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

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President Joe Biden is finally on a winning streak.

He and his allies in Congress have passed or are about to pass several major bills. Alongside a major domestic semiconductor production bill, Biden could soon win a budget reconciliation bill that includes significant climate action, a three-year extension of the Act’s expanded insurance premium subsidies. Affordable Care (ACA) and several provisions designed to reduce prescription drug prices, all while reducing the deficit through a new minimum corporate tax, increased IRS enforcement and cost savings incorporated into health care arrangements.

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

The health care provisions are a good example. The prescription drug measures and insurance subsidies will make a difference in the lives of many Americans, but they do not fundamentally change an inefficient, expensive and inequitable health care system. They’re 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 haven’t expanded. Medicaid as permitted by the ACA. The bill also made a wider range of prescription drugs subject to price negotiations.

The history of health care politics, however, suggests that this is how change generally happens in this area – not just in the United States but around the world.

It’s not that liberal leaders didn’t try to make sweeping reforms.

For decades, American presidents have worked to transform the health care system. Franklin D. Roosevelt did not include National Health Insurance in the Social Security Act of 1935 because he feared opposition from physicians would defeat the entire bill. But Harry S. Truman took over, twice proposing such legislation, only to see the leading organization of physicians, the American Medical Association, step up in exactly the way Roosevelt had feared.

And yet, despite Truman’s legislative defeats, Congress passed the Hill-Burton Act, which funded the building of hospitals in underserved areas, and the National Heart Act, which expanded the National Institutes of Health. (NIH) into several interrelated institutes focused on specific disease areas. . While not the sweeping transformations envisioned by Truman and his allies, it increased access to health care nationwide, and the expanded NIH laid the foundation for much of the research modern medicine.

Lyndon B. Johnson is often hailed as a president who did great things – nothing seems more emblematic of his legislative credentials than the passage of Medicare and Medicaid in 1965. In fact, however, Medicare represented a strategic post-defeat retreat. Truman’s proposals. by those who dreamed of national health insurance. Realizing that the elderly were a sympathetic and vulnerable population that private insurers had little interest in covering, they were successful in obtaining health coverage for the elderly.

During the 1970s, Presidents Richard M. Nixon and Jimmy Carter and Senator 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 any of the universal coverage proposals. A limited measure that became law was the Health Maintenance Organizations (HMO) Act of 1973, which required employers to offer HMOs as an insurance option, while imposing restrictive regulations that effectively limited their initial growth. . For better or for worse, this legislation had consequences: it laid the foundation for the “managed care” revolution of the 1980s and 1990s, which transformed health care by requiring pre-approval of medical services by insurers to limit overspending.

Even during the 1980s — generally seen as an era of social policy retreat — congressional Democrats succeeded in expanding Medicaid eligibility and began the process of de-stigmatizing the program and making it a central pillar of care. American health. These achievements did not spark widespread celebrations, but they continued the slow expansion model of affordable coverage.

Bill Clinton’s presidency embodied more than half a century of political health care struggles – in 1994, his iconic universal coverage plan collapsed and burned. Yet Clinton banded together 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, enabled workers to retain employer coverage after leaving a job and increased patient numbers. privacy. During his second term, Clinton won passage of the Children’s Health Insurance Program, a major expansion of federal-state health coverage for low-income children.

None of these measures introduced a single-payer health care system, as activists might have wished. However, all made only limited improvements to the existing system, solved problems and established a starting point for subsequent legislative cycles.

This set the stage for Barack Obama, who carried out the most complete reinvention of our system to date. Yet the ACA relied almost entirely on the regulation, reorganization and subsidization of existing private insurance structures. His use of individual and employer mandates mirrored earlier Republican proposals dating back to Nixon, suggesting that with greater willingness to strike a deal, Kennedy or Clinton could have accomplished something similar decades earlier. The ACA also dramatically expanded Medicaid and completed a 30-year process to integrate what had once been a poorly funded and stigmatized “social medicine” program into the heart of the American system.

The ACA, however, left a lot of things up in the air. Perhaps its most notable shortcomings have been the sudden drop in insurance subsidies to a level where many middle-income Americans still cannot afford private coverage, and the failure to address the price of prescription drugs.

This set the stage for Biden’s presidency and hope that Biden will usher in great 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 (in particular, a stubborn pandemic, runaway inflation and the invasion of Ukraine by Russia) intervened.

A drastic change will not happen, again. Yet Congress is poised to pass health care legislation that follows the now-familiar pattern: It may not excite activists, but it will make crucial changes to the health care system that will will make many Americans’ medications cheaper and their insurance premiums cheaper. more affordable.

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

This pattern also fits the global history of health care policy. In most other countries, the health care system has also developed gradually over time. This includes the UK’s National Health Service, which evolved from workers’ insurance programs set up in 1911 and expanded to include emergency medical care benefits during World War II. Similarly, the systems in Canada, France and Germany also developed gradually and built on pre-existing structures and institutions.

Like presidents and lawmakers before him, Biden is now plotting the next round of changes that will make health care more attainable for more Americans.

So the reconciliation bill may not transform health care overnight, but it’s still a huge win.

Rodney N.

The author Rodney N.