Health care has dominated national politics for more than a decade. Voters told pollsters it was a top concern heading into the 2020 campaign, and that only intensified with the coronavirus pandemic.  As the new administration launches, this is a good time to look at the health care agenda and how it differs from the last administration.

The constant tumult of the recent years provides a warning, though, that political prognosticating can be uncertain, at best.

Still, broad outlines have emerged already about stark differences that should define the 46^th versus the 45^th presidency. These will have direct effects on your finances, health, and well-being, so let’s jump into a longer view of Bidenhealth and what it may mean to the country.

The new administration, unlike the regime that just exited, considers health care a right, not a privilege. That has a lot of practical implications.

President Biden and his Democratic colleagues believe that government can play an effective role in improving people’s health, notably by expanding the access to health care and improving its affordability.

They have committed to decision- and policy-making rooted in facts, evidence, and science.

They are experienced in governing and legislating — and they are eager to use and to build up rather than to oppose, attack, or dismantle federal agencies.

The new administration has not started with picking fights with the poor and less affluent, immigrants, LGBTQ people, and communities of color.

This presidential term likely will see an emphasis on not only direct health issues but also efforts to deal with social determinants of health — with the president emphatic about his commitment to addressing climate change and improving the environment, as well as attacking racism, poverty, sexism, and economic inequity.

Telling experiences

Because presidents set the tone of their administrations from the top, important insights can be gained from Biden’s own deeply personal experiences with health care and health insurance. He has seen the system work in shattering circumstance and praises it for how it performed for him in two of the worst moments of his life — when, as a newly elected senator in 1972, his wife and daughter were killed and his two sons were seriously injured in a car wreck, and during the terminal brain cancer of Beau, 46, his oldest son.

Biden has spent decades in the Senate, steeping himself in the intricacies of health care policy and laws, as well as the people who are involved in the many sides of disputes in these areas. While his party has moved, politically speaking, to the left on health care overall, Biden has stuck to centrist or center-left views. As the No. 2 in the administration that pushed through the landmark Affordable Care Act, Biden is an enthusiast for Obamacare and sees it, for now, as a cornerstone of his approach to health coverage. During the campaign, he made it clear that he would not embrace a national single-payer plan, the progressive left’s so-called Medicare for All proposal.

The president, as an elite politician, has a healthy ego. He differs from his predecessor, though, in encouraging his own people and experts to take the spotlight in campaigning for his administration’s goals. Biden drew fire from friends and opponents alike in recent times, because of his willingness to go silent while undertaking important behind-the-scenes toil, while others want their chief executive to dominate the air waves or be a social media darling. Biden has experienced how crucial it can be to allow an administration’s top people to hash out in messy but collegial fashion their policies, strategies, and tactics ahead of their public reveal. His record shows he can be persistent and knows, especially as a leader, how to stay engaged and not, as his predecessor did, to careen from one priority to the next.

Still, Biden and company must tackle mountains of crises, many related to the coronavirus pandemic and health care, including a reeling economy, record-setting joblessness, widespread hunger, huge fears about evictions, and, of course, a nation riven by politics as well as racial and economic inequities. His hopes to get the nation to a better place, especially after the pandemic, may be checked or stopped altogether by formidable Republican opposition.

Dr. Anthony Fauci, the nation’s leading infectious-disease expert, has surprised himself, his family, and commentators by his changed public mien since the Biden Administration began. Fauci has been relaxed, smiling, and candid without caveats as he delivers still-grim news about the terrible toll the coronavirus continues to take on the country.

He said at a recent press briefing that, unlike his year with the 45^th leader of the nation, he feels “liberated” by Biden.

 “I take no pleasure at all in being in a situation of contradicting the president,” Fauci said, adding that he felt free under Biden to speak without ‘repercussions’ … ‘The idea that you can get up here and talk about what you know, what the evidence, what the science is, and know that’s it — let the science speak — it is somewhat of a liberating feeling. One of the new things in this administration is if you don’t have the answer, don’t guess. Just say you don’t know the answer.’”

Biden has been emphatic that his team will make policy and decisions based on facts and evidence. They have pledged to rebuild and rely on federal departments — especially health-related operations battered in the last regime — like the giant Health and Human Services agency, the Food and Drug Administration, the Centers for Disease Control and Prevention, and the Centers for Medicare and Medicaid Services.

A Cabinet-level commitment

The new president underscored his team’s commitment to science (and medical science) by elevating to the Cabinet level his nominee as his top science advisor: Eric S. Lander — director of the Broad Institute of MIT and Harvard. The New York Times also reported that:

“Alondra Nelson, a professor at the Institute for Advanced Study in Princeton, N.J., and president of the Social Science Research Council in Brooklyn, will serve as deputy director for the Office of Science and Technology Policy. Frances H. Arnold and Maria Zuber will serve as the external co-chairs of the President’s Council of Advisors on Science and Technology, a council of prominent eminent volunteer experts from outside the federal government. Dr. Arnold, a protein scientist at Caltech, won the Nobel Prize in Chemistry in 2018, only the fifth woman to do so. Dr. Zuber, vice president for research at MIT, was the first woman to lead a NASA spacecraft mission.”

