5 things Biden could do to change healthcare—with or without Congress

A signpost with the words Affordable Care Act
President-elect Joe Biden can walk back some of the more controversial decisions under the Trump administration to change the Affordable Care Act, including restoring cuts to marketing and outreach. (Getty/kroach)(Credit: Getty/kroach)

President-elect Joe Biden had major proposals to expand coverage in his healthcare plan, including lowering the eligibility to get tax credits to help consumers pay for Affordable Care Act (ACA) exchange plans.

But a divided Congress means some of Biden’s most ambitious proposals are likely dead on arrival. However, experts say there are some regulatory moves Biden can make to boost coverage without needing Congress, such as:

1. Boosting funding for more targeted enrollment in ACA’s exchanges

The Trump administration cut funding for both marketing and the navigators who helped consumers pick an ACA exchange plan. The rationale was that the exchanges were already in operation for several years and people knew about them. But Biden could restore that funding and change the strategy.

“The early marketing around HealthCare.gov was around getting young, healthy people to sign up,” said Cynthia Cox, director of the Kaiser Family Foundation’s ACA program. “There might need to be more targeted outreach to more marginalized communities to people who aren’t as online.” This will entail more in-person and community work to find people who are persistently uninsured.

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2. Creating a special enrollment period

Another move by the Trump administration was to limit the open enrollment period for the ACA to six weeks. Biden could decide to quickly start a new special enrollment period for anyone who is uninsured and enroll in ACA coverage, said Katie Keith, principal at consulting firm Keith Policy Solutions, in a Health Affairs blog. “Doing so could be especially important to would-be enrollees who are newly uninsured due to the pandemic and may not be familiar with the annual open enrollment period,” she wrote.

Some state-run exchanges created a new enrollment period at the onset of the pandemic back in March.

3. Halting Medicaid work requirements, but only in some states

The Trump administration has approved work requirement waivers for eight states, but they have not been implemented yet, and court rulings have struck down four, according to data from the Kaiser Family Foundation. Another seven applications are pending. “I would assume Biden would reject any pending work requirement waivers out there in several states,” Cox said.

The Trump administration and Arkansas, whose work requirement program was struck down by a federal court ruling, have appealed to the Supreme Court to uphold the program. Biden could try to unwind the work requirement waivers that were already approved but “it is not possible that this will happen overnight,” wrote Joan Alker, executive director of Georgetown’s Center for Children and Families, in a blog post.

4. Walking back cuts to the ACA insurer user fees

To make changes to the operations of the ACA, Biden can rely on money from user fees that each plan pays as part of their monthly premiums they charge customers. This money is earmarked for operations of the plans so can be used to help bolster exchange enrollment including via funding navigators and other forms of outreach.

But the Centers for Medicare & Medicaid Services proposed to reduce those user fees from 3% to 2.25% for the 2022 coverage year. It remains unclear whether the agency will finalize the decrease, which is part of the 2022 Notice of Benefit Payment Parameters, before Biden assumes the White House on Jan. 20.

5. Reduce eligibility burdens on Medicaid eligibility

Along those same lines, Biden can create incentives for states to make it easier for people to sign up for Medicaid.

“There are some administrative burdens that states may place on enrollees to continuously verify their continued eligibility,” Cox said. “The federal government can have incentives to make it easier for people eligible to enroll.”

Some advocates have claimed that the Trump administration sought to add complexity to their systems for verifying Medicaid coverage. The think tank Center on Budget and Policy Priorities slammed the agency’s efforts last year for tightening standards for eligibility verification.