The Washington PostDemocracy Dies in Darkness

Biden’s big win came from embracing a long policymaking tradition

Incrementalism doesn’t excite activists — but it’s how health-care systems are built

President Biden. (Demetrius Freeman/The Washington Post)
7 min

President Joe Biden is finally on a winning streak.

He and his congressional allies have either passed or are on the verge of passing several major pieces of legislation. Along with an important domestic semiconductor production bill, Biden could soon secure a budget reconciliation bill that includes significant climate action, a three-year extension of expanded Affordable Care Act (ACA) insurance premium subsidies and several provisions designed to lower prescription drug prices, all while reducing the deficit through a new corporate minimum tax, increased IRS enforcement and cost savings built into the health-care provisions.

The reconciliation bill is still a downsized remnant of Biden’s once ambitious “Build Back Better” proposal, leaving the question of whether this limited — but still real — achievement excites voters enough to improve Biden’s approval rating.

The health-care provisions are a case in point. The prescription drug measures and insurance subsidies will make a difference in the lives of many Americans, but they do not fundamentally change a health-care system that is inefficient, expensive and inequitable. They are also more limited than the proposals in the original Build Back Better bill, which included new Medicare benefits, increased Medicaid coverage for postpartum care and premium subsidies for those whose states did not expand Medicaid as allowed under the ACA. The bill also subjected a wider range of prescription drugs to price negotiations.

The history of health-care policy, however, suggests that this is how change usually happens in this area — not only in the United States but around the world.

Not that liberal leaders haven’t tried for sweeping reforms.

For decades, U.S. presidents have labored to transform the health-care system. Franklin D. Roosevelt did not include national health insurance in the 1935 Social Security Act because he feared that opposition from doctors might defeat the entire bill. But Harry S. Truman picked up the baton, twice proposing such legislation, only to see the leading physicians’ organization, the American Medical Association, mobilize in exactly the manner Roosevelt had feared.

And yet, despite Truman’s legislative defeats, Congress did pass the Hill-Burton Act, which funded hospital construction in underserved areas, and the National Heart Act, which expanded the National Institutes of Health (NIH) into multiple interrelated institutes focused on specific disease areas. While not the sweeping transformations that Truman and his allies had envisioned, this did increase health-care access across the country, and the expanded NIH provided the foundation for much of modern medical research.

Lyndon B. Johnson is often lauded as a president who got big things done — with nothing seemingly more emblematic of his legislative skill than passage of Medicare and Medicaid in 1965. In fact, however, Medicare represented a strategic retreat after the defeat of Truman’s proposals by those who dreamed of national health insurance. Recognizing that the elderly were a sympathetic and vulnerable population whom private insurers had little interest in covering, they succeeded in achieving health-care coverage for seniors.

During the 1970s, presidents Richard M. Nixon and Jimmy Carter and Sen Ted Kennedy (D-Mass.) all pursued various forms of national health insurance and, in Carter’s case, serious hospital cost control. None passed, and Kennedy later regretted not compromising on one of the universal coverage proposals. One limited measure that did become law was the Health Maintenance Organizations (HMO) Act of 1973, which required employers to offer HMOs as an insurance option, even while imposing restrictive regulations that effectively limited their early growth. For good and bad, this legislation was consequential: It laid the groundwork for the “managed care” revolution of the 1980s and 1990s, which transformed health care by requiring insurer preapproval of medical services to limit excessive spending.

Even during the 1980s — commonly thought of as an era of social policy retrenchment — congressional Democrats managed to expand eligibility for Medicaid and began the process of de-stigmatizing the program and making it a central pillar of American health care. These achievements didn’t generate widespread celebration — but they continued the pattern of slowly expanding affordable coverage.

Bill Clinton’s presidency epitomized more than a half-century of health-care policy struggles — in 1994, his signature universal coverage plan crashed and burned. Yet Clinton regrouped politically and worked with the bipartisan duo of Kennedy and Sen. Nancy Kassebaum (R-Kan.) to pass legislation that provided a basis for federal regulation of private insurance, allowed workers to keep employer coverage after leaving a job and increased patient privacy. During his second term, Clinton secured passage of the Children’s Health Insurance Program, a major expansion of state-federal health coverage for lower-income children.

None of these measures introduced a single payer health-care system, as activists might have wished. All of them, however, made limited improvements to the existing system, addressed problems and established a starting point for later rounds of legislation.

That set the stage for Barack Obama, who achieved the most comprehensive reimagining of our system yet accomplished. Yet the ACA relied almost entirely on the regulation, reorganization and subsidy of existing private insurance structures. Its use of individual and employer mandates reflected earlier Republican proposals going back to Nixon, suggesting that with greater readiness to cut a deal, Kennedy or Clinton might have accomplished something similar decades before. The ACA also vastly expanded Medicaid and completed a 30-year process of bringing what had once been a poorly-funded, stigmatized program of “welfare medicine” into the core of the U.S. system.

The ACA did, however, leave much undone. Perhaps its most notable gaps were the sudden drop-off of insurance subsidies at a level where many middle-income Americans still cannot afford private coverage, and not addressing the price of prescription drugs.

This set the stage for Biden’s presidency and hopes that Biden would usher in big legislation, like Roosevelt and Johnson before him. But the realities of a 50-50 Senate, a deeply divided party with unresolved ideological conflicts, and, of course, the unpredictability of national and global events (specifically, a stubborn pandemic, raging inflation and Russia’s invasion of Ukraine) have interfered.

Sweeping change won’t happen, once again. Yet Congress is on the verge of passing health-care legislation that fits into the now familiar pattern: It may not excite activists, but it will make crucial changes to the health-care system that will make many Americans’ medications cheaper and their insurance premiums more affordable.

The challenge for the Biden administration is ensuring that voters understand that this kind of incremental change, whether in health care or on climate and technology policy, is exactly the kind of technical, politically messy, but ultimately substantive and sustainable progress that Biden promised during the 2020 election.

This pattern also fits with the global history of health-care policy. In most other countries, the health-care system also developed incrementally over time. That includes the United Kingdom’s National Health Service, which evolved out of programs for workers’ insurance implemented in 1911 and expanded to include emergency medical care provisions during World War II. Likewise, the systems in Canada, France and Germany also developed gradually and built on preexisting structures and institutions.

Just like presidents and legislators before him, Biden is now teeing up the next set of changes that will make health care more achievable for more Americans.

The reconciliation bill, therefore, may not transform health care overnight, but it is still a huge win.