The early leadership picks

In his early health-specific appointments, focusing in particular on pandemic response, Biden not only tapped Fauci as chief Covid-19 adviser, but also:

• Xavier Becerra, California’s attorney general and a former congressman, to lead the Health and Human Services Department
• Dr. Rochelle Walensky, chief of infectious diseases at Massachusetts General Hospital, as the director of the Centers for Disease Control and Prevention
• Jeff Zients, a veteran of the Obama administration, to be the White House coordinator of the coronavirus response
• And Dr. Vivek Murthy, who was a key coronavirus adviser to the president-elect, as surgeon general. Murthy was surgeon general during the Obama Administration.

These leadership picks, generally, have won praise for the individuals’ credentials and accomplishments. Questions have arisen as to whether Walensky and Becerra have the management and administrative chops to run the sizable bureaucracies that will report them.

Becerra raised eyebrows because he lacks direct experience in health care and he upsets Republicans because of his prominence as a legal crusader against the past president’s policies and how he asserted they would damage the state of California.

Don’t underestimate him, the media and opinion shapers in the Golden State have argued. Becerra, they note, has run well the largest state’s AG’s office with 4,500 lawyers. He has been immersed for decades in the making of rules, policies, and laws — some of the chief roles overall of HHS. The graduate of Stanford (and its law school) spent decades in Washington on Capitol Hill, including on the powerful House Ways and Means committee, as well as the panels on health and Social Security. He was a notable congressional battler during the years of fights over Obamacare and was liked and savvy enough that many thought he was headed to a House leadership role. The president knew him, and some liken his personal story to Biden’s own, rising from the working class.

Starting with his pick of Vice President Harris (female, South Asian, and black), Biden has sent a ringing message, too, with his team choices about inclusivity. Becerra will be the first Latino to hold the top post at the sprawling health department. Of the 18 CDC chiefs in modern times, only two before Walensky were women and one, Brenda Fitzgerald, a Trump appointee, had one of the shortest tenures on record (she was forced to resign after six months after disclosing she had bought tobacco stocks). Murthy, along with Harris, has heartened Americans of South Asian descent with his return engagement as surgeon general.

By the way, the presidentially picked interim heads of the FDA (Janet Woodcock), CMS (Elizabeth Richter), and the U.S. Public Health Corps that the Surgeon General heads (Susan Orsega) are women. Woodcock and Richter may be contenders for permanent appointments, while Orsega, a nurse (!) and infectious disease expert, will work with Murthy. 

Two presidents before Biden — Obama and Trump — threw their administrations’ early and defining energies at big, bruising battles over basically two things, one being health care.

Obama (and Biden) struggled to reset the country after the catastrophic 2008 economic collapse they inherited from President Bush. Obama also rejoiced in passing the ambitious ACA, extending federal support to states and less affluent and middle-class Americans so tens of millions of people could get affordable health insurance.

Trump threw the full force of his GOP White House and Republican-controlled Congress at trying to repeal Obamacare, an unrealized GOP goal that had then lingered for almost a decade. That effort failed. Instead, the administration jammed through a tax cut for plutocrats and wealthy corporations. That was a spilling of red ink that amounted to trillions of dollars and defined the spree of debt-and-deficit finances that marked the rest of the Trump term.

Biden will have the narrowest of Democratic control in the House and Senate and will face a GOP-packed federal judiciary.

The pandemic, through no choice of his own, has become Biden’s Job One from day one — and its associated crises will be all-consuming for who knows how long ….

That could mean that the blustery ACA combat won’t be a central matter, at least for a bit.

Options to increase access, affordability

But the administration still will push for improved access and affordability in health care. Biden and company can take such steps, in part, because their predecessors cared so little about doing things the right way — by making the case in congressional hearings and passing laws. Officials in the previous administration also too often failed to follow legal procedures to execute plans and policies by regulations, policies, or executive order. Courts, even with judges appointed by the previous president, have blocked many Trump initiatives because they were carried out in improper ways. The courts and the new administration have much to sort out with the disposition of many lawsuits filed by the previous regime and those still pending, including a dubious challenge to the ACA by Republican state attorneys general as well as litigation over attempts to rein in Big Pharma’s soaring prescription drug prices.

Biden has issued a raft of executive orders of his own, undoing those of his predecessor. More are likely on the way, along with actions on health agencies’ rules and regulations. These may hit their own legal bumps and political resistance.

