President Biden came into office in a strong position on health care, but broader strategic mistakes and limited ambitions are restricting what is possible even at this early stage of his term. Two consequential changes—expanded Affordable Care Act subsidies and prescription drug price controls—might still get approved by Congress, but even their enactment would fall short of the hopes and expectations of his party’s most active supporters. Disappointment over a missed opportunity now seems likely.
Underachievement was not inevitable. Biden delivered a surprisingly able performance on health care during his party’s 2020 primaries. He was the most vocal opponent of Medicare for All, which was championed by many of his rivals, including Sens. Bernie Sanders and Elizabeth Warren. Staking out a more moderate position—with conviction—was central to his victory. It turns out that many Democratic primary voters are no more eager than independents or Republicans to pay higher taxes, or lose their private insurance, in return for a single-payer plan.
In retrospect, Biden’s views on a Canadian-style health system should be seen as an extension of a more general political instinct, which is to play it relatively safe on health care. It is not so much that he opposes Medicare for All on principle as that he sees it as an impossibly dangerous political project. His main argument against it was its cost, and the immense tax increase it would require, not that the government would deliver inferior care. He has seen firsthand the political damage big reform plans can inflict. He was vice president during the bruising battle over the Affordable Care Act in 2009 and 2010, which helped flip control of the House, and he saw Bill Clinton’s presidency nearly collapse over an epic health-care failure in 1994, which led to a GOP House for the first time in four decades. He has no interest in repeating those episodes, which means he instinctively steers away from controversial schemes.
The one exception in his campaign platform—a public option—proves the rule. Biden pushed this idea as the main alternative to Medicare for All, and it is certainly popular among Democratic voters. A public option would give consumers the choice between staying with private insurance or opting for a government-run alternative. There would be no coercion. And yet it is one thing to debate this idea during a campaign, and quite another to try to get it through Congress. Needless to say, the insurance industry is not eager to see the federal government become a competitor. After the close results of the 2020 election, the Biden team quietly set aside the plan, and he has rarely mentioned it since.
What is left of the Biden health agenda is really two prominent proposals: an expansion of public subsidies for enrollment in ACA coverage and price controls on prescription drugs. Both are still in play, but their prospects have dimmed with the collapse of the administration’s legislative strategy.