It has been one month since President Joe Biden and Vice President Kamala Harris were installed in their respective offices following months of campaigning, Republican-led attacks on the integrity of their election victory, and an insurrection at the US Capitol. President Biden presented himself in both the Democratic primaries and the eventual election against former President Trump as the moderate candidate who could unite an increasingly divided America, bringing together Democrats and Republicans on policies that would help the American people. His policies are reminiscent of that of former President Obama, which is especially evident in his health policy positions. While politicians in the left-wing of the Democratic Party such as Senator Bernie Sanders have embraced a single-payer Medicare-for-All plan (casually referred to as M4A), President Biden has been intent on protecting and expanding the outreach of the Affordable Care Act (also referred to as Obamacare). But before analyzing the Biden-Harris healthcare position, it is important to understand what health policy in America looked like before President Obama and what the Affordable Care Act is.

A Brief History of American Health Policy

Possibly the first real attempt to establish a nationwide health service began with President Theodore Roosevelt in 1912. Roosevelt was the founder of the Progressive Party whose platform included a national health service very similar to the German health-insurance program masterminded by Otto von Bismarck a few years earlier. These similarities were more noticeable several years later when the United States entered World War I and following phenomena such as the Red Scare (when the fear of communism spreading was intensely promoted) ended the Progressive Party’s attempts to push their health policy program into state legislatures.

Years later, the infamous Black Tuesday of 1929 signified the beginning of the Great Depression which saw rates of nationwide poverty and unemployment that were unrivaled until the ongoing pandemic. President Franklin Roosevelt took the reins of the presidency at this time and put forward a New deal, a series of public policy proposals and financial reforms designed to help Americans with recovery from the Depression. One of the many proposals in the New Deal was the Social Security Act, arguably his most famous legacy still in use today. The original bill included a vague plan of comprehensive healthcare coverage but the American Health Association, a private healthcare lobby that allied itself with the GOP, helped to push the idea that universal healthcare was bringing the United States closer to being a socialist republic because he was trying to push the powers of governments past reasonable limits. In order to get the bill passed through the United States Congress, Roosevelt was forced to drop the inclusion of a national health insurance program. This back-and-forth about the role of government and how far its limits can or should be pushed to deliver its citizens healthcare continues to be the main point of contention in health policy between the GOP or the present-day Republican Party and the Democratic Party.

The following decades did not result in much by way of a nationally unified healthcare plan. President Harry Truman proposed a Fair Deal to stop inflation and raise the minimum wage in his 1949 State of the Union address. In his Fair Deal, he also included the Hill-Burton Act which provided financial support to hospitals and health facilities so that they could modernize and keep up with growing and ageing populations. There were also a variety of acts that provided funding for the research regarding the diagnosis, prevention, and treatment of cardiovascular, metabolic, and neurological diseases. But there was still no plan to ensure health coverage for Americans.

It was not until President Lyndon B Johnson (in office 1963-1969) that there was some semblance of a federal health insurance plan to cover Americans. As part of his Great Society, a series of programs that was rooted in ambitious reform of domestic policies that were not working for the American people, Johnson made two amendments to Roosevelt’s Social Security Act. While the initial act did not include universal health coverage, Johnson’s amendments resulted in the creation of Medicare and Medicaid. This legally required the provision of federal health insurance to adults over the age of 65 and for poorer individuals who required public assistance.

President Obama and The Affordable Care Act

President Obama signed the Affordable Care Act (ACA) in March 2010. The main aim of the ACA was to lower the cost of health insurance so that more people could get coverage. The ACA legally required people to be insured either through an employer or otherwise or pay tax penalties as per a concept known as “individual mandate”. This forced people to buy insurance instead of waiting for a time of need to do so. Obama also built on the work of Johnson by expanding the eligibility of Medicaid so that more people could be covered by the scheme.

But perhaps the most spoken about part of the ACA is what it has done for people with pre-existing conditions. Before the passage of the ACA, people who had chronic illnesses or certain medical conditions prior to starting a new health care plan were said to have “pre-existing conditions''. These include diabetes, HIV, and cancer. Insurance companies who received their applications for health insurance could deny these individuals coverage or inflate their rates. The Pre-Existing Condition Insurance Plan (PCIP) in the ACA made it illegal for insurance companies to deny coverage on this basis.

The Affordable Care Act is the first major piece of healthcare legislation in the United States after the passage of Medicare and Medicaid. But that is not to say that it is perfect. The US still spends the most amount of money per patient per year because insurance providers have not lowered their costs. Providers have also managed to find loopholes within the ACA to increase profits. They have been pulling out of ACA’s online marketplaces that allow individuals to compare health insurance plans and select the one best for them. Around 1 in 3 counties only have one insurer. The eternal debate of the limits of the federal and state governments comes up several times with the numerous provisions of the ACA, most importantly with Medicaid expansion. Several states have opted against this expansion, creating what is called the Medicaid coverage gap, in which individuals eligible for coverage are not covered, of several million people. The ACA is still tied to insurance which people receive from their employers who find it more cost-effective to pay the penalty that the ACA imposes for not paying for employee coverage rather than doing just that, leading to millions of people not being insured.

The Act passed the House of Representatives with a narrow 220-215 vote and passed the Senate with many disappointed Republicans. Since then, it has been subject to criticism and scrutiny, with many efforts to repeal it in legislative houses and both state appellate courts and the Supreme Court. Perhaps this is a metaphor for the ACA itself- popular enough to scrape by, but not enough to solve some of America’s biggest healthcare problems.

President Biden and the ACA

President Biden was by then-President Barack Obama’s side during the formation and the passage of the ACA and cites it as an inspiration frequently. He had campaigned on the idea of making some changes to the familiar ACA, most notably with a public option. While the ACA helped expand Medicaid and cover pre-existing conditions, it just made alterations to health insurance and a very privatized healthcare system. Biden intends to add a public option like Medicare, allowing Americans to choose between a private insurance or the public option. He also planned to close the Medicare coverage gap by eliminating premiums and making sure that the public option available to them covers all of the benefits they would otherwise be entitled to. Biden’s campaign promises also included automatically enrolling lower-income Americans who already received financial support through other means such as the Supplemental Nutrition Assistance Program (SNAP, also called “food stamps”).

But Biden is not inheriting the presidency at a normal time, when executing his plans would only take reluctant unity from Democrats and Republicans in the House and Senate. He is forced to lead in the midst of a pandemic that has the staggering death toll of more than 500 000 American lives, manage a vaccine rollout, and pull the country out of an economic crisis. With two historic Senate victories from Georgia, he has both houses under Democrat control. Hence, his journey in making changes to healthcare policy may look different to that of his predecessors, with perhaps less political opposition but increased challenges created by the pandemic. At a time when the state-funded vs privatisation of healthcare debate is a hot topic globally, including in the UK, we wait to see how the landscape will change in the US, and in turn influence our own systems.