Opinion: Biden is already trying to reverse Trump’s assault on healthcare. He has a long way to go

President Biden took several steps Thursday to undo some of the damage President Trump inflicted on the health insurance program created by the 2010 Affordable Care Act, and that’s a good thing. Trump needlessly undermined the state exchanges that made coverage available and affordable to millions of lower-income Americans who don’t have access to an employer’s health plan.

But make no mistake, Biden’s actions won’t do much to improve the U.S. healthcare system as a whole. The problems of ever-rising costs and large numbers of uninsured Americans remain, and will continue to fester until more dramatic and permanent steps are taken.

The president signed a couple of healthcare-related executive orders Thursday, the more controversial of which reversed or started reversing Trump policies that cut off federal family planning dollars — which cannot be used to pay for abortions — to groups here and abroad that used other funds to offer abortions or abortion referrals. The other order focused on Trump’s mean-spirited and misguided efforts to weaken the ACA and Medicaid.

It will certainly help to have the federal government resume promoting state insurance exchanges. It will also help hold down premiums in those exchanges to cut back on temporary insurance plans that offer cheaper but far more limited coverage — plans that drew younger, healthier people out of the exchanges.

The exchanges addressed the needs of a relatively small share of the population, however. According to the Kaiser Family Foundation, only about 15% of Americans in 2019 were in the group served by the exchanges — people who weren’t covered by workplace health plans, Medicare, Medicaid or military health benefits.

Every American is affected by the rising cost of healthcare. The ACA explored ways to change the incentives that were driving up healthcare spending, but costs continue to rise far faster than inflation. And consumers are feeling that in their pocketbooks, whether it be the rising cost of prescription drugs or the growing deductibles they have to cover when they seek treatment.

Tackling costs is probably the hardest aspect of healthcare reform. The Trump administration had two main strategies: to force hospitals to disclose their prices to promote price competition, and in the case of prescription drugs, to piggyback on the price controls that other countries set for certain medications. It also sought to end the secretive rebate payments drug companies made to the “pharmacy benefit managers� many insurers use, hoping to force those discounts to flow directly to consumers.

Those were concrete steps, albeit limited ones. But the fundamental problem is that, unlike seemingly every other industry, technological advancements and innovation keep making healthcare more expensive, not less. The sort of productivity growth seen in other industries hasn’t been apparent in healthcare.

Unless we as a society want to devote an ever larger portion of our resources to healthcare, we have to find ways to get more value out of our healthcare dollars. Maybe that means paying doctors, hospitals and drug and device makers less for their services — which would face considerable opposition. More likely, it means paying for fewer services that are wasteful, duplicative or in some other way unnecessary, and keeping people healthier in the first place.

Although there’s interest and ongoing research in each of these areas, progressive Democrats are focused on the first option — paying providers less for care, medications and medical devices. They would do that through “Medicare for all,� which would set a budget for U.S. healthcare spending. But members of Congress are hardly the best guardians of the Treasury, and it’s easy to envision lawmakers raising the budget annually rather than trying to hold down spending, which could lengthen wait times for surgeries or limit the availability of the costliest drugs and treatments.

Biden is famously not a Medicare for all kind of guy. His focus on the campaign trail was more on reducing insurance premiums than on holding down the costs that are forcing premiums to rise.

Rising premiums help explain why almost 29 million Americans went uninsured in 2019. Congress can remove some of that disincentive by putting more tax dollars into premium subsidies, as California has done. In fact, Biden’s $1.9 trillion COVID-19 relief proposal calls on Congress to provide ACA subsidies large enough to hold premiums to no more than 8.5% of a household’s income, which would be a significant expansion for families earning more than 2½ times the federal poverty level.

Many uninsured Americans, however, are low-income people living in the 12 states that haven’t expanded Medicaid, as the ACA intended, or who are in the country illegally and ineligible for premium subsidies. Extending coverage to those groups is both a public health issue and a political challenge. Biden can’t coerce states into changing their stance on Medicaid, and he hasn’t sought to extend ACA subsidies to people regardless of immigration status — and probably doesn’t have the votes to do so.