When President-elect Joseph R. Biden Jr. is sworn into office in January 2021, he will bring an ambitious health care agenda in the face of a thinly divided Congress. While control of the US Senate remains uncertain, we can begin to draw some conclusions about how President-elect Biden will prioritize the various aspects of his platform, the means by which he may pursue them, and their probability of enactment.

President-elect Biden’s extensive plans to advance the nation’s COVID-19 pandemic response are likely to be his highest health care–related priority. He has called for a major expansion of the federal role in testing, contact tracing, and resource deployment, as well as increased funding for states, localities, and individuals, which will require the cooperation of the US Congress. If and when the aggressive federal response efforts and the arrival of an effective vaccine can begin to turn the tide on the pandemic, the Biden administration can then turn to the longer-term and more complex proposals for health care reform.

Biden’s health plan is largely organized around restoring, strengthening, and expanding the system in place under the Affordable Care Act (ACA). Through rulemaking, the US Department of Health and Human Services under the Biden administration might be expected initially to roll back much of the deregulation and regulatory changes made during the President Donald J. Trump era, restoring programs and policies to the way they were interpreted or implemented based on ACA statute.

Even if he is working with a cooperative Congress, the larger and more ambitious features of President-elect Biden’s health care plan — such as lowering the Medicare eligibility age and implementing a federal public option insurance plan — may prove more difficult to achieve. Looming over the health care agenda, ultimately, is the uncertain future of the ACA. Whether the US Supreme Court upholds or overturns the landmark health care law will determine the scope of reform that may be necessary, that is, whether it entails a collection of “fixes” and expansions on the existing system or necessitates a wholesale replacement.

The incoming Biden administration may focus on moving much of its health care policy agenda via the reconciliation process, which requires only 50 Senate votes to pass legislation (plus the vice president as the 51st vote). Top Biden advisors also are openly discussing the possibility of eliminating the filibuster, though it remains to be seen whether President-elect Biden and congressional leaders will ultimately do away with that longstanding Senate tradition completely. It should be noted that the Biden administration will prioritize issues on which there has been broader bipartisan support, such as prescription drug pricing, price transparency, telehealth, and mental and behavioral health.

This issue brief examines the authorities and processes available to President-elect Biden to pursue and implement his policy agenda, whether regulatory or legislative; the policies that are likely to define the Biden health care agenda; and how the potential fate of these initiatives will unfold during his first term.

About the Authors

The Wynne Health Group team on this project includes Billy Wynne, JD, chair; Devin Zatorski, president; Taylor Cowey, vice president; Alyssa Llamas, MPH, policy director; Josh LaRosa, MPP, policy director; and Lauren Testa, MPH, associate vice president.