WASHINGTON (AP) — Former President Donald Trump threatened over the weekend to reopen the contentious fight over the Affordable Care Act after failing to repeal it while in the White House, saying he is “seriously looking at alternatives” if he wins a second term.

Trump’s comments drew rebuke from Democratic President Joe Biden ‘s campaign, which cast them as another “extremist” proposal from the GOP front-runner. And they rapidly moved to mobilize a response, including new advertising in battleground states contrasting Biden’s efforts to lower drug costs with Trump’s comments.

“Donald Trump is campaigning on a threat to rip away health care from millions of Americans, so we’re going to use every tool in our arsenal to make sure the American people know that lives are literally on the line next November,” said Biden campaign communications director Michael Tyler.

The back-and-forth points to what could be a key issue in a general election rematch between Trump and Biden if both win their parties’ nominations, as is widely expected.

Biden’s team has long operated under the assumption that Trump would be the GOP nominee, given his commanding lead in the polls, and has stepped up efforts in recent weeks to cast his proposals as extreme and to paint him as a danger to democracy. Biden, in particular, has begun painting a vision of a catastrophic future if Trump wins — a strategy that could motivate lukewarm Democratic voters who may be driven more by a desire to stop Trump than to deliver a second term to Biden amid lingering concerns over high inflation, the direction of the country and his age.

Health care has generally been a better issue for Democrats than Republicans, who have largely abandoned efforts to repeal the Affordable Care Act in recent years.

And Biden’s campaign quickly seized the opportunity. Beyond the new ads, the campaign will host a press call Tuesday with former House Speaker Nancy Pelosi and North Carolina Gov. Roy Cooper to highlight the potential impact of repealing the law, while state Democratic parties in swing states will host their own events.

“Donald Trump’s America is one where millions of people lose their health insurance and seniors and families across the country face exorbitant costs just to stay healthy. Those are the stakes next November,” Biden-Harris 2024 spokesperson Ammar Moussa said in a statement.

Trump has not spent much time discussing health care as he has laid out an aggressive agenda for a potential second term that has focused on immigration crackdowns and mass deportations, as well as efforts to target political rivals.

But Trump weighed in on the issue Saturday morning on his Truth Social site.

“The cost of Obamacare is out of control, plus, it’s not good Healthcare. I’m seriously looking at alternatives,” he wrote. “We had a couple of Republican Senators who campaigned for 6 years against it, and then raised their hands not to terminate it. It was a low point for the Republican Party, but we should never give up!”

He was referring to July 2017, when the late Sen. John McCain, R-Ariz., blocked Trump’s long effort to repeal the health care law, which has proven increasingly popular.

About 6 in 10 Americans say they have a favorable opinion of the health reform bill signed into law in 2010, known commonly as the Affordable Care Act or Obamacare, according to a KFF poll conducted in May 2023.

A recent ABC News/Ipsos poll found 37% of Americans trust Democrats to do a better job than Republicans on handling health care, versus about 1 in 5 — 18% — who trust Republicans over Democrats on this issue. About one-third (34%) trust neither party.

Still, a June 2023 AP-NORC poll showed a minority of U.S. adults — 44% — approving of how Biden was handling health care, with 53% disapproving. That included 69% of Democrats and 17% of Republicans — measurements in line with Biden’s overall job approval.

Trump’s comments came in response to a Wall Street Journal op-ed he shared highlighting concerns raised by Sens. Elizabeth Warren, D-Mass., and Mike Braun, R-Ind., that large insurance companies are using their pharmacies “to evade federal requirements that limit the percentage of premium dollars spent on profits and administration, known as the Medical Loss Ratio (MLR), resulting in sky-high prescription drug costs and excessive corporate profits.”

Biden’s Health and Human Services Department says more than 40 million are insured through coverage related to provisions of the Affordable Care Act.

Moussa said Trump “would try to rip it away if he returns to power. He was one vote away from getting it done when he was president — and we should take him at his word that he’ll try to do it again.”

___ Colvin reported from New York. Linley Sanders contributed to this report.

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The government can keep enforcing “Obamacare” requirements that health insurance plans cover preventative care — such as HIV prevention, some types of cancer screenings and other illnesses — while a legal battle over the mandates plays out, under a court agreement approved Tuesday.

The pact approved by the 5th U.S. Circuit Court of Appeals preserves — at least for now — cost-free preventive care coverage for millions of Americans under the Affordable Care Act.