In less abstract terms, the new president may be able to shore up Obamacare quickly, by restarting outreach programs to boost ACA enrollment. The new administration may have as much as $1 billion to do so, fees collected under the ACA and unspent by Biden’s predecessors. 

He also has reopened ACA exchanges for the pandemic-afflicted and others for several months, giving them access to subsidized and more affordable health coverage to replace employer-provided policies they may have lost. This could affect 15 million Americans, including 4 million of the uninsured who could get free coverage with an ACA “bronze” (limited) plan and 5 million more people who could get subsidies for that same policy, health policy analysts estimate.

Biden has ordered a review of his predecessor’s endorsement of so-called short-term, or “skinny,” health plans that were promoted as an ACA alternative. Critics grew more vocal about skinny plans when, as they had before, they generated more and more complaints. They offer lower monthly premiums. But because they were exempted by the last administration from key ACA requirements, they provided a nasty shock to buyers: When they needed health coverage most, the plans provided little or none. The fate of “skinny plans,” especially as they come up for renewal, now will be in doubt with the administration review.

If these administrative actions alone do not boost the ACA, Biden also already has shown how he wants Obamacare expanded, now with new subsidies that would deal with a big criticism of the program — that it leaves big gaps for “gig” workers and those who earn more but still need help in paying for or obtaining health coverage. As part of his $1.9 trillion pandemic relief plan, Biden has told Congress that lawmakers need to help Americans keep their health insurance, even as they struggle with a bad economy and the pandemic. The ACA has proven its value in doing this, as well as in withstanding years of attacks to increase the number of lower- and middle-class Americans with affordable health insurance.

If Biden can defend and expand Obamacare during his term, his GOP opponents may see their hopes to repeal the ACA dim yet more. Unless they can come up with persuasive alternatives, will they in 2024 still be stubborn enough to try to repeal a program that would have lasted through four presidential terms? 

Helping the poor and people in need

Biden’s arrival also is a big deal for the poor, old, children, and those with chronic mental or physical illness. That is because he and his new CMS chief will unwind his predecessor’s policies of assaults on Medicaid recipients. The president has ordered a review of these, effectively putting them on ice.

Previously, aid recipients were subjected by states, under purported cost-saving “experiments” approved by federal officials, to harsh requirements, such as that they seek work and document repeatedly that they were doing so — even when it was clear that they were physically or cognitively incapable. CMS also had encouraged states to try to convert their funding from a robust federal allocation to a supposedly less costly and less generous block grant system, in which further cuts could be made.

Instead, Biden also may encourage a trend that developed under his GOP predecessor — the state-by-state expansion of Medicaid. Just a dozen states, most of them southern and with bad health outcomes for the less affluent, have declined to jump on programs with increased federal help if they expanded health coverage for the poor.

Biden already has made a priority of federal support for children, and especially poor kids, as the news site Vox reported of his pandemic-relief package:

“The plan includes $25 billion to help child care providers weather the pandemic and reopen safely, $15 billion in child care assistance for families to help parents get back to work, and an expanded tax credit to help families afford care. Together with the $10 billion set aside in the December stimulus package, the proposal would reach the $50 billion advocates have said is necessary to stabilize the child care industry. ‘We were really, really pleased to see the amount of funding in the plan,’ [said] Rhian Allvin, CEO of the National Association for the Education of Young Children … ‘It definitely is what we have been asking for.’ But it still has to pass Congress, where Republicans have already cast doubt on Biden’s plan. And even if it succeeds, it’s still only the beginning of the full childcare reform that many experts say the country urgently needs.”

With all the challenges Biden and his people will need to attack all at once, can they also shore up three pillars of the nation’s health and social safety net — Medicaid, Medicare, and Social Security?

With all his other challenges, can Biden move public opinion so Congress would act over the opposition of hospitals and health care providers and extend Medicare benefits to more Americans by lowering its eligibility age?

The 45^th president stunned even supporters in his party when he discussed how Republicans would target these hugely popular programs, into which tens of millions of Americans have poured billions of dollars of their taxes. The last president, for example, as one of his ideas to reduce the burgeoning debts and deficits he helped boost, proposed to slash payroll taxes that fund Social Security. Independent watchdogs of the program’s finances warned such a move could cause rapid insolvency in Social Security. The plan evaporated. But financial fixes must come soon for these programs or there will be consequences.

Biden’s predecessor promised from the time he started his presidential campaign until he ended his term to provide a comprehensive U.S. health plan. He never did. The health legacy of the new administration could be shaped by its work on issues that push the public to think expansively about bettering their health and well-being.

In other words, it is hard for us to be truly healthy if we’re under the existential threat of climate change — an issue that former Secretary of State John Kerry will push to the fore in policy and actions, reminding people, for example, how unhealthy increasingly powerful hurricanes can be for nursing home residents or how damaging raging wildfires can be for Westerners’ breathing. Biden, of course, has rejoined the Paris agreement that commits this country to concrete steps to combat climate change.

