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As the COVID-19 outbreak becomes an all-out public health and economic crisis, the 2020 election is being transformed. Rather than economic inequality, or even Donald Trump, this year’s election looks more and more like it will be fought over the current pandemic — and the inability of