Conventional wisdom says that the first 100 days after inauguration are when a newly elected president accomplishes the most with Congress, fresh with a mandate from the voters for a new start. After that, the political honeymoon comes to an end and it gets much harder to get things done.
But instead of a honeymoon, President Joseph R. Biden Jr. will come into office on Jan. 20 with a country deeply divided by party, ideology, gender, race, education, and geography. The Senate will either remain under Republican control or be split 50-50 with the Democrats, depending on the results of a Jan. 5 runoff in Georgia, where two Republican incumbents are facing Democratic challengers. The Democrats would need to win both seats to claim an equal number of seats in the Senate, with Vice President Kamala D. Harris being able to cast tie-breaking votes; filibuster rules will still require 60 votes for most bills. The Democrats will keep control of the House with the smallest majority in decades.
Yet President Biden's first 100 days will be critical to charting a different course on COVID-19 that slows transmission and deaths until enough Americans have been vaccinated to end the pandemic. We can be encouraged that he will put doctors in charge of the response to COVID-19, and not just any doctors, but internal medicine physician specialists as well as ACP members. Vivek Murthy, MD, will be nominated to serve again as Surgeon General, and Anthony S. Fauci, MD, MACP, will serve as chief medical adviser to the president; both will help lead the administration's efforts to end the COVID-19 pandemic. Rochelle P. Walensky, MD, FACP, will be appointed as director of the CDC. The Biden administration is expected to use the federal government's regulatory authority to require the wearing of masks in federal facilities and on public transportation. Mr. Biden has pledged to rejoin the World Health Organization, ramp up testing and tracing, get personal protective equipment to frontline health care workers, and ensure the effective distribution and prioritization of COVID-19 vaccines.
Yet COVID-19 is not the only issue that President Biden should prioritize. On Dec. 9, 2020, ACP released a comprehensive set of proposals on issues we hope he will address early in his administration.
Coverage and cost. ACP urged the Biden administration to use its executive authority to expand coverage under the Affordable Care Act (ACA), reverse Trump administration rules that allow sale of plans that do not cover needed benefits and care, increase funding and support for ACA outreach and enrollment, and stop states from imposing work requirements for Medicaid eligibility. President-elect Biden's more ambitious plan seeks to expand Medicare to persons ages 50 through 64 years, create a public option available to everyone, automatically enroll people in non-Medicaid expansion states in the public option, and lift the income caps on federal subsidies to buy health insurance coverage. These policies, supported by ACP, will face an uphill battle in the Senate. ACP has urged the Biden administration to rein in prescription drug prices, but Congress is unlikely to go as far as to allow the federal government to negotiate Medicare drug prices or eliminate the tax deductibility for direct-to-consumer advertising, as ACP recommends.
Immigration. Presidents have considerable power to shape immigration policy without needing to go through Congress. President-elect Biden has promised that on the first day of his administration, he will terminate the Trump administration's ban on travel from seven majority-Muslim countries, restore the Deferred Action for Childhood Arrivals (DACA) program to protect “Dreamers” from deportation (a federal judge recently ordered that the program be reinstated), permanently end the practice of separating children from their parents at the border, and appoint a federal task force to reunite immigrant children who were separated, changes from current policy that are strongly supported by ACP. ACP also recommended that the new administration address the backlog in visas for international medical graduates (IMGs) seeking permanent residency status and ensure the effective and efficient processing of visas for IMGs seeking to enter the United States. We asked it to reverse a rule that denies residency to legal immigrants if they are likely to use public programs like Medicaid, a major barrier to legal immigrants getting the health care they need.
Women's health and LGBTQ health. ACP recommends that the Biden administration reverse restrictions on federal funding for Planned Parenthood, gag rules that limit what physicians can say to patients about their reproductive health, and federal regulations and executive actions that weaken protections for LGBTQ persons.
Environmental health. As called for by ACP, President-elect Biden has promised to rejoin the Paris Accord on the first day of his administration, which would recommit the United States to specified targets for reducing carbon emissions. He can begin the process of reversing Trump administration regulations that eased restrictions on carbon emissions. His more ambitious plans to promote green technologies and achieve a carbon-free power sector by 2035 likely will be stymied by the Senate, although the new administration can be aggressive in using its executive authority to achieve as much of this as it can.
Racism and health. ACP called on President-elect Biden to reverse an executive order that prohibits implicit bias training for federal employees and contractors, including in medical schools; to redirect federal funding and priorities to address social drivers of health; and to seek bipartisan solutions to systemic racism in law enforcement that affects health.
Payment and delivery system reforms. ACP urged the new administration to implement alternative payment models to support the value of care provided by internists and their clinical care teams, to continue the Trump administration's commitment to increasing payments for evaluation and management services and putting patients over paperwork, to increase the total amount of federal dollars invested in primary and comprehensive care, and to continue to expand coverage and payment for telehealth and phone consultations with patients.
President-elect Biden will face huge obstacles during his first 100 days and beyond them. But what he can get done matters. He can begin to prioritize the changes ACP recommended on a range of issues to improve the health of Americans. Of course, COVID-19 should and must be his top priority. At the current rate of more than 2,000 Americans dying each day, more than 200,000 additional lives could be lost in the 100 days after Mr. Biden is sworn in, unless he can marshal public support for decisive actions to stem the tide. Much like in wartime, the first 100 days of Mr. Biden's presidency will be a matter of life and death for many, and we should all hope for his success.