The headlines about presidential candidate Joe Biden’s new health care plan called it “a nod to the past” and “Affordable Care Act 2.0.” That mostly refers to the fact that the former vice president has specifically repudiated many of his Democratic rivals’ calls for a “Medicare for All” system, and instead sought to build his plan on the ACA’s framework.

Sen. Bernie Sanders, one of Biden’s opponents in the primary race and the key proponent of the Medicare for All option, has criticized Biden’s proposal, complaining that it is just “tinkering around the edges” of a broken health care system.

Still, the proposal put forward by Biden earlier this week is much more ambitious than Obamacare – and despite its incremental label, would make some very controversial changes.

“I would call it radically incremental,” says Chris Jennings, a political health strategist who worked for Presidents Bill Clinton and Barack Obama and who has consulted with several of the current Democratic candidates.

Republicans who object to other candidates’ Medicare for All plans find Biden’s alternative just as displeasing.

“No matter how much Biden wants to draw distinctions between his proposals and single-payer, his plan looks suspiciously like “SandersCare Lite,” writes former congressional aide and conservative commentator Chris Jacobs in a column for The Federalist.

Biden’s plan is built on the idea of expanding the ACA to reduce costs for patients and consumers — similar to what Hillary Clinton campaigned on in 2016. It would do things Democrats have called for repeatedly since the ACA was passed. Among Biden’s proposals is a provision that would “uncap” federal help to pay for health insurance premiums — assistance now available only to those with incomes that are 400% of the poverty level, or about $50,000 for an individual.

Under Biden’s plan, no one would be required to pay more than 8.5 percent of their income toward health insurance premiums.

But it includes several proposals that Congress has failed repeatedly to enact, including some that were part of the original debate over the ACA. Plus, Biden’s plan has some initiatives that are so expansive, it is hard to imagine them passing Congress — even if Democrats sweep the presidency and both houses of Congress in 2020.

Here are some of the more controversial pieces of the Biden health plan:

Public option

Although many of the Democratic presidential candidates have expressed varying degrees of support for a Medicare for All plan, nearly all have also endorsed creating a government-sponsored health plan, known colloquially as a “public option,” that would be available to people who buy their own health insurance. That eligible group would include anyone who doesn’t get insurance through their job or who doesn’t qualify for other government programs, like Medicare or Medicaid.

A public option was included in the version of the ACA that passed the House in 2009. But its proponents could not muster the 60 votes needed to pass that option in the Senate over GOP objections — even though the Democrats had 60 votes at the time.

Biden’s public option, however, would be available to many more people than the 20 million or so who are now in the individual insurance market. According to the document put out by the campaign, this public option also would be available to those who don’t like or can’t afford their employer insurance, and to small businesses.

Most controversial, though, is that the 2.5 million people currently ineligible for either Medicaid or private insurance subsidies because their states have chosen not to expand Medicaid would be automatically enrolled in Biden’s public option, at no cost to them or the states where they live. Also included automatically in the public option would be another 2 million people with low incomes who currently are eligible for ACA coverage subsidies – and who would also be eligible for expanded Medicaid.

That part of Biden’s proposal has prompted charges that the 14 states that have so far chosen not to expand Medicaid would save money, compared with those that have already expanded the program, because expansion states have to pay 10% of the cost of that new population.

Jennings, the Democratic health strategist, argues that extra charge to states that previously expanded Medicaid would be unavoidable under Biden’s plan, because people with low incomes in states that haven’t expanded Medicaid need coverage most. “If you’re not going to have everyone get a plan right away, you need to make sure those who are most vulnerable do,” Jennings says.

Abortion

The Biden plan calls for eliminating the “Hyde Amendment,” an annual rider to the spending bill for the Department of Health and Human Services that forbids the use of federal funds to pay for most abortions. Biden recently ran into some difficulty when his position on the Hyde ammendment was unclear.

Beyond that, Biden’s plan also directly calls for the federal government to fund some abortions. “[T]he public option will cover contraception and a woman’s constitutional right to choose,” his plan says.

In 2010, the Affordable Care Act very nearly failed to become law after an intraparty fight between Democrats who supported and opposed federal funding for abortions. Abortion opponents wanted firm guarantees in permanent law that no federal funds would ever be used for abortion; abortion-rights supporters called that a deal breaker. Eventually a shaky compromise was reached.

And while it is true that there are now far fewer Democrats in Congress who oppose abortion than there were in 2010, the idea of even a Democratic-controlled Congress voting for federal abortion funding seems far-fetched. The current Democratic-led House has declined even to include a repeal of the Hyde Amendment in this year’s HHS spending bill, because it could not get through the GOP-controlled Senate or get signed by President Trump.

Undocumented immigrants

When Obama said in a speech to Congress in September 2009 that people not in the U.S. legally would be ineligible for federal help with their purchase of health insurance under the ACA, it prompted the infamous “You lie!” shout from Rep. Joe Wilson, R-S.C..

Today, all the Democratic candidates say they would provide coverage to undocumented residents. There is no mention of them specifically in the plan posted on Biden’s website, although a Biden campaign official told Politico this week that people in the U.S. who are undocumented would be able to purchase plans on the health insurance exchanges, but would not qualify for subsidies.

Still, in his speech unveiling the plan at an AARP-sponsored candidate forum in Iowa, Biden did not address this issue of immigrants’ health care. He said only that his plan would expand funding for community health centers, which serve patients regardless of their ability to pay or their immigration status, and that people in the U.S. without legal authority would be able to obtain coverage in emergencies. That is already law.

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Good news came out from the Centers for Disease Control and Prevention Wednesday: Preliminary data shows reported drug overdoses declined 4.2% in 2018, after rising precipitously for decades.