That coverage was thrown into question by a March ruling from a federal judge in Texas, who said some of the preventive care requirements under former President Barack Obama’s 13-year-old health care law are unconstitutional.

The ruling by U.S. District Judge Reed O’Connor had nationwide effects. The Biden administration had argued last week at the appeals court that the ruling should be stayed while appeals are pursued.

The agreement was filed with the court Monday. In it, the plaintiffs in the case, including a Christian dentist who opposes coverage for contraception and HIV prevention on religious grounds, agreed to a broad stay nationwide. In return, during the appeal process, the handful of plaintiffs would be allowed to provide insurance plans that don’t include the preventive care. If O’Connor’s ruling were reversed, they would have to provide the coverage, but they would not be penalized for having dumped the coverage during appeals.

O’Connor’s March ruling deals with requirements for coverage driven by recommendations by the U.S. Preventive Services Task Force. The judge ruled that because the task force is made up of volunteers, enforcing its recommendations violates the Constitution’s Appointment Clause, which lays out how government officials can be appointed.

Not all preventive care was threatened by O’Connor’s ruling. An analysis by the nonprofit KFF foundation found that some screenings, including mammography and cervical cancer screening, would still be covered without out-of-pocket costs because the task force recommended them before the health care law was enacted in March 2010.

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WASHINGTON (AP) — The Affordable Care Act — “Obamacare” — has inspired many exaggerated claims through the years, both from fans and foes. Now President Joe Biden is adding his own.

With a few loose words turned into a pithy formula, the president implies that his enhanced version of the ACA is much better than it really is. Biden suggests that considerably more people are getting health insurance for less than $10 a month than what’s actually been the case.

BIDEN: “The American Rescue Plan did more to lower costs and expand access to health care than any action since the passage of the Affordable Care Act. It made quality coverage more affordable than ever — with families saving an average of $2,400 on their annual premiums, and four out of five consumers finding quality coverage for under $10 a month.” — Jan. 27 statement on health insurance enrollment.

THE FACTS: His numbers are off the mark. According to the Centers for Medicare and Medicaid Services, or CMS, about one in three of HealthCare.gov consumers (32%) is paying less than $10 a month in premiums after tax credits.

That’s not four out of five, as Biden suggests, which would translate to a much bigger share — 80%.

Biden’s coronavirus relief bill did significantly reduce costs for people covered through the health insurance marketplaces. It increased taxpayer-provided subsidies for the private plans offered by participating insurers, and it made more people eligible for financial assistance. As a result, enrollment has grown to 14.5 million people this year, an increase of about 20% from the previous sign-up season.

The four-out-of-five statistic cited by Biden actually seems to refer to something else.

According to figures from CMS, four out of five consumers have access to a plan for less than $10 a month after financial assistance. These consumers can find a plan for less than $10 if they want to. But it doesn’t mean they’ve picked one. Or even that they’re aware such low-priced plans are available.

Consumers may have good reasons not to go for rock-bottom premiums. Such plans may not have the hospitals and doctors they’re looking for, or the copays and deductibles may be higher than what they’d like.

“While it is important for consumers to have access to low-cost premiums, many consumers are choosing to balance premiums with other plan features like copays and deductibles,” says Massey Whorley of the consulting firm Avalere Health. “Access to coverage starts with affordable premiums, but consumers are also thinking ahead to when they actually use their insurance.”

So while most consumers can find plans for less than $10 a month after financial assistance, finders aren’t necessarily keepers.

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Humana also referred readers, who undoubtedly include Congressional staffers and possibly their bosses, to a report from the Better Medicare Alliance, an industry-financed lobbying group for MA plans, released earlier this year. The report, the “2021 State of Medicare Advantage,” predictably lauded these plans, noting that 98% of beneficiaries were satisfied with their coverage; 97% were “specifically satisfied” with their network of physicians, hospitals, and specialists; and that “Medicare Advantage’s overall satisfaction rate rises to 99% among minority beneficiaries.” The lobbying group also applauded 70 members of Congress from both sides of the aisle who had sent a letter to the Secretary of Health and Human Services in support of MA plans. The group then took to Twitter to single out individual members of Congress such as Alabama Rep. Terri Sewell, thanking her for co-signing the letter and for “expressing strong support for Medicare Advantage.” Such gestures are like valentines, a lobbyist once told me, to flatter legislators into supporting a group’s agenda.

