The Guttmacher Institute is evaluating how sexual and reproductive health and rights fit into U.S. health care reform efforts. Previous analyses have described people’s wide array of sexual and reproductive health needs and laid out a set of principles for how to address them within the health care system. This analysis applies those principles to one specific health care reform proposal. Evaluations of additional proposals can be found here.

This is an analysis of President-Elect Biden’s proposed changes to the U.S. health insurance system, as presented on his campaign’s website as of November 2020. Additional details were included in other campaign website documents, as noted below. This analysis will be updated as more details emerge or legislative language is released.

Summary

An incremental approach to health care reform (the “Biden Plan”) that establishes a publicly funded option for individuals purchasing coverage on the Affordable Care Act’s (ACA) health insurance marketplaces and for lower-income people in states that have not adopted the ACA’s Medicaid expansion. It also builds on the ACA by expanding premium tax credits and expanding eligibility.

Ensure Comprehensive Insurance Coverage for Everyone

Provide coverage to all without cost or paperwork barriers: Creates a public health insurance option that will exist alongside other forms of coverage. Enables the government to negotiate with providers for lower prices. Offers a premium-free version of the public option to people with incomes below 138% of the federal poverty level (FPL) who live in states that have not expanded Medicaid coverage to this level; automatically enrolls people in this option when they interact with public institutions like schools and programs for people with low incomes, such as the Supplemental Nutrition Assistance Program.

No explicit restrictions related to immigration status; however, appears to keep existing ACA rules blocking undocumented immigrants and Deferred Action for Childhood Arrivals (DACA) recipients from coverage.

For the ACA marketplaces overall, increases premium subsidies and expands them to people with incomes above the current limit of 400% FPL. Allows people with an offer of employer-based coverage to instead purchase the public option or another subsidized plan through the ACA marketplaces.

Cover the complete scope of sexual and reproductive health services without barriers: Explicitly includes contraceptive and abortion coverage in the new public option. Does not explicitly address other reproductive health needs, but the public option appears to be subject to the ACA’s essential health benefits requirements (which specifically include maternity care and some STI and reproductive cancer care). ACA marketplace cost-sharing rules and subsidies appear to apply.

Additionally, President-Elect Biden has stated that he opposes the Hyde Amendment, which blocks federal funds from being used for abortion care in Medicaid and other programs. A separate campaign document promises coverage requirements beyond the public option for gender-affirming care and for HIV treatment and prevention.

Build and Maintain a Robust Provider Network

Ensure that patients may seek care from any qualified provider: Not explicitly addressed for the public option. For Medicaid, Biden has stated that his administration would reissue guidance preventing states from excluding providers (such as Planned Parenthood) from the program because they offer abortion-related services, information or referrals.  

Fully reimburse providers and invest in their education, facilities and technology: Doubles federal funding for community health centers. Calls for “dramatically increasing funding” for the Indian Health Service.

Keep pace with emerging services and methods, such as telehealth: Separate campaign documents support broadband networks and other telehealth infrastructure and funding, particularly in rural areas and Native American communities.

Guarantee and Enforce Strong Patient Protections

Eliminate legal, cultural and safety-related barriers to care: President-Elect Biden has stated that he would direct the U.S. Department of Justice to “do everything in its power” to counter state abortion restrictions.

Respect patients’ privacy and autonomy and guard against coercion: Existing ACA protections would appear to apply. Most notably, the ACA prevents the federal government from interfering with the principle of informed consent, patient-provider communication and patients’ timely access to care.

Fight discrimination and promote equitable health care access and experiences: Existing ACA provisions would appear to apply, including strong antidiscrimination protections for patients. Explicitly promises to protect people from discrimination in health care settings based on gender, gender identity and sexual orientation. Promises nationwide implementation of California’s maternal mortality strategy, which “halved the state’s maternal death rate.” A separate campaign document supports a task force to address racial disparities in health care.

Overall Assessment

Strengths:

  • Creates a new public insurance option to encourage competition and expands ACA premium subsidies, both of which could lower insurance costs and expand coverage.

  • Closes coverage gaps in states that have not expanded Medicaid by automatically enrolling people who would otherwise be eligible for that program in the public option.
  • Appears to apply current ACA protections to the new public option, including subsidies, antidiscrimination rules, and coverage requirements for maternity care and other services.
  • Explicitly covers abortion and contraceptives in the public option, lifts federal restrictions on abortion coverage (like the Hyde Amendment), and reinforces specific protections for Medicaid providers who offer abortion services (like Planned Parenthood).

Weaknesses:

  • Does not address details on provider reimbursement or investment, or offer assurances related to patient privacy and autonomy.

  • Appears to maintain the ACA’s restrictions that exclude undocumented immigrants and DACA recipients from buying coverage, with or without premium subsidies.