To attract people to those marketplaces, the advisers are interested in restoring millions of dollars that federal health officials cut during President Trump’s first two years in office for advertising and other outreach strategies to motivate consumers to sign up.
Firm decisions have not been made, according to three people familiar with this thinking, who spoke on the condition of anonymity about matters that are not public. A transition spokesman declined to discuss the possibilities.
But the idea of opening ACA insurance marketplaces outside their usual sign-up cycle has been a bedrock approach Biden has espoused since shortly after the coronavirus arrived. He has maintained that making it easier for people to turn to ACA health plans would help buffer Americans who have lost work because of the pandemic’s economic ripple effects and forfeited job-based health coverage as a result.
Since Trump has been in office, the sign-up time for ACA health plans has been restricted to a six-week window late every year instead of the previous three months; the deadline for the most recent open enrollment is this week. When Trump resisted entreaties to reopen sign-ups in late March, Biden tweeted his displeasure: “I can’t believe this needs to be said, but President Trump needs to reopen Obamacare enrollment, and he needs to do it now. Lives are at stake.”
More broadly, the two steps being considered would serve as tangible evidence of the incoming president’s determination to use the decade-old legislation as a basis for improving the nation’s health-care system.
“Biden’s health reform agenda is grounded in reinvigorating the Affordable Care Act, which has been probably the most politically divisive issue in the last decade,” said Larry Levitt, executive vice president of the Kaiser Family Foundation, a health policy group.
During the Democratic presidential primaries, many of Biden’s opponents favored the more left-leaning idea of switching to a version of single-payer health care called Medicare-for-all. One of them, Sen. Bernie Sanders (I-Vt.), has championed such proposals for much of his political career.
Biden stood out for his opposition to Medicare-for-all, insisting that the government could expand Americans’ access to health insurance and affordable care by embellishing upon the ACA, the statute that passed a Democratic Congress in the second of his eight years as vice president under President Barack Obama.
In his main campaign health plan, Biden said the government should create a new public insurance alternative alongside the private health plans sold in ACA marketplaces. He also wants to lower the age at which people typically become eligible for Medicare, the vast federal insurance program for older Americans, from 65 to 60.
And in a dozen states that have not expanded Medicaid as the ACA allows, Biden wants to offer people who could otherwise be folded into that safety-net program a chance to receive insurance through the new public alternative without paying monthly premiums.
The catch for Biden is that all three of these changes to the ACA would require Congress to agree. How likely it is that he would be successful is unclear, depending in large part on two Senate runoff elections in Georgia next month that will decide whether that chamber will join the House in being controlled by the incoming president’s fellow Democrats.
Which party controls the Senate also will determine Biden’s odds of being able to blunt a possible adverse decision in a case before the Supreme Court in which a group of Republican attorneys general, accompanied by the Trump administration, is trying to get the law overturned. The case will continue after Biden takes office.
A central legal question in the case is whether all or part of the ACA is now invalid after a Republican Congress in late 2017 lowered to zero a tax penalty the ACA created for people who violated the law’s requirement that most people carry health coverage. With a cooperative Congress, Biden could shield the legal risk by reinstating a penalty — or by clarifying the law’s language to say explicitly that the rest of the ACA can remain without it.
Unlike the court case and the president-elect’s goals for expanding coverage, the two steps being considered by the transition’s health policy team could be accomplished through executive powers.
ACA health plans represent a small portion of private insurance in the United States, with nearly 11 million people having chosen a marketplace plan for 2020. That enrollment has stayed relatively stable over the past few years, despite the Trump administration’s efforts to weaken the law.
Three dozen states rely on the federal online marketplace, HealthCare.gov. In those states, a consumer can ask for the government to allow them a “special enrollment period” if they undergo a life-changing event, such as marriage, the birth of a child or a move to a different area. Losing a job qualifies, but many people are unaware of that, prompting Biden and other Democrats to say it would be better during the coronavirus pandemic to open the enrollment doors to everyone without requiring individual permission.
Many of the other states, which run their own ACA marketplaces, already have opened the doors.