Neera Tanden worries the election was ‘bait-and-switch’ on health care

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Neera Tanden thought the Democrats had a health-care record they could win on.

Neera Tanden led President Joe Biden’s Domestic Policy Council. Now she’s moving on — and worried about cuts to health programs that might be coming under Donald Trump. MUST CREDIT: Marvin Joseph/The Washington Post

The president’s domestic policy adviser spent 2024 touting a package of health-care achievements during the Biden administration – such as empowering Medicare to negotiate with drug companies and enrolling a record number of Americans in the Affordable Care Act – as a key element of Democrats’ strategy to hold onto the White House. President Joe Biden and Vice President Kamala Harris put health-related issues, notably abortion access, at the center of their campaigns.

Instead, Donald Trump danced around questions about what he would do to the nation’s health system if elected. Now, Trump will return to the Oval Office on Monday, and his allies in Congress are already eying major changes to health-care programs, a development that has clearly frustrated Tanden, as evidenced in an exit interview with The Washington Post.

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“What I’m concerned about is there was a bit of a bait-and-switch in this election,” Tanden said Thursday, sitting on a couch in her West Wing office beneath a photo of a grinning Biden. She pointed to GOP proposals circulating on Capitol Hill to potentially cut federal spending on Medicare and Medicaid by trillions of dollars during the next decade.

“I think that this will be a head snap to millions of Americans,” Tanden said. “I do not think that they went into the ballot box in November of 2024 thinking that 20 million, 30 million, 40 million people could lose health-care coverage – and that is the choice that people face when they cut $1 trillion, $2 trillion, $3 trillion from health care.”

Health care has long been considered Democrats’ most reliable election year issue. The Affordable Care Act helped the party win back the House in 2018. A backlash to Trump’s coronavirus response helped them take back the White House and Senate two years later. Abortion politics helped stave off big losses in the 2022 midterms.

Democrats were hoping to revisit those issues as part of a 2024 playbook – this time, with Biden’s drug-price changes as a central message, after polls showed those policies were broadly popular, if not particularly well-known.

It didn’t work. Trump and Republicans swept the White House and Congress. Now, Tanden and her colleagues are packing up, rather than hunkering down and preparing for four more years in power.

The office next door to Tanden, where her deputies once sat, is covered in moving boxes. On her own desk are sheaves of paper and a notepad from the Hip Hop Caucus, which she offers to a curious reporter. “I’m trying to get rid of stuff,” Tanden said.

In her exit interview, the domestic policy chief was reflective, saying that while Democrats wanted to push on health-care issues in the presidential campaign, it was hard to get traction given that Trump had learned to be far more slippery, she argued.

The former president, whose early political career was marked by his opposition to the Affordable Care Act, has backed away from the issue after the GOP’s failed repeal efforts in 2017 led to backlash against Republican leaders and Trump.

“Candidate Trump in 2024 did not say every day … ‘attack Obamacare,’” Tanden said. “He still didn’t like Obamacare, that’s clear. But it wasn’t the full frontal assault” that characterized Trump’s first presidency, she said.

Tanden cited the Biden administration’s decision to expand subsidies for the Affordable Care Act as a “bet that paid off,” given the program’s record enrollment. A fight over whether the Trump administration will continue those subsidies is looming this year.

Other bets proved too risky. The Biden administration postponed a planned ban on menthol cigarettes amid pressure from civil rights groups and some Democrats, who warned that cracking down on the products – which are popular in the Black community – would cost Democrats key votes in swing states. (The decision to shelve the ban did not stop Republicans, who still ran ads pointing to Biden’s proposed rule to restrict menthol cigarettes.)

Some experts said the ban, which the White House projected would help avert hundreds of thousands of cancer-related deaths, would have been the most significant move that Biden took on public health.

Tanden insisted that the Biden administration was leaving Trump a healthier America than they found it, with coronavirus no longer a public health emergency, a record number of Americans with health insurance and drug overdose deaths trending in the right direction.

New policies to rein in drug costs also are taking effect, such as a Biden plan to cap older Americans’ out-of-pocket spending on prescription drugs at $2,000 per year, and another initiative that requires drug companies to pay rebates to Medicare if they boost prices for certain drugs faster than the rate of inflation.

Biden was an imperfect messenger of that agenda. He tripped over his words, most notably at the June presidential debate during which he claimed “we finally beat Medicare” when he meant to say his administration had finally beaten the pharmaceutical industry by achieving drug-price negotiations for Medicare. But many Democrats struggled to convey the intricacies of their drug-price cuts, in part because most adults were not aware of the program – and also because of the changes’ complexity.

“The inflation rebates are a complicated thing to explain to any human,” Tanden said.

Asked how she reconciled record levels of health coverage with America’s persistently poor health outcomes, Tanden acknowledged that the nation was dealing with a relatively high rate of chronic disease, exacerbated by conditions such as obesity. But she said that expanding access to the Affordable Care Act and other insurance programs was part of the solution.

“Coverage actually does drive keeping people alive,” she said.

Biden originally picked Tanden to serve as his top budget official in 2021 before that selection was scuttled amid backlash to Tanden’s social media posts. He later tapped her in 2023 to lead the domestic policy council. In the interview, she conceded that serving as budget official wasn’t a good fit after all, and that she would rather be working on policy.

“This is where my heart is,” Tanden said.

But that heart is troubled, she suggested, by the possibility of cuts to the safety net – something that would affect her as a policy professional, but also as a person who knows the value of those programs. Tanden has spoken about relying on food stamps to eat, and Section 8 vouchers to pay the rent, when she was a young child being raised by a single mother.

She noted that a growing number of Americans depend on programs such as Medicaid and the Affordable Care Act, too. Any effort to weaken them would lead to a political backlash, she predicted – just like eight years ago.

“Candidates can be very skillful at eliding the actual consequences of their decisions, but you can’t when you’re governing,” Tanden said. “I think those consequences will be a lot clearer.”