As of Jan. 20, 2021 — Inauguration Day —the federal government is about to get much more involved in health care and the COVID-19 pandemic response. Exactly how much more involved, now that Joe Biden is president-elect, depends on whether Republicans keep control of the Senate. And that likely won't be determined until early January, when Georgia's two Senate run-off races are held.

Trump's nearly four years as president have been marked by a scaled-back federal investment and involvement in health care in a range of ways — giving states more authority to run their own health insurance markets, for example, and leaving them to come up with their own strategies for COVID-19 testing, contact tracing and more.

Biden's pledge during the campaign was to reverse that trend. He wants to double-down and invest in the changes the Affordable Care Act made to the country's health care system, he says. He wants to pour trillions into a unified coronavirus strategy. And he wants to work with Congress to create a Medicare-like public insurance plan that anyone can buy into — what he's called the "public option."

Here's a guide to his policy platforms and promises related to health care. Again, how much he's able to deliver on will in some cases depend on what happens in the Senate.

ISSUE: The Affordable Care Act

Starting Tuesday, long before Biden is inaugurated in January, the Supreme Court will hear arguments about the constitutionality of the Affordable Care Act, also known as Obamacare. The court's decision likely won't come until spring, and in the meantime, the Biden administration could try to make the case against the law moot.

"There are a couple of things Congress could do to make it so there's actually no nothing to litigate — so the Supreme Court wouldn't have to decide this case, it would just go away," says Sabrina Corlette, co-director of theCenter on Health Insurance Reforms at Georgetown University. Even if Republicans control the Senate, she says, it still might be possible for Congress and the White House to find a compromise. "I don't think the litigation is a win for Republicans politically, and so they may just be perfectly happy to work out a deal."

If the Supreme Court does overturn the law next spring and Congress fails to make that deal, President Biden and Congress would have to work quickly to come up with another way to address the possibility of tens of millions of people becoming uninsured amid a pandemic.

Assuming the ACA does survive this latest Supreme Court challenge, Biden has said he wants to "build on" the law. For example, he wants to address complaints that ACA premiums are unaffordable — the current law only provides federal premium subsidies for households that make up to 400% of the federal poverty level. Biden's plan would expand these subsidies to include people who make more money than that. He would also reverse some of the ways the Trump administration has tried to undercut the exchanges; Biden says he would restore funding for ACA consumer outreach and for help with ACA sign-ups.

The most significant change he would like to make to the ACA is creating a Medicare-like program that would be a "public option" — a health insurance program administered by the federal government, just as Medicare is, but available to people of any age — that could compete against private insurance plans in the marketplace. This idea was part of the original ACA but did not make it into the final law.

"A Medicare-like public option would likely be substantially less expensive than current private insurance plans," explains Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation. "That's because of the leverage the government would have to drive down the prices of doctor visits and hospital care."

One example of how this works is in payment rates for doctors and other providers: "Medicare pays hospitals about half of what private insurance companies pay, so a Medicare-like public option at Medicare prices would be much less expensive than private insurance plans," Levitt says. Plus, he says, "the government-sponsored insurance plan also wouldn't have a profit margin like private insurers have, which would also help lower premiums."

But, Levitt says, the public option is one of many health care ideas Biden campaigned on that "are likely dead in the water if Republicans keep control of the Senate."

Douglas Holtz-Eakin, president of the conservative American Action Forum, agrees: "I don't see any of that being easy for Republicans in the Senate to tolerate."

ISSUE: COVID-19 Pandemic

Early Monday morning, Biden announced a COVID-19 advisory board to, as he said in his victory speech, "help take the Biden-Harris COVID plan and convert it into an action blueprint that will start on January 20, 2021."

Also Monday, Pfizer announced that its vaccine candidate appears to be working, at least in preliminary evidence from tests in people. Biden released a statement calling the news "excellent" but warned that widespread vaccination is many months away and that "Americans will have to rely on masking, distancing, contact tracing, hand washing, and other measures to keep themselves safe well into next year."