Flattery seems to have worked! Congress has given Medicare Advantage plans every advantage over traditional Medicare in an ongoing effort to diminish that program in favor of a privatized version of Medicare.

The underlying goal, I have long argued, is to shift more of the cost of medical care to seniors themselves, relieving the financial pressure on the federal government to pay for their health needs. Over the years, the government has overpaid Medicare Advantage plans to encourage their growth. In addition plans have been able to get more money by overstating the severity of their beneficiaries’ illnesses.

All this money has enabled Medicare Advantage plans to entice new members with goodies like dental, vision, and hearing benefits, free transportation to doctors’ offices, and two weeks of meals after a hospital stay. MA plans are allowed to offer those benefits, which the traditional Medicare program and Medigap policies that accompany it usually do not offer. With such a government-sanctioned edge, no wonder MA plans have been able to bring 42% of the Medicare population into their fold.

There’s a dark side, though, to the rising popularity of Medicare Advantage plans, which the public does not see, since the media has largely taken a pass on covering the story. Academic research, however, is beginning to reveal that thousands of Medicare beneficiaries, taken in by over-the-top poll results from the Better Medicare Alliance and ubiquitous TV commercials featuring Joe Namath may not be so delighted with their plans after all. People are enticed by cheaper premiums and lots of benefits, but they often don’t go beyond the premiums to understand how the plans’ cost-sharing and provider networks really work.

“These findings suggest that Medicare Advantage members in rural areas are experiencing limited access to care,” Sungchul Park, an assistant professor at Drexel’s Dornsife School of Public Health, told me. “They may realize that staying in an Advantage plan is not good for them, and they switch.”

In March, the policy journal Health Affairs published a significant study that offers strong warnings for Medicare Advantage members, particularly those living in rural areas. The study found that while switching from traditional Medicare to MA plans was not common for beneficiaries in either rural or urban areas, those living in rural areas were twice as likely (10.5%) to leave an MA plan as people who live in urban or suburban areas (5%). In other words, more beneficiaries who had chosen Advantage plans in rural areas were dissatisfied with their coverage. About one-fifth of beneficiaries in rural areas who were dissatisfied with the ease of getting to their doctor or getting care at the same location switched to traditional Medicare.

“These findings suggest that Medicare Advantage members in rural areas are experiencing limited access to care,” Sungchul Park, an assistant professor in the department of health management and policy at Drexel’s Dornsife School of Public Health and the lead study author, told me. “They may realize that staying in an Advantage plan is not good for them, and they switch.”

“If you’re living in an area with few providers to begin with, you might have access to an even smaller number of providers in your network,” said David Meyers, an assistant professor of health services policy and practice at Brown University and another of the study’s authors.

What makes these results even more noteworthy is that so many rural beneficiaries were willing to leave their Advantage plans even though most of them can’t buy a supplemental insurance (Medigap) policy to fill in traditional Medicare’s coverage gaps. Many seniors have health problems that make them uninsurable at this point. But without a Medigap policy, they must pay the 20% of a bill that Medicare does not pay. People in traditional Medicare usually buy Medigap policies, which cover things like coinsurance, copayments and deductibles, when they first become eligible for Medicare. Depending on which of the 10 standardized Medigap plans they buy, they may have negligible out-of-pocket expenses. However, only four states — New York, Connecticut, Maine, and Massachusetts — allow people to return to traditional Medicare and buy a Medigap policy without an insurer taking into consideration their health after their initial enrollment period. That makes it more likely in other states for an insurer to deny someone a Medigap plan — coverage is not guaranteed. But staying in an MA plan may mean they cannot access certain doctors to treat their condition. They’re stuck in a bind.

Meyers and his colleagues have recently published other studies, which raise more questions about the care minorities receive in Medicare Advantage plans. In January, one study published in the Journal of General Internal Medicine found that MA plans with higher premiums, higher enrollment, and higher market share tended to have wider networks. The study also found “substantial racial/ethnic disparities in access to wider MA networks when it came to primary care, psychiatry, and mental and behavioral health” care for Hispanic and Asian beneficiaries. This June, another Health Affairs study found that as of 2018, 47% of Hispanics, and 37% of Blacks were in MA plans, compared to 26% of whites. The study concluded that the biggest increases in MA enrollment were among Black enrollees and those who lived in the poorest neighborhoods.

