It has been 11 years since the Affordable Care Act became law, which means it’s been 11 years since one of the most famous moments in Joe Biden history. At the signing ceremony, in the East Room of the White House, Biden told former President Barack Obama that enacting the legislation was a “big f**king deal.”
Biden, who was vice president at the time, said it in a whisper. But an open microphone picked it up. From there, it went on to live television and, afterwards, into political lore.
Biden will be speaking about the Affordable Care Act Tuesday afternoon, during a visit to Ohio. White House officials did not respond to a HuffPost inquiry about whether he plans to reprise his “BFD” line. But the description is even more fitting now, following enactment of the American Rescue Plan, which Democrats passed and Biden signed earlier this month.
Under its provisions, there will be more financial assistance available to people buying health insurance on their own and new incentives for states to expand their Medicaid programs, as a dozen conservative states have refused to do. The reforms are temporary, but Biden and the Democrats have said they want to make them permanent, quite possibly as part of a bill that would also address the high cost of prescription drugs.
But there’s a certain irony in Biden presiding over these much-needed upgrades. He was among the many White House officials wary of pursuing health care at the start of Obama’s term. In fact, had Obama taken Biden’s advice, the Affordable Care Act as we know it probably would not exist.
It doesn’t take away from Biden’s enthusiasm for the achievement. And there’s every reason to believe he’s serious about continuing to work on health care now that he’s president ― although how far he will go, especially on controversial subjects like prescription drug prices and the “public option,” is an open question.
Biden Was Wary Of Obama’s Health Care Push
In late 2008 and early 2009, during the presidential transition and first weeks of Obama’s term, administration officials debated what priorities to take up when ― and how much the new president could take on right away. The economy was still in crisis. The politics of health care were notoriously difficult, because of all the powerful special interests with a stake in the outcome and the many moving pieces any serious legislation was bound to have.
Biden thought adding comprehensive health reform to the agenda for the first few months was a mistake and said so, loudly. He had plenty of company, too, including then-Chief of Staff Rahm Emanuel, who remembered from his time in Bill Clinton’s White House how a failed health care crusade can undermine a presidency.
Obama pushed ahead anyway and, by all accounts, Biden was a happy warrior in the cause. He was also an effective emissary to former colleagues in the Senate, where Democrats had literally no votes to spare. During the final House vote on legislation, Biden was sitting next to Obama at a table in the Roosevelt Room, watching the proceedings on television ― and was the first person to embrace the president afterwards.
That may help explain Biden’s connection to health care today, even though, as a senator, he had focused mostly on unrelated issues like the courts and foreign policy.
Another factor may be some recent history, both personal and public. Biden led the Obama administration’s Cancer Moonshot and launched a private nonprofit cancer initiative after losing his son to the disease. He also spent the last year of his campaign amid a once-in-a-lifetime public health crisis.
Those two connections might steer him in different directions.
Biden, The Drug Industry And Prescription Prices
From the cancer initiative, Biden has spent a lot of time talking about pharmaceutical breakthroughs ― and listening to officials from the industry, including one Pfizer veteran who ended up running the project.
The industry has a vested interest in all kinds of issues on the agenda, starting with leadership at the U.S. Food and Drug Administration (FDA). One of the leading candidates for that job, Janet Woodcock, has come under attack from consumer groups who think she has been too close to the drug industry.
The industry also has a big stake in prescription drug legislation, which Democrats have vowed to enact. Progressive Democrats in particular want some form of direct price negotiation with drugmakers, as is common in other countries. The industry opposes that, arguing that government price-setting could deter innovation — an argument likely to resonate more than usual following the unprecedented quick development of the COVID-19 vaccines.
The prescription drug proposal Biden ultimately embraced as part of his campaign “unity” platform looks a lot like what progressives have wanted all along. It promises, for example, to “ensure that Americans do not pay more for prescription drugs than people in other advanced economies.” But that proposal is considerably stronger than where he started. Biden’s original campaign plan called for government negotiation of prices but did not have a strong fallback mechanism in case negotiations didn’t produce lower costs.
When Biden won the presidency, many analysts were skeptical that he would push hard for aggressive plans given his history; a 2020 analysis from Morningstar, Inc., noted that “Biden has historically supported innovation in the drug industry and has published views on pricing reform that are more moderate than those in the task force recommendation, leading us to doubt whether the task force’s most aggressive and controversial recommendations would be prioritized.”
Still, the need for action and popularity of aggressive proposals will be difficult to ignore. And Biden has for years talked about the need to help people who can’t afford their prescriptions.
“One can’t discount the influence of the pharmaceutical industry, but there is also a powerful logic for Democrats to tackle drug prices,” Larry Levitt, executive vice president at the Henry J. Kaiser Family Foundation, told HuffPost. “It’s hard to find popular health reforms that provide cost relief to families and businesses while also producing savings for the government that can be used to pay for other priorities. Lowering drug prices checks all of those boxes.”
Biden, The Pandemic And The Public Option
At the same time, Biden has also focused on caregiving, in a way that’s relatively rare among politicians and especially rare among older male politicians. He’s spoken frequently about living through personal tragedy and, as a candidate, he proposed improving the pay and working conditions for care workers ― while simultaneously subsidizing both child care and long-term care for the elderly and people with disabilities.
Notably, he made this “care agenda” a core part of his economic platform ― a signal of how seriously he takes it. And already Democrats are talking about including parts of that agenda in one of the next big pieces of legislation they pass through Congress. The case for action has only gotten stronger with the pandemic, which has drawn attention to the frequently poor quality of care in long-term care settings and the poor working conditions for staff.
The pandemic has also made plain the big gaps in America’s health insurance system, gaps that the Affordable Care Act can’t fill even with the newly enacted increases in financial assistance. Getting to truly universal coverage would require even more upgrades to the Affordable Care Act ― or, as progressives have proposed, replacing all existing arrangements with a single, government-run “Medicare for All” program.
Biden rejected that suggestion as a candidate, saying the political and practical obstacles are too great, and instead proposed to create a “public option” that would be available to anybody. That too would be a difficult fight and, as with his prescription drug proposal, there’s no way to know yet how high a priority Biden intends to make it.
One possibility is that Biden holds off on a big health care push for at least a few months, figuring that other items, like saving the planet from climate change, are more urgent ― and that incremental improvements to the Affordable Care Act, like the ones in the COVID-19 relief program, can do a lot of good in the meantime.
That’s one reason the ACA really was a BFD. It made improving on the system easier.