President Donald Trump has spent four years trying to undermine the Affordable Care Act. President-elect Joe Biden has pledged to bolster the law and give states new tools to expand coverage.
Among them: more money and additional guides to help people buy health insurance on the ACA exchanges; support for states that want to allow more people onto Medicaid rather than fewer; and a crackdown on health care plans that don't offer the minimum benefits required by Obamacare.
Unlike the Biden health care idea that has attracted the most attention — the addition of a Medicare-like public option to the ACA exchanges — Biden could make these changes through executive orders, without congressional approval.
By doing so, advocates hope Biden would reverse the uptick in the rate of Americans without insurance. The percentage of Americans without coverage declined during the Obama administration after implementation of the ACA, but the rate climbed during the Trump administration, even before the economic blowback of the coronavirus pandemic cost 7.7 million Americans their employer-sponsored health insurance.
"It's critical that we get that turned around," said Joan Alker, executive director of Georgetown University's Center for Children and Families, which promotes access to affordable health care.
The U.S. Supreme Court could extinguish Biden's efforts to strengthen Obamacare by striking down the law in a case brought by Republican governors and state attorneys general. But after oral arguments earlier this month, most court observers consider that outcome to be highly unlikely. A final ruling isn't expected before March.
Assuming the law stands, state officials who support the ACA are looking forward to having an ally in the White House.
Pennsylvania Insurance Commissioner Jessica Altman, a strong ACA supporter, said that after four years of federal hostility toward the law, she and other state officials will be grateful "for all of us to be rowing in the same direction."
One of the main issues health policy experts expect Biden to quickly address is Healthcare.gov, the federal health insurance marketplace where people can enroll in ACA-compliant health insurance plans and learn about the federal subsidies they qualify for based on their income. (These plans are distinct from employer-sponsored health plans.)
The ACA gave all the states the option of running their own health exchanges, and so far, 14 states and Washington, D.C., have elected to do so. The rest either use the federal website Healthcare.gov or rely on some aspects of it in a hybrid arrangement.