There’s a dark side, though, to the rising popularity of Medicare Advantage plans, which the public does not see, since the media has largely taken a pass on covering the story.

“Racial and ethnic minorities tend to concentrate in specific plans that may be lower in quality than the plans white beneficiaries are enrolling in,” Meyers said. “Hispanic and Black beneficiaries also tend to enroll in low-premium plans, and we’ve found lower premiums may be associated with narrower networks.” Meyers added that it’s well-established by existing research that Black and Hispanic enrollees experience poorer outcomes in the Medicare Advantage program than white enrollees.

Given such findings and the zeitgeist of the moment, it is disappointing to see the media take a pass reporting on Meyers’ research, which is significant for millions of Americans of color and those living in rural areas. That’s hardly surprising, since as I have pointed out in this space, journalists barely cover Medicare these days, despite its importance to so many Americans. The Health Affairs press office picked up only 12 stories about its March report on rural Americans leaving MA plans. All appeared in trade or health-related news outlets. It picked up only five stories — four in the trade press and one in a fitness magazine — discussing the findings of the Health Affairs study published in June. The AARP Bulletin, which reaches 35 million readers, including those in rural areas heavily targeted by Medicare Advantage sellers, did not run a story about Meyer’s findings, according to an AARP spokesperson.

So where can journalists, people on Medicare, and those about to join actually learn objectively what their options are? The best source of such information about the limitations of Medicare Advantage plans Meyers and his colleagues have pointed out is their State Health Insurance Assistance Program, or SHIP, for short. The SHIPs were set up by Congress in 1990 to help Medicare beneficiaries, who were confronting a confusing marketplace long before there were Advantage plans.

I called three SHIP programs in rural states asking about options for a hypothetical relative. They all suggested the person make an appointment to see a counselor, but gave me a bit of information when I asked about ease of seeing physicians. In Indiana, a counselor said a doctor can leave an Advantage plan “for any reason they see fit. It’s definitely not uncommon.” A North Dakota counselor noted, “there aren’t a lot of doctors in rural areas, and they (people) have to travel to bigger areas. Original Medicare might be a better option because it is accepted nationwide. It’s more broad.” In Georgia, a counselor advised, “Each option works for some, but it doesn’t work for others.”

This spring a rare and excellent Medicare story appeared, this one in Kaiser Health News and picked up by some of Kaiser’s media partners. Fred Schulte reported that Humana had overcharged Florida seniors on Medicare nearly $200 million in 2015 by overstating how sick they were. The Health and Human Services Office of the Inspector General said this would be “by far the largest” audit penalty ever imposed on a Medicare Advantage company if finalized. Humana told KHN it disputed the findings. I sent an email to the company asking for an update and Humana did not respond to the request. Schulte is a veteran journalist who has covered this issue for years and is one of the rare reporters to write critically about Medicare Advantage plans, let alone cover Medicare in the first place. He reported that despite their popularity, MA plans have been the target of many government investigations, Medicare audits, and Department of Justice and whistleblower lawsuits.

Schulte’s dogged pursuit of Advantage plan overcharges and the health researchers’ findings about network shortcomings in rural areas and for Americans of color should be reason enough to revive media interest on this neglected beat. You can bet when Joe Namath is back in the fall hawking Medicare Advantage plans, he won’t be talking about narrow networks, lack of access to doctors, or overcharging the government. But someone should.

—

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care column.

Trudy Lieberman | Columnist

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In late July, sponsored content appeared sandwiched between paragraphs of legitimate journalism in Politico Pulse, the outlet’s daily health care newsletter. Humana, the country’s second-largest seller of Medicare Advantage (MA) plans, told readers that “with Medicare Advantage, seniors save an average of $1,640 in annual out-of-pocket spending compared to fee-for-service Medicare.” Humana added that it was “committed to affordable quality care,” echoing that shopworn slogan from the marketing pitch used to sell Obamacare in 2009.

