President-elect Joe Biden's chances of making waves in healthcare policy got a major boost Wednesday when Democrats by the thinnest of margins flipped control of the Senate.
That outcome, along with the Democrats' slim majority in the House, gives the party the coveted Washington trifecta that provides a much greater chance of controlling the legislative agenda and passing favored legislation — at least if it can be done with 50 votes.
With both Democratic candidates for Senate in Georgia winning their runoff elections Tuesday, the party wrested control of the chamber from Republicans.
Both margins are razor-thin, however. Also, the more progressive members in the House could try to hold out for bigger changes than Biden's relatively moderate platform lays out.
The president-elect's more ambitious healthcare plans, like a public option and lowering the Medicare age to 60, would still be difficult to accomplish as long as filibusters are allowed. Legislation making those changes might not be possible without 60 votes.
The Affordable Care Act, though, will be a major benefactor to Democratic control in Washington.
"There's more political agreement among Democrats about how to fix the ACA ... but fundamentally changing how healthcare works, there's less agreement on that," said Cynthia Cox, vice president of the Kaiser Family Foundation.
Because of this, some analysts predict little volatility for the industry.
"Investors should expect little change," an SVB Leerink note sent Wednesday said.
They added, though, that changes to the ACA, which are now more likely with Democratic control, are good for insurers heavily invested in the exchanges like Centene and Molina.
Democrats could pursue policy changes that can be done through budget reconciliation, however, because that needs only a majority — with Vice President-elect Kamala Harris as the tie-breaking vote.
Budget reconciliation legislation has to change spending or revenue and not in only an incremental way. There are also limits to how often reconciliation can be used.
As health policy expert Larry Levitt said on Twitter, "a lot can be done with a simple majority vote in the Senate." That's how the Children's Health Insurance Program was created, noted Levitt, executive vice president for health policy at KFF.
One straightforward advantage is more ease getting Biden's cabinet nominees approved. His nominee for HHS secretary, Xavier Becerra, is likely to encounter some resistance from Republicans for perceived activism in the courts and his pro-choice stance.
Biden has said COVID-19 response will be his top priority, and Congress is likely to roll out more funding to states for vaccine distribution and other measures like personal protective equipment, testing and contact tracing.
Biden and Becerra are staunch ACA supporters, and after four years of the Trump administration chipping away at the law, there is much that can be done to shore it up.
"We've got millions of Americans without insurance, who are facing a potentially deadly disease without any way to pay for treatment," said Sara Rosenbaum, professor of health law policy at George Washington University's Milken Institute School of Public Health. "And so I assume that this will be a huge issue for him, along with economic recovery."
One likely priority will be trying to make moot the challenge to the law currently before the Supreme Court, which arose because a GOP-controlled Congress zeroed out the individual mandate penalty. Although justices appeared unlikely to throw out the law when they heard arguments in November, restoring a small tax penalty would make the ACA secure from the high court.
"Another tactic would be to wait and see how the court rules and try to do damage control immediately after if the court rules in a way that is unfavorable to the ACA, but the fact is you risk throwing the healthcare system into chaos even if they were able to act very quickly afterward," Cox said.
Other ACA policy changes Biden has proposed include lowering deductibles and beefing up subsidies and tax credits in the ACA exchanges to make coverage more affordable. Providers and payers generally support these measures in the hope they will make the exchanges more stable and the coverage pool more diverse.
Biden's administration could also restore funding to consumer outreach and assistance in obtaining ACA coverage.
Another possibility is fixing the ACA's so-called "family glitch." The issue is that financial help in enrolling in an ACA plan is not available for people who are deemed to have access to affordable job-based health insurance, but affordability is determined by self-only coverage rates. That means families facing more expensive coverage aren't eligible for the assistance.
The administration might also encourage more states to pursue Medicaid expansion under the ACA, possibly by having the federal government cover 100% of the costs instead of the 90% covered currently.
Though incremental, the changes would have a big impact, Cox said. "It would significantly increase the number of people who have insurance, and it would also do away with a lot of the critiques people have about the ACA," she said.