Indeed, Biden, in his raft of executive orders reversing those of his predecessor, will seek to ensure that Americans enjoy federal safeguards on the air they breathe and the water they drink, as well as trying to protect them better from toxic substances in the environment.

These can be consequential as well as petty controversies: The 45^th president bickered often with deep-blue California, and auto fuel efficiency standards were among the issues he battled the state over. He took an industry-friendly stance, seeking to allow reduced regulation and more air pollution. Car makers initially supported relaxing these regulations, but they deserted the past president when he lost his re-election campaign, so — with Biden ordering a review of regulations in this area — people across the country will breathe easier in this one emblematic rollback. Others will be tougher, and the Biden administration may spend its full term advancing not only its environmental proposals but unwinding those left to it.

Dealing with social determinants of health

To improve the nation’s health, Biden also has vowed to deal with what experts call its social determinants, including how racial and economic inequities damage the well-being of big numbers of people in this country, whether they are people of color, poor, LGBTQ, immigrants, or others.

The relentless turmoil of 2020, including coast-to-coast protests over racial injustice and a pandemic that has disproportionately killed and infected black and Latino people, has amplified the importance of Biden’s appointment of Yale researcher Marcella Nunez-Smith to head a new federal task force on racial disparities and the coronavirus pandemic.

As the Washington Post reported:

“The new task force — the brainchild of Vice President … Harris — is based on legislation she introduced in the Senate in April and will become the permanent Infectious Disease Racial Disparities Task Force when the pandemic ends … Harris described the task force as a way to bring together ‘health care and other policy experts, community-based organizations, and federal, state, local, tribal, and territorial leaders to confront the racial and ethnic disparities … head on.”

With prodding from the likes of Nunez-Smith, Harris, Becerra, and Murthy, the force of federal power may focus as never before on well-documented disparities in the care of black Americans, Latinos, and native people. Federal regulators may be more receptive than ever to addressing women’s disproportionate mistreatment by the medical establishment. Biden already has issued an order giving LGBTQ people important rights and federal protections against discrimination.

A major shift on immigrants

And, when it comes to immigrants, Biden could not take a more diametrically opposite path than what his predecessor pursued, which too often was downright cruel and almost always filled with falsehoods. Biden has told lawmakers he wants the nation to provide a pathway to citizenship for millions of immigrants and immediate green cards for the DACA youth, the young people who have been in a legalized limbo under the Deferred Action for Childhood Arrivals program. DACA youths were brought to this country by parents and other relatives while young and know no other country besides this one.

They and many other immigrants, assailed relentlessly by the 45^th president and his minions, provide us with invaluable blood, sweat, and tears in their essential work. Immigrants care for our kids, grow our food, stock our store shelves, deliver our goods, and they have lived in constant fear of getting forced to return to chaotic, dangerous homelands that many left long ago. It makes little sense to deprive them of important medical and other services, as the previous administration sought to, as this can only worsen and imperil the overall public health — as the pandemic has shown by ripping through their communities.

This is also crucial to know about immigrants: The United States is a rapidly graying country, with a shrinking birth rate. Immigrants play a significant and increasing role in U.S. health care and its employment — they are our doctors, nurses, aides, and clinical support staff. This country also has benefited immeasurably from immigrant brain power that has flocked to our colleges and universities, many staying on afterward for graduate school and advanced research. Institutions of higher learning have reported that the previous administration’s hostility toward immigrants and non-Americans, along with the pandemic, has sent enrollment of international students plummeting.

Connect the dots. Try these names: Katalin Karikó. Moncef Slaoui. Noubar Afeyan. Ugur Sahin. Özlem Türeci. Albert Bourla. When the miraculous history gets put down about the expeditious development of the coronavirus vaccines, the work of these individuals — immigrants to this country and others from Hungary, Turkey, Greece, and Lebanon — will be writ large.

In the months ahead, as we all watch to see whether President Biden delivers on all or even some of the promises that all administrations make at the start, we will hope that other big pledges he has made get fulfilled. Biden has talked extensively about cooling off our conversations, taking the time to listen to each other, negotiating disagreements in full voice but with a willingness to compromise. He has pleaded for politicians to take the vitriol and ad hominem attacks out of their remarks. He has urged us to take the politics and partisanship out of common sense, evidence-based public health measures, including our continuing to wash our hands (vigorously and often), cover our faces, keep our distance, avoid closed and confined spaces, and to stay home and keep the company of people in our one household. He says he needs all of us to help him quash the coronavirus, with testing, vaccination, contact tracing, and other steps. There’s not much choice but to beat the bug and get our country to a far better place, the president says.

Fingers crossed it happens sooner rather than later. Here’s hoping, too, that you and yours stay healthy and well in ’21 and beyond!