Humana also referred readers, who undoubtedly include Congressional staffers and possibly their bosses, to a report from the Better Medicare Alliance, an industry-financed lobbying group for MA plans, released earlier this year. The report, the “2021 State of Medicare Advantage,” predictably lauded these plans, noting that 98% of beneficiaries were satisfied with their coverage; 97% were “specifically satisfied” with their network of physicians, hospitals, and specialists; and that “Medicare Advantage’s overall satisfaction rate rises to 99% among minority beneficiaries.” The lobbying group also applauded 70 members of Congress from both sides of the aisle who had sent a letter to the Secretary of Health and Human Services in support of MA plans. The group then took to Twitter to single out individual members of Congress such as Alabama Rep. Terri Sewell, thanking her for co-signing the letter and for “expressing strong support for Medicare Advantage.” Such gestures are like valentines, a lobbyist once told me, to flatter legislators into supporting a group’s agenda.

Flattery seems to have worked! Congress has given Medicare Advantage plans every advantage over traditional Medicare in an ongoing effort to diminish that program in favor of a privatized version of Medicare. The underlying goal, I have long argued, is to shift more of the cost of medical care to seniors themselves, relieving the financial pressure on the federal government to pay for their health needs. Over the years, the government has overpaid Medicare Advantage plans to encourage their growth. In addition plans have been able to get more money by overstating the severity of their beneficiaries’ illnesses.

All this money has enabled Medicare Advantage plans to entice new members with goodies like dental, vision, and hearing benefits, free transportation to doctors’ offices, and two weeks of meals after a hospital stay. MA plans are allowed to offer those benefits, which the traditional Medicare program and Medigap policies that accompany it usually do not offer. With such a government-sanctioned edge, no wonder MA plans have been able to bring 42% of the Medicare population into their fold.

There’s a dark side, though, to the rising popularity of Medicare Advantage plans, which the public does not see, since the media has largely taken a pass on covering the story. Academic research, however, is beginning to reveal that thousands of Medicare beneficiaries, taken in by over-the-top poll results from the Better Medicare Alliance and ubiquitous TV commercials featuring Joe Namath may not be so delighted with their plans after all. People are enticed by cheaper premiums and lots of benefits, but they often don’t go beyond the premiums to understand how the plans’ cost-sharing and provider networks really work.

“These findings suggest that Medicare Advantage members in rural areas are experiencing limited access to care,” Sungchul Park, an assistant professor at Drexel’s Dornsife School of Public Health, told me. “They may realize that staying in an Advantage plan is not good for them, and they switch.”

In March, the policy journal Health Affairs published a significant study that offers strong warnings for Medicare Advantage members, particularly those living in rural areas. The study found that while switching from traditional Medicare to MA plans was not common for beneficiaries in either rural or urban areas, those living in rural areas were twice as likely (10.5%) to leave an MA plan as people who live in urban or suburban areas (5%). In other words, more beneficiaries who had chosen Advantage plans in rural areas were dissatisfied with their coverage. About one-fifth of beneficiaries in rural areas who were dissatisfied with the ease of getting to their doctor or getting care at the same location switched to traditional Medicare.

“These findings suggest that Medicare Advantage members in rural areas are experiencing limited access to care,” Sungchul Park, an assistant professor in the department of health management and policy at Drexel’s Dornsife School of Public Health and the lead study author, told me. “They may realize that staying in an Advantage plan is not good for them, and they switch.”

“If you’re living in an area with few providers to begin with, you might have access to an even smaller number of providers in your network,” said David Meyers, an assistant professor of health services policy and practice at Brown University and another of the study’s authors.

What makes these results even more noteworthy is that so many rural beneficiaries were willing to leave their Advantage plans even though most of them can’t buy a supplemental insurance (Medigap) policy to fill in traditional Medicare’s coverage gaps. Many seniors have health problems that make them uninsurable at this point. But without a Medigap policy, they must pay the 20% of a bill that Medicare does not pay. People in traditional Medicare usually buy Medigap policies, which cover things like coinsurance, copayments and deductibles, when they first become eligible for Medicare. Depending on which of the 10 standardized Medigap plans they buy, they may have negligible out-of-pocket expenses. However, only four states — New York, Connecticut, Maine, and Massachusetts — allow people to return to traditional Medicare and buy a Medigap policy without an insurer taking into consideration their health after their initial enrollment period. That makes it more likely in other states for an insurer to deny someone a Medigap plan — coverage is not guaranteed. But staying in an MA plan may mean they cannot access certain doctors to treat their condition. They’re stuck in a bind.

