation, plan choice, and network and provider access. Enrollment continually increased and now will reach over 24 million in 2025.
In summary, Biden fought back on all the limitations to Medicaid and the Exchanges that Trump 45 put in place. While the uninsured rate generally rose under Trump 45, it dropped dramatically under Biden. Because of Biden’s work as Vice President and President, almost 47 million people today have coverage. As I note, it is not a perfect world due to costs and the plight of both the uninsured and underinsured, but Biden deserves the most credit of any president in the past few decades for following through on a true coverage agenda.
I would note two critical outcomes here: despite the state of primary care, access to upfront primary care and preventive services has increased. And despite the critics’ predictions that the ACA is overly expensive (to some degree it is and changes need to be made), we did not see the huge healthcare cost rise many predicted. As a recent study in Health Affairs Forefront Blog found, the ACA has reduced, not increased, expected cost increases and the country benefited from tens of millions gaining coverage. As the number of uninsured fell, the moving average of national healthcare expenditures (NHE) growth decreased until COVID-related spending began in 2020. For the historic coverage drive and the concomitant spending restraint, we can and should thank Biden.
See my blog on why the GOP should safeguard the ACA here: https://www.healthcarelabyrinth.com/the-gop-should-safeguard-the-aca/ .
Medicare Drug Negotiations: I have made the case that price is fundamentally broken in America. Whether for medical services or drugs, most price is not based at all on cost. Hospital prices are obscene as are provider costs overall. But so are drug prices. If Biden did not make progress on price overall, he did begin to address the issue of drug pricing in America.
Appropriate drug use is key to bringing down costs in the healthcare system globally. At the same time, high drug prices force millions to forego necessary doses or drug regimens altogether. The drug channel lacks transparency. Actors, such as brand drug makers and pharmacy benefits managers, perversely work relationships intended to benefit themselves and not the public.
It is unjustifiable that America has the highest drug prices in the developed world. Prices are manyfolds more than in other rich nations. Between two-thirds and three-quarters of Big Pharma profits come from the United States. America does little to nothing to control drug prices, while other developed nations use national negotiations, comparative clinical- and cost-effectiveness, and international reference pricing (benchmarking price to comparable nations).
There is plenty to hate in the Inflation Reduction Act (IRA), including misguided changes to cost-sharing for Medicare Part D. But the Medicare drug negotiation law is not one of them. The Medicare drug negotiations have only just started. The first 10 Part D drugs were negotiated in 2024 and will take effect on January 1, 2026. In a parting shot, Biden unveiled the next 15 drugs to be subject to negotiations early (prior to Feb. 1). These will be negotiated (hopefully) in 2025 and go into effect on January 1, 2027. The Biden administration says that about one-third of all Medicare Part D drug spend will be impacted by the first two years of negotiations.
Now, I am the first to admit that the negotiation process needs to mature and bear much more fruit. The 2024 drug negotiations dropped the initial 10 drugs’ prices by 22% on average on a net price (post rebate) basis. So, the record is mixed: the prices that will go into effect in 2026 would appear to be below some other smaller government programs that negotiate prices, but be well above prices in other developed countries. See my blog on this subject here: https://www.healthcarelabyrinth.com/the-two-sides-of-drug-prices-after-negotiations/


But Biden should be cut a break here. It is easy to Monday-morning quarterback complex negotiations. The program is novel for America and Biden had to take a go-slow approach initially, especially given legal and political issues. The process can and should mature over time, including having better and better review of comparative clinical- and cost-effectiveness. In short, the Medicare drug price negotiation law was a seminal event for America. It is the first recognition that something needs to be done on drug pricing and healthcare price as a whole. And for this we should thank Biden. It can work if given a chance.
Those in my party would argue that the Medicare drug negotiation law distorts the free market and will stifle innovation. On the first issue, the drug market – cloaked in unseemly opaqueness as well as complex and chicanerous reimbursement schemes – is by no means a free market. The economic rules I learned about some 40 years ago in college do not apply to it. On the second issue, there is little evidence so far that innovation has been stifled, despite the catcalls of Big Pharma and their pinstriped lobbyists. There are many avenues, including government and multinational research programs and investments, to deal with impacts to innovation if that does occur. Further, a review of innovation would suggest that brand drug makers are investing in innovation for themselves and not with the overall American public in mind. Lastly, how do we explain to all of those cut off from affordable medication that we will continue to subsidize low prices in other developed nations?
So, as he leaves office, again thank you President Biden for your conviction on coverage as well as drug price reform.
What may be in store?
As President Trump again takes office as 47, it is hard to know where things go on these two issues. Trump and the now fully GOP-controlled Congress want to extend the 2017 tax cuts and that will take trillions in spending cuts under the budget reconciliation process.
I have made the case – perhaps with an air of hopefulness – that radical changes to healthcare will not occur. After all, the vote counts in each house are tight and there are some notable moderates who could hold sway.
I also believe, though, that some changes need to occur in government programs and healthcare overall lest it become even more unaffordable. Three examples:
- We do need to rein in explosive Medicare costs and that includes changes in Medicare Advantage (MA).
- As much as I support this program, I do think Medicaid reform needs to happen in some form. I don’t favor the bludgeon of a block grant approach. But I could support the scalpel of a carefully crafted and nuanced per capita cap program (or hybrid entitlement and per capita cap) with well-thought-out escape hatches for economic downturns and demographic changes. This might bring more accountability, standardization, and focus. It would safeguard Medicaid for the long term.
- And as much as I support this law as well, the ACA mandated benefits may be too rich and contribute to cost increases and benefit designs that work against true access to care.
I also believe that there are trillions in savings over time through reform that does not have to impact coverage. One great example here: finally standing up to the hospital lobby and endorsing site neutral payments. That could save hundreds of billions in Medicare and commercial insurance. See my blog on this topic here: https://www.healthcarelabyrinth.com/it-is-time-for-site-neutral-payments-in-our-healthcare-system/ . To the critics, other studies show you can make money at a hospital with Medicare payments. See that here: https://www.healthcarelabyrinth.com/the-truth-about-hospital-costs-and-payments/ . I would note that site neutral payments, Medicare drug negotations, and a number of other reforms would also help make healthcare across the board much more affordable.
But the process we will see in Washington in 2025 undoubtedly will have major impacts on healthcare programs and coverage. See my blog on all the spending cuts being put on the table right now: https://www.healthcarelabyrinth.com/what-could-healthcare-spending-cuts-look-like/ . If seismic changes are not made in healthcare programs, the adoption of spending cuts in the budget reconciliation process could erode some of the gains we have seen in these two areas – coverage and drug prices. One example related to coverage implications: nine states have so-called rollback triggers with regard to Medicaid expansion under the ACA. Reductions to state matches in Medicaid could mean these states eliminate their expansions and impact up to 3.7 million people who have gained coverage. Other states could rollback too.
Here is hoping that lawmakers and policymakers think through the long-term implications of their decisions before putting the mammoth bill with healthare cuts to a vote.
Marc’s Healthcare Reform blog series:
https://www.healthcarelabyrinth.com/a-modest-election-year-proposal-for-healthcare-reform/
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— Marc S. Ryan