Biden will be taking office with the coronavirus blazing through the country — new records of cases and deaths are becoming routine, and more than 237,500Americans have already died from COVID-19.

"Among health care issues, there's no question the pandemic is top of the list right now," notes Levitt. "The pandemic will still be with us for quite some time and will likely dominate the next presidential term."

Biden has remarked often that he would "listen to science" in his approach to stopping the pandemic, whereas Trump has repeatedly contradicted his own top health officials. Biden has pledged to put the federal government in charge of a nationally coordinated COVID-19 response, once he has the presidential reigns in January, and to use the Defense Production Act to ramp up production of masks, face shields, and other personal protective equipment.

While Trump has deferred to the states to come up with and implement testing strategies, Biden wants to establish a Pandemic Testing Board that would coordinate a nationwide response. Among other goals the board would increase drive-by testing twofold and push for the creation of at-home tests and instant tests.

Like Trump, Biden has pledged to guarantee free coronavirus testing regardless of a person's insurance status. He also has said he would subsidize health insurance coverage for people who are relying on COBRA health insurance because of a job-loss during the COVID-19 emergency.

Contact tracing has also been left to the states until now, though few states have enough contact tracers to help keep the spread of the virus at bay. An NPR survey estimates there are 53,000 contact tracers across the country — Biden would like to create a U.S. Public Health Jobs Corps to mobilize 100,000 contact tracers. Similar ideas have been floated already by Democrats in Congress, although — again — whether such a plan could be passed into law depends in part on which party controls the Senate.

And while the Trump administration invested around $12 billion in the development of potential vaccines to fight COVID-19, negotiations between the White House and Congress over a new COVID-19 relief bill that would include money to distribute those vaccines along with other stimulus measures, have stalled. There does seem to be bipartisan support for this funding, but it's unclear if a new relief bill can happen before inauguration day. Biden will likely push hard for this and other vaccine-related funding: His platform calls for an investment of $25 billion in vaccine manufacturing and distribution.

"I think it would be savvy for the Biden administration to use the pandemic as a vehicle for making forward progress with respect to health care," says Jamila Michener, co-director of the Center for Health Equity at Cornell University. "The pandemic gives you an opening to, for example, rebuild and further build the public health workforce." Michener says Biden could also support federal health agencies such as the Center for Disease Control and Prevention — agencies "that the Biden administration has immediate and influence over, that [under Trump] have very much been eroded and are just kind of flailing in the wind."

ISSUE: Medicare & Medicaid

When it comes to Medicare and Medicaid, the federal health programs that together provide coverage to 115 million people, Biden has signaled he wants to expand eligibility for these programs.

For Medicare, the federal program for people over 65, and certain younger people with disabilities. Biden has said he would like to allow people to enroll as early as age 60 and make dental, vision and hearing coverage standard issue in traditional Medicare. Currently, most Medicare beneficiaries have to buy a supplemental policy to add on those benefits.

In a divided Congress, these changes to Medicare that would cost taxpayers more money aren't likely to make it into law. "I've never seen any appetite on the Republican side of the aisle for something that would have greater Medicare spending," says Holtz-Eakin. "That's not the way they typically run."

In terms of Medicaid, the state-run program for low-income adults, children, pregnant women and people with disabilities, "we shouldn't underestimate the powers that lie in the executive branch," Michener says. States and the federal government jointly fund Medicaid.

Trump's administration has been creative in how it encouraged states to change the program, she explains, "like allowing for eligibility and enrollment restrictions, restricting benefits, increasing co-pays, increasing or requiring premiums, [and] implementing work reporting requirements."

There's no reason why the Biden administration couldn't do the same, although to very different policy ends. More progressive or liberal states might ask the federal government to be able to use Medicaid funding for housing costs, for instance, Michener says.

"Because the notion is that housing is health," she explains. "So if we can support people in keeping them housed in a variety of ways, whether it's paying for legal services for people who are being potentially evicted, or what have you, then that might be part of how we think about what a program like Medicaid can do to maintain health outside of the narrow confines of hospitals or doctors offices."