“It looks like this is the first turnaround since the opioid crisis began,” says Bertha Madras who served on President Trump’s opioid commission, and is a professor of psychobiology at Harvard Medical School.

She says it won’t be entirely clear until the CDC finalizes the numbers but, “I think the tide could be turning.”

But not everyone was celebrating. Some states actually saw double-digit increases.

“It’s deflating,” Rachel Winograd says. She’s an associate research professor at the University of Missouri-St. Louis. “It’s incredibly discouraging to see the increase in Missouri in 2018 that happened at the same time as we really ramped up so many efforts to save lives and improve lives in our state.”

The provisional data shows Missouri deaths increased by 17% — one of 18 states that saw a year-over-year increase.

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Over the last several years, Missouri has received $65 million in federal grants to address the opioid crisis, Winograd says, and she has helped the state decide where and how to spend that money. They’ve focused on expanding access to medication-assisted treatment, and “saturating our communities with naloxone — the opiate overdose antidote,” she says.

“Any scholar who’s been studying this epidemic will tell you that those are effective tools at saving lives. We’ve drastically increased access to those services and we know we’ve saved thousands of lives.

“The fact that the numbers didn’t go down and that people were dying at an even higher rate — it was devastating,” Winograd says.

The numbers out Wednesday are not final, notes Farida Ahmad, mortality surveillance lead of the National Center for Health Statistics at the CDC. She says they should be close to the final numbers, though. For provisional data, “our threshold is for 90% completeness,” she says.

Michael Botticelli, the executive director of the Grayken Center for Addiction at Boston Medical Center and formerly President Obama’s drug czar, says the geographic variation in drug deaths is troubling.

“I think it’s important to pay attention to and really understand what is happening in each of these states, and why are some states seeing dramatic increases versus those seeing dramatic decreases?” he says.

The reasons for this geographic variation are numerous. For one, this data only reflects the difference from one year to the next, so states that had a bad year in 2017, can show an improvement in 2018, even if the overall picture is still grim.

Another variable is fentanyl, the highly potent synthetic opioid that’s been responsible for a rising number of overdoses in recent years. Some states have a lot of fentanyl in their drug supply, and others do not.

“We saw increases all along the Mississippi river, and I would not be surprised if that was due to an increase in the proportion of fentanyl in their drug supply,” Winograd says. Deaths from fentanyl continue to rise, according to Ahmad from the CDC.

Other variations in the drug supply could contribute to the differences from state to state, says Christopher Ruhm, a professor of public policy at the University of Virginia. He notes stimulants have a different geographic spread than fentanyl, and those deaths are also on the rise.

“Some of this may be due to the nature of the drug epidemic in different places, some of it may also be due to how much we are providing medication-assisted treatment, and engaging in other policies to try to address this problem,” Ruhm says.

The social safety net also plays a role, says Winograd. In Missouri, “we just have fewer resources to help people in need,” she says.

“We have a lack of housing, incarceration rates are increasing — these are all connected and making the most vulnerable people in our society at highest risk of overdose deaths.”

Missouri was among five states that showed increased overdose numbers and had not expanded Medicaid, Winograd notes. Medicaid expansion means more people have coverage for addiction treatment, and research shows it’s making a difference.

Ohio was a bright spot on the 2018 map, showing a 22% decrease in 2018, although in raw numbers, it still had 4,000 reported deaths.

“It is still a nightmare. And the danger in media over-portraying this is actually quite substantial,” says Shawn Ryan, an addiction doctor in Ohio and past-president of the Ohio Society of Addiction Medicine. “If we look at just that decrease nationally — which is not that big — we’re missing the point. In order to get back to baseline, we have a very long way to go.”

In the CDC’s preliminary national numbers, 67,744 people are reported to have died from drug overdoses in 2018. Even though that’s several thousand less than died from drug overdoses in 2017, it’s still many, many more people than died of AIDS in the worst years of the crisis.

The decline should not be a signal to slow down efforts — or funding — to combat the epidemic, Ryan says.

He cites the proposed CARE Act, a legislative effort led by Senator Elizabeth Warren, D-Mass., and Representative Elijah E. Cummings, D-Md., which would allocate $100 billion over 10 years for addiction and recovery services. The CARE Act is modeled on the Ryan White Act, put in place to combat the AIDS epidemic.

“That’s actually much more in line with what’s needed,” says Ryan.

$100 billion would dwarf past federal funds for the epidemic. Grants from the State Targeted Response to the Opioid Crisis program, authorized by the 21st Century Cures Act, totaled $1 billion. In 2019, State Opioid Response federal grants are set to total $1.4 billion.

“If you look at the dollars spent to date, the fact that we’ve had the impact we’ve had is actually because of people being invested and working very hard for not that many dollars,” says Ryan.

Boticelli agrees that the only way to ensure the national trend continues is to adequately fund it. “We can’t look at a 5% reduction and say our work is done. I think it basically shows us that we have to redouble our efforts,” he says. “How are we going to ensure that states have the resources that they need to continue to focus energy on this epidemic?”

In a statement Wednesday, Health and Human Services Secretary Alex Azar celebrated the decline and indicated that federal funding won’t be going away. “By no means have we declared victory against the epidemic or addiction in general. This crisis developed over two decades and it will not be solved overnight,” Azar wrote.

Rachel Winograd says for her, the increase in deaths in Missouri is an indication that there’s much more to do.

“I am very proud of what Missouri has done. I don’t think we should have done anything differently,” she says. “And I do think that we’ve been even more aggressive than many of the states that saw decreases, in terms of our focus on evidence-based solutions.

“It’s not that we did the wrong thing — it’s that we didn’t do enough of the right thing,” she adds. “And we need more sustainable funding to do that.”

Carmel Wroth contributed reporting to this story.

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