Here is a disclaimer for any omnipotent force that is reading this post: By writing about what might happen under a Biden presidency, I am in no way predicting the results of Tuesday’s election. I am merely having a conversation with our readers about one of the many possibilities that you, the Great One (or perhaps the Evil One), might bestow upon us next week. Naturally, we all appreciate your many very funny pranks from the past, like George W. Bush getting elected by the Supreme Court and then doing the Iraq War, a classic. But I am not, in any way, attempting to trigger fate’s wrath by discussing what a President Joe Biden might do on health care.
Every presidential campaign involves no small amount of exaggeration and even some straight-up fibbing about the extent of that candidate’s priorities and plans. Whether or not any of Biden’s campaign promises will be realized, after all, will depend greatly on the makeup of the Senate. On top of that, much could ride on Democrats’ willingness to abolish the Senate filibuster. These are critical open questions.
But the Biden campaign has almost gone out of its way to foster a specific sort of unknowableness about the shape of his presidency. So much has been staked on the idea of Getting Trump Out, and so much energy is absorbed by whatever nugget of insanity has lodged itself in Trump’s brain that day, that much less attention has been paid to the granular details of Biden’s plans and their policy specifics. In a matchup between Trump, the Covid-19 enabler, and Biden, there might not be much point in delving too deeply into other matters, in terms of picking one or the other to be president. Similarly, most of the important intraparty fights from the Democratic primary are wrapped in a fragile cloth that will break as soon as Biden wins the presidency (if he does). We don’t yet have a fix on what kind of president Joe Biden would really be, because what his campaign has labored to convey to voters is that he would be a better person than Donald Trump.
But assuming Biden wins, proceeds as he has promised, and guides Congress to enact a health care reform bill, there are still many unanswered questions about how his plan would work. We have never heard from Joe Biden about why his plan only covers 97 percent of Americans. This would leave approximately 10 million people uncovered; we don’t know what these Americans did to deserve this fate or how they might avoid it. And this is Biden’s plan at its most ambitious—before Congress gets to touch it and Joe Manchin decides it needs to be less generous for reasons known only to him.
The last time Biden took a question about this puzzling detail, as far as I can tell, was on a debate stage in September 2019, when Julián Castro noted that Biden’s plan “leaves 10 million people uncovered.” Biden responded by shaking his head, and no one thought to demand an actual answer from him. Since then, he has repeatedly said his plan covers everyone. It does not. This is a lie, and it is a lazy one. It would be one thing if some think tank had analyzed his proposal, determined that it wouldn’t cover everyone, and this was a back-and-forth dispute between the Biden campaign and some other group of Beltway brains. But the source of Castro’s claim is Biden’s own website, where the promise to limit coverage to approximately 97 percent of Americans remains to this day. Biden hasn’t been consistent or honest on this point. But then, why would he, when no one is asking him about it?
Another of Biden’s more inexplicable primary debate moments was when he said that “every single person who is diagnosed with cancer or any other disease can automatically become part of this plan.” Biden was referring to the part of his plan that promises “automatic enrollment” to everyone who makes under 138 percent of the federal poverty level—those who should qualify for Medicaid currently, barring the Supreme Court’s decision to allow states to decline it. The question of how a public option with income-based premiums can “automatically” enroll people, whose incomes may fluctuate frequently, has never been satisfactorily answered. Biden said in that debate that anyone who qualified for Medicaid would be automatically enrolled, but people who currently qualify for Medicaid are not automatically enrolled. Far from it: Many are kicked off Medicaid, having gone to the effort of enrolling themselves, because their income fluctuated above the poverty line, or simply because of an error.
So how are we going to do this? What agency is going to make these determinations? How will people who are automatically enrolled get word of their automatic enrollment? How will those enrolled be informed that they have been automatically unenrolled if their incomes jump above the magic enrollment line? What’s to be done about people whose incomes might yo-yo back and forth? The media didn’t find it particularly important to ask these questions, but someone so “enrolled” in Biden’s plan would need to have clear answers, lest they go to the doctor one day and discover only then and there that they no longer have insurance.
Biden says his plan would enroll qualified people who sign up for other benefits, like SNAP, but this would leave large coverage gaps. Only 84 percent of people eligible for SNAP used it in 2017, and in households with individuals who qualify for SNAP but are above the poverty line, just 41 percent participated. (Participation is much higher among people with the lowest incomes, according to the USDA.) This suggests that people who are poor, but not the poorest, are not participating in SNAP at a rate that would ensure they all get automatically enrolled in health insurance. Pete Buttigieg’s similar, public option–based health care plan would have employed “retroactive premiums” at tax time, to essentially tax people for the premiums that they owed while they were insured—even if they didn’t know they were covered. Biden’s campaign hasn’t suggested anything like that, but he also hasn’t suggested how people will be automatically enrolled without a premium, if they qualify, or how people who are automatically enrolled but then exceed the income limit for free insurance will pay the difference. These were all gaping questions during the Democratic primary that simply didn’t get asked.
Biden did offer something of a confusing answer back in September of last year, when he said something to the effect that people would “automatically buy into” the plan. If the government makes people “automatically” pay for something, that is called a tax. That’s not necessarily a bad thing: Taxes are a good way to pay for things, largely because they enable us to compel the rich to pay a lot more for stuff that helps the poor. But it does mean that referring to this arrangement as a “premium” and pretending you are offering people a “choice”—particularly when you campaigned against Medicare for All on the basis of it being funded by taxes—is dishonest. This will affect the politics of whatever health care bill Biden proposes, regardless of how well it “plays” with voters now. People don’t like the wool being pulled over their eyes.
Finally, we also know very little about Biden’s promise to bring back the individual mandate. The mandate, repealed in 2017, was arguably the only unpopular part of the Affordable Care Act. As a recent New York Times piece reported, many experts now agree that the mandate was unnecessary to make the law work. Arguably, this should have been obvious at the time: The assumptions underpinning the policy—that young, healthy idiots would stay carefree and uninsured if they weren’t forced to buy coverage—were clearly wrong. Yet Biden has said little to nothing about the mandate throughout the campaign, except that he will bring it back and that “now it would be” popular, “compared to what’s being offered.” This is not a good reason to do something once elected; we can only hope he quietly drops it. But it remains part of his proposed policy.
Much of what we don’t know about how the next four years will shape health care will depend on how many Democratic senators are in the next Congress; even assuming Democrats do eliminate the filibuster, the actual number matters a lot. Each additional Democrat above 51 reduces the influence of centrist senators like Manchin over the shape of the bill. But one thing we do know is that we have to brace ourselves for bad times: a bill that will be even less significant than what Biden proposed to a Democratic primary electorate; a lot of rhetoric about how this isn’t the radical Bernie Sanders plan, which voters rejected, by the way; having to fight tooth and nail over reducing the percentage of income that premiums can cost from 10 to 8.5 percent; the Objective media suddenly remembering to have a fit about the deficit. And at the end of it all, it’s almost certain that millions of people will still struggle to afford health care and coverage. Sanders and Elizabeth Warren took a lot of pointed questions about their health care plans over the past year. At some point, someone may want to ask Biden about his.