Even with Democrats technically in the majority in Congress, the party split is so slim that passing major health care legislation will be extremely difficult.
So speculation about President-elect Joe Biden's health agenda has focused on the things he can accomplish using executive authority. Although there is a long list of things he could do, even longer is the list of things he is being urged to undo — actions taken by President Donald Trump.
While Trump was not able to make good on his highest-profile health-related promises from his 2016 campaign — including repealing the Affordable Care Act and broadly lowering prescription drug prices — his administration did make substantial changes to the nation's health care system using executive branch authority. And many of those changes are anathema to Democrats, particularly those aimed at hobbling the ACA.
For example, the Trump administration made it easier for those who buy their own insurance to purchase cheaper plans that don't cover all the ACA benefits and may not cover pre-existing conditions. It also eliminated protections from discrimination in health care to people who are transgender.
Trump's use of tools like regulations, guidance and executive orders to modify health programs "was like an attack by a thousand paper cuts," said Maura Calsyn, managing director of health policy at the Center for American Progress, a liberal-leaning think tank. Approaching the November election, she said, "the administration was in the process of doing irreparable harm to the nation's health care system."
Reversing many of those changes will be a big part of Biden's health agenda, in many cases coming even before trying to act on his own campaign pledges, such as creating a government-sponsored health plan as part of the ACA.
Chris Jennings, a health aide to Presidents Barack Obama and Bill Clinton, said he refers to those Trump health policies as "bird droppings. As in you have to clean up the bird droppings before you have a clean slate." Republicans, when they take over from a Democratic administration, think of their predecessors' policies the same way.
Though changing policies made by the executive branch seems easy, that's not always the case.
"These are issue-by-issue determinations that must be made, and they require process evaluation, legal evaluation, resource consideration and timeliness," said Jennings. In other words, some policies will take more time and personnel resources than others. And health policies will have to compete for White House attention with policies the new administration will want to change on anything from the environment to immigration to education.
Even within health care, issues as diverse as the operations of the ACA marketplaces to women's reproductive health to stem cell research will vie to be high on the list.
Why the changes are hard to reverse
Some types of actions are easier to reverse than others.
Executive orders issued by the president, for example, can be summarily overturned by a new executive order. Agency "guidance" can similarly be written over, although the Trump administration has worked to make that more onerous.
Since the 1980s, for example, every time the presidency has changed parties, one of the incoming president's first actions has been to issue an executive order to either reimpose or eliminate the "Mexico City Policy" that governs funding for international family planning organizations that "perform or promote" abortion. Why do new administrations address abortion so quickly? Because the anniversary of the landmark Supreme Court abortion decision Roe v. Wade is two days after Inauguration Day, so the action is always politically timely.
Harder to change are formal regulations, such as one effectively banning Planned Parenthood from the federal family planning program, Title X.. They are governed by a law, the Administrative Procedure Act, that lays out a very specific — and often time-consuming — process. "You have to cross your i's and dot your legal t's," said Nicholas Bagley, who teaches administrative law at the University of Michigan Law School.
And if you don't? Then regulations can be challenged in court — as those of the Trump administration were dozens of times. That's something Biden officials will take pains to avoid, said Calsyn. "I would expect to see very deliberate notice and comment rule-making, considering the reshaped judiciary" with so many Trump-appointed judges, she said.
What comes first?
Undoing a previous administration's actions in a new administration is an exercise in trying to push many things through a very narrow tube in a short time. Department regulations have to go not just through the leadership in each department, but also through the Office of Management and Budget "for a technical review, cost-benefit analysis and legal authority," said Bagley. "That can take time."
Complicating matters, many health regulations emanate not just from the Department of Health and Human Services, but jointly from HHS and other departments, including Labor and Treasury, which likely means more time to negotiate decisions among multiple departments.
Finally, said Bagley, "for really high-profile things, you've got to get the president's attention, and he's got limited time, too." Anything pandemic-related is likely to come first, he said.
Some items get pushed to the front of the line due to calendar considerations, as with the abortion executive orders. Others need more immediate attention because they are part of active court cases.
"You have all these court schedules and briefing schedules that will dictate the timeline where they make all these decisions," said Katie Keith, a health policy researcher and law professor at Georgetown University.
A high-profile example in that category is the Trump administration's efforts to allow states to set work requirements for many low-income adults who gained Medicaid coverage under the Affordable Care Act's expansion of the program. The Supreme Court has agreed to hear a case challenging HHS approval of work requirements for Arkansas and New Hampshire in the next few months. Some Democrats are concerned about how the high court with its new conservative majority might rule, and the Biden administration will have to move fast if officials decide they want to head off that case.
But court actions also might help the Biden administration short-circuit the onerous regulatory process. If a regulation the new administration wants to rewrite or repeal has already been blocked by a court, Biden officials can simply choose not to appeal that ruling. That's what Trump did in ending insurance company subsidies for enrollees with low incomes in 2017.
Allowing a lower-court ruling to stand, however, is not a foolproof strategy. "That raises the possibility of having someone [else] intervene," said Keith. For example, Democratic attorneys general stepped in to defend the ACA in a case now pending at the Supreme Court when the Trump administration chose not to. "So, you have to be pretty strategic about not appealing," she said.
One other big decision for the incoming administration is whether it wants to use the opportunity to tweak or add to Trump policies rather than eliminate them. "Is it undoing and full stop?" asked Keith. "Or undoing and adding on?"
She said there is "a full slate of ideologically neutral" policies Trump put out, including ones on price transparency and prescription drugs. If Biden officials don't want to keep those as they are, they can rewrite them and advance other policies at the same time, saving a round of regulatory effort.
But none of it is easy — or fast.
One big problem is just having enough bodies available to do the work. "There was so much that undermined and hollowed out the federal workforce; there's a lot of rebuilding that needs to done," said Calsyn of the Center for American Progress. And Trump officials ran so roughshod over the regulatory process in many cases, she said, "even putting those processes back in place is going to be hard."
Incoming officials will also have other time-sensitive work to do. Writing regulations for the newly passed ban on "surprise" medical bills will almost certainly be a giant political fight between insurers and health care providers, who will try to re-litigate the legislation as it is implemented. Rules for insurers who sell policies under the ACA will need to be written almost immediately after Biden takes office.
Anyone waiting for a particular Trump policy to be wiped from the books will likely have to pack their patience. But law professor Bagley said he's optimistic it will all get done.
"One of the things we've grown unaccustomed to is a competent administration," he said. "When people are competent, they can do a lot of things pretty quickly."