“Each of these changes are individually moderate, but when you pile them on top of each other, you get a big boost to Affordable Care Act,” said Jonathan Cohn, author of The Ten Year War, a new story on the Health Act. “It doesn’t change the structure of the law, but it makes it a lot more generous.”
Those close to the effort say their ambitions – and their limitations – reflect the preferences of those who lead the way. Mr Biden, who was involved in the adoption and introduction of Obamacare as Vice President, started from the idea of expansion, not upheaval. And the leaders of Congress who wrote Obamacare have been watching it in the wild for a decade, slowly developing laws to address the loopholes and flaws they see. Many see their work as a continuous, step-by-step process in which the legislature should make adjustments, assess their effects and adapt again.
“When you think about where the ACA was headed four years ago, and contrary to where we are right now, on the verge of a massive expansion of affordability, that’s pretty exciting,” said Christen Linke Young, assistant director of domestic affairs White House Health and Veterans Affairs Council.
But Bob Kocher, an economic advisor in the Obama administration who is now a partner in venture capital firm Venrock, said Mr. Biden’s mission on Obamacare, beyond the current changes, seemed more humble, more like “don’t break it” .
“I don’t think he has any ambitions beyond administration,” he said.
To assist in the effort, President Biden has hired a number of former Obama administration advisors. His selection for top jobs at the Centers for Medicare and Medicaid Services, the Office of Management and Budget, and key HHS officials worked on the early rounds of policy making in Obamacare. Many key Congressional health care professionals have now also helped write the Affordable Care Act.
The Affordable Care Act, born in the Great Recession, was drafted with a focus on costs. Political compromises and concerns about runaway deficits kept the 10-year price of the bill below $ 1 trillion and included enough spending cuts and tax increases to pay for. These restrictions caused the architects to cut back financial aid to Americans who bought their own cover. Staff who wrote the formulas said they ran hundreds of simulations to see how most people could be covered within their budget.
Those who drafted the rules to interpret the law also remember drafting rules that were flawed on the lower spending side to avoid setbacks or litigation.