Meyers and his colleagues have recently published other studies, which raise more questions about the care minorities receive in Medicare Advantage plans. In January, one study published in the Journal of General Internal Medicine found that MA plans with higher premiums, higher enrollment, and higher market share tended to have wider networks. The study also found “substantial racial/ethnic disparities in access to wider MA networks when it came to primary care, psychiatry, and mental and behavioral health” care for Hispanic and Asian beneficiaries. This June, another Health Affairs study found that as of 2018, 47% of Hispanics, and 37% of Blacks were in MA plans, compared to 26% of whites. The study concluded that the biggest increases in MA enrollment were among Black enrollees and those who lived in the poorest neighborhoods.

There’s a dark side, though, to the rising popularity of Medicare Advantage plans, which the public does not see, since the media has largely taken a pass on covering the story.

“Racial and ethnic minorities tend to concentrate in specific plans that may be lower in quality than the plans white beneficiaries are enrolling in,” Meyers said. “Hispanic and Black beneficiaries also tend to enroll in low-premium plans, and we’ve found lower premiums may be associated with narrower networks.” Meyers added that it’s well-established by existing research that Black and Hispanic enrollees experience poorer outcomes in the Medicare Advantage program than white enrollees.  

Given such findings and the zeitgeist of the moment, it is disappointing to see the media take a pass reporting on Meyers’ research, which is significant for millions of Americans of color and those living in rural areas. That’s hardly surprising, since as I have pointed out in this space, journalists barely cover Medicare these days, despite its importance to so many Americans. The Health Affairs press office picked up only 12 stories about its March report on rural Americans leaving MA plans. All appeared in trade or health-related news outlets. It picked up only five stories — four in the trade press and one in a fitness magazine — discussing the findings of the Health Affairs study published in June. The AARP Bulletin, which reaches 35 million readers, including those in rural areas heavily targeted by Medicare Advantage sellers, did not run a story about Meyer’s findings, according to an AARP spokesperson.

So where can journalists, people on Medicare, and those about to join actually learn objectively what their options are? The best source of such information about the limitations of Medicare Advantage plans Meyers and his colleagues have pointed out is their State Health Insurance Assistance Program, or SHIP, for short. The SHIPs were set up by Congress in 1990 to help Medicare beneficiaries, who were confronting a confusing marketplace long before there were Advantage plans.

I called three SHIP programs in rural states asking about options for a hypothetical relative. They all suggested the person make an appointment to see a counselor, but gave me a bit of information when I asked about ease of seeing physicians. In Indiana, a counselor said a doctor can leave an Advantage plan “for any reason they see fit. It’s definitely not uncommon.” A North Dakota counselor noted, “there aren’t a lot of doctors in rural areas, and they (people) have to travel to bigger areas. Original Medicare might be a better option because it is accepted nationwide. It’s more broad.” In Georgia, a counselor advised, “Each option works for some, but it doesn’t work for others.”

This spring a rare and excellent Medicare story appeared, this one in Kaiser Health News and picked up by some of Kaiser’s media partners. Fred Schulte reported that Humana had overcharged Florida seniors on Medicare nearly $200 million in 2015 by overstating how sick they were. The Health and Human Services Office of the Inspector General said this would be “by far the largest” audit penalty ever imposed on a Medicare Advantage company if finalized. Humana told KHN it disputed the findings. I sent an email to the company asking for an update and Humana did not respond to the request. Schulte is a veteran journalist who has covered this issue for years and is one of the rare reporters to write critically about Medicare Advantage plans, let alone cover Medicare in the first place. He reported that despite their popularity, MA plans have been the target of many government investigations, Medicare audits, and Department of Justice and whistleblower lawsuits.

Schulte’s dogged pursuit of Advantage plan overcharges and the health researchers’ findings about network shortcomings in rural areas and for Americans of color should be reason enough to revive media interest on this neglected beat. You can bet when Joe Namath is back in the fall hawking Medicare Advantage plans, he won’t be talking about narrow networks, lack of access to doctors, or overcharging the government. But someone should.

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care column.

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WASHINGTON (AP) — Until recently, the act of governing seemed to happen at the speed of presidential tweets. But now President Joe Biden is settling in for what appears will be a long, summer slog of legislating.

Congress is hunkered down, the House and Senate grinding through a monthslong stretch, lawmakers trying to draft Biden’s big infrastructure ideas into bills that could actually be signed into law. Perhaps not since the drafting of the Affordable Care Act more than a decade ago has Washington tried a legislative lift as heavy.

It’s going to take a while.