Biden has also talked about Medicaid expansion, a key part of the ACA that expanded coverage to more than 12 million people. Only about a dozen states have declined to adopt expansion of the program. Biden campaigned on the idea that the new public option could help fill the need for low-income people who don't qualify for Medicaid in those states that haven't expanded eligibility. If the public option can't get through Congress, though, it's unclear how the Biden administration might address this issue.

Biden may also move to reverse the executive actions Trump took to limit health care options for immigrants, which is another "one of the areas where Biden could do a lot administratively without Congress," Levitt says. That may include reversing the "public charge" rule, which aimed to deny green cards to some immigrants who use food stamps or other public benefits. (On Nov. 2, a federal judge blocked enforcement of Trump's public charge rule.) Biden has also said he wants to expand ACA coverage to DACA recipients, and allow undocumented immigrants to purchase plans in the ACA marketplaces, although without federal subsidies.

ISSUE: Drug & Health Care Costs

This is the area in health policy where Biden's policies might be most like President Trump's. Both of them have said they want to end surprise medical billing and bring down prescription drug prices, and they even agree on some ideas about how to do that.

A key way in which Biden differs from Trump in his favored way to lower drug prices is Biden's support for allowing the federal government to negotiate drug prices on behalf of Medicare beneficiaries. This was an important part of the drug pricing law the House of Representatives passed in 2019, but was a nonstarter for the Senate led by Sen. Mitch McConnell, R-Ky. If Republicans maintain control of the Senate and McConnell remains majority leader, this is very unlikely to get through Congress.

But there is the potential for bipartisan agreement on other measures to bring down drug costs, and to help remedy the problem of sky-high medical bills. "I could see surprise medical bills being dealt with" in the next administration, Holtz-Eakin says.

The practice of surprise billing — when, for example, a patient goes to an in-network hospital but is treated by out-of-network providers who then bill the patient directly — is a particular problem that Congress has tried to address. Out-of-network surgical assistants (health care providers the patient never met) have become an increasing problem in this regard, policy analysts say, and surprise "hospital facility fees" are another problem. Surprise bills and skimpy, or high deductible-insurance plans have forced many Americans into medical bankruptcy.

Trump pushed hard on Congress to deal with surprise billing from out-of-network health care providers, and lawmakers got close last December, but ultimately failed to come to an agreement about how to get it done. Biden has also said he would like to end the practice, but hasn't explained which approach he would support.

ISSUE: Other Key Health Issues

Beyond the big ticket health policy items of the Affordable Care Act and the pandemic, "there are a whole host of health care issues where I would expect a Biden administration to move to reverse much of what President Trump has done," says Levitt.

"For example, in reproductive health, President Trump has restricted federal funding for agencies that provide abortion counseling like Planned Parenthood," Levitt says. "Biden has opposed that and I would expect him to reverse those restrictions."

Not only does Biden support Roe v. Wade, he has said he wants to codify its protections in law. His administration would likely make moves to allow more federal funding for abortion and to ensure no-cost contraception coverage for more employees.

Trump put some effort into the opioid crisis — he declared in a public health emergency and created a plan to address it, though the Government Accountability Office and other opioid policy experts say the implementation of that policy has fallen flat. Biden has said he wants to increase access to treatment services for opioid use disorder, curb opioid prescriptions and prosecute pharmaceutical companies that helped feed the nation's addiction problems.

Then there are the significant racial health disparities laid bare by the pandemic. "Some of the bigger picture health policy pieces that the Biden administration is going to pursue are going to be kind of disproportionately beneficial for people of color," Michener says. She's also heard the Biden campaign pledge to address racial disparities more head on, for instance by addressing maternal mortality.

The Trump administration also has been criticized for not doing enough to address the significant racial disparities in the COVID-19 pandemic, including by not releasing demographic data that demonstrated how communities of color were significantly harder hit in terms of cases of the illness and deaths.

Better access and analysis of data around racial health outcomes for COVID-19, Michener says, is "the low-hanging fruit that will easily be plucked by the Biden administration."

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