“Passing legislation is not a made-for-TV movie,” said Phil Schiliro, a former legislative affairs director at the Obama White House and veteran of congressional battles, including over the health care law.

Biden appears comfortable in this space, embarked on an agenda in Congress that’s rooted in his top legislative priority — the $4 trillion “build back better” investments now being shaped as his American Jobs and American Families plans.

To land the bills on his desk, the president is relying on an old-school legislative process that can feel out of step with today’s fast-moving political cycles and hopes for quick payoffs. Democrats are anxious it is taking too long and he is wasting precious time negotiating with Republicans, but Biden seems to like the laborious art of legislating.

On Monday, Biden is expected to launch another week of engagement with members of both parties, and the White House is likely at some point to hear from a bipartisan group of senators working on a scaled-back $1 trillion plan as an alternative.

At the same time, the administration is pushing ahead with the president’s own, more sweeping proposals being developed in the House and Senate budget committees, tallying as much as $6 trillion, under a process that could enable Democrats to pass it on their own. Initial votes are being eyed for late July.

“This is how negotiations work,” White House deputy press secretary Andrew Bates said during last week’s twists and turns of the infrastructure negotiations.

“We continue to work closely with Democrats of all views — as well as Republicans — on the path forward. There are many possible avenues to getting this done, and we are optimistic about our chances,” Bates said.

During his administration, President Donald Trump had the full sweep of Republican control of the House and Senate for the first two years of his tenure, but the limits of legislating quickly became clear.

Trump tended to govern by tweet, rather than the more traditional legislative process, bursting out with policy ideas and official administrative positions often at odds with his party in Congress.

The Trump-era results were mixed, and Republicans were unable to clinch their top legislative priority, repealing and replacing the Affordable Care Act. But they went on to secure a sizable achievement when Trump signed the GOP tax cuts into law at the end of 2017.

Sen. Rob Portman, R-Ohio, who is a leader of today’s bipartisan negotiations, said Sunday on NBC’s “Meet the Press” that Trump, too, proposed an infrastructure package. If Biden sticks with the bipartisan talks he could not only fulfill a campaign promise but “keep his pledge of doing things across the aisle and getting something done,” Portman said.

“Everybody wants to do infrastructure,” he said.

Even as Biden reaches for a bipartisan deal, skeptical Democrats are wary of a repeat of 2009, when Barack Obama was president and they spent months negotiating the details of the Affordable Care Act with Republicans. Eventually Democrats passed the package that became known as “Obamacare” on their own.

Lawmakers also have been energized by the speed at which Congress was able to approve COVID-19 relief — the massive CARES Act at the start of the pandemic in 2020 and more recently Biden’s American Rescue Plan in February. They are eager for swift action on these next proposals.

The Senate has set a procedural vote Tuesday on the For the People Act, a significant rewrite of voting and election law that the White House has called a “cause” for the president. Democrats are working on changes that could win moderate Democrat Joe Manchin’s support, but they’d still need 60 votes to advance the bill.

“I wouldn’t say we expect there to be 10 magical votes to appear from the Republicans in the Senate, they’ve been pretty clear that they don’t want to make it easier to vote, they don’t want to make it more accessible to vote,” White House press secretary Jen Psaki told “CBS This Morning” on Monday. “So this is just a first step, we’ll see where it goes. We’ll see what happens over the next couple of days.”

Biden’s strategy this time is a two-part approach. He is trying to secure a bipartisan deal on roads, bridges and broadband — the more traditional types of infrastructure — while also pursuing the broader Democratic priorities package.

The budget committees are preparing some $6 trillion in spending on what the White House calls the human infrastructure of Americans’ lives with child care centers, community colleges and elder care in Biden’s plans, adding in Democrats’ other long-running ideas. Among them, expanding Medicare for seniors with vision, hearing and dental services, and lowering the eligibility age to 60.

Regardless of whether Biden succeeds or fails in the on-again-off-again talks with Republicans, Democrats will press on with their own massive package, the president at least having showed he tried.

“There are two kinds of negotiation,” said Democrat Barney Frank, the former congressman and committee chairman from Massachusetts who was central to many Obama-era legislative battles. “One that will be successful and give you a good bill,” he said, and the other that will be unsuccessful, but will at least “take away any stigma of being partisan.”

Congress is eyeing an end-of-summer deadline to launch the budget reconciliation process, which would allow passage of the bills on majority votes instead of the usual 60 needed for most legislation. The Senate is split 50-50, but Vice President Kamala Harris can cast a tie-breaking vote.

As the process drags on, it’s a reminder that it took more than a year in Congress to pass Affordable Care Act, which was signed into law in spring 2010.

“Tweets are so easy,” Schiliro said. “Legislating is different from that, so to develop good legislation takes time.”

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COLUMBUS, Ohio (AP) — President Joe Biden pledged Tuesday that his $1.9 trillion rescue package would build on the promise of the Affordable Care Act, the hallmark legislation of Barack Obama’s presidency that became law 11 years ago.

Biden’s COVID-19 relief law pumps up “Obamacare” premium subsidies to address longstanding problems of affordability, particularly for people with middle-class incomes. More taxpayer assistance means, in effect, that consumers who buy their own policies through HealthCare.gov will pay hundreds of dollars less out of their own pockets.

“We have a duty not just to protect it, but to make it better and keep becoming a nation where health care is a right for all, not a privilege for a few,” Biden said at the James Cancer Hospital in Columbus, Ohio. “Millions of families will be able to sleep a little more soundly at night because they don’t have to worry about losing everything if they get sick.”

Biden’s speech in the capital of a political battleground state is part of a mini-blitz by the White House to highlight the relief package. Newly minted Health Secretary Xavier Becerra will echo Biden’s comments Tuesday in Carson City, Nevada, and join a Florida-themed Zoom event. Second gentleman Douglas Emhoff will pitch the aid in Omaha, Nebraska.

Yet events interrupted the push, as Biden needed to also address a mass shooting in Boulder, Colorado, that left 10 people dead. He spoke about the shooting and need for background checks before leaving for Ohio. And while touring a cancer center in Columbus, Biden was asked if he had the political capital to move forward on new gun control measures.

“I hope so,” said Biden, crossing his fingers. “I don’t know. I haven’t done any counting yet.”

On health care, the numbers suggest that consumers’ fears about medical costs could be eased by the new rescue package.

The COVID-19 legislation cuts premiums paid by a hypothetical 64-year-old making $58,000 from $1,075 a month to about $413, based on Congressional Budget Office estimates. A 45-year-old making $19,300 would pay zero in premiums as compared with about $67 on average before the law. People who have even a brief spell of unemployment this year can get a standard plan for zero premium and reduced copays and deductibles.

“The ACA is over a decade old and this is literally the first time that Democrats have been successful at improving it,” said analyst Larry Levitt of the nonpartisan Kaiser Family Foundation. “Democrats have succeeded politically by selling the ACA’s protections for preexisting conditions, but affordability has always been a challenge. And now Democrats have successfully improved the premium help available under the law.”

New and existing customers will be able to take advantage of the savings starting April 1 by going to HealthCare.gov. States that run their own health insurance markets will offer the same enhanced assistance, although timetables for implementation may vary.

The administration announced Tuesday that people will now be able to enroll for subsidized HealthCare.gov coverage until Aug. 15, an extension of three months. Biden has opened up the health insurance markets as part of his coronavirus response.

The Centers for Medicare and Medicaid Services, which runs the insurance markets, also said that additional savings for people who’ve been dealing with unemployment will be available through HealthCare.gov starting in early July. The richer subsidies were incorporated in the COVID-19 relief bill.

By spreading the word about the higher subsidies, the White House is hoping to super-charge enrollment. But the 11 million people who already have private plans through the health law will also benefit.

Republicans see Biden’s sweeter subsidies as an example of Democratic overreach on the COVID-19 bill. Policy consultant Brian Blase, a former health care adviser in the Trump White House, expects most of the additional taxpayer assistance will merely substitute for what private households would have otherwise paid.

Their complaints notwithstanding, Republicans may face a political dilemma. The higher health care subsidies are keyed to the pandemic and expire by the end of 2022. That will let Democrats set up election-year votes to make the new benefits permanent, or add even more.

The COVID-19 bill follows Biden’s strategy of building on the Obama-era health law to move the U.S. toward coverage for all.

Another provision offers a dozen or so holdout states led by Republicans a financial inducement to expand Medicaid to more low-income adults. So far there have been no takers.

It’s unclear how big a dent the Biden legislation will make in the number of uninsured people, which has risen to an estimated 33 million or more. But it represents the biggest expansion of federal help for health insurance since the ACA’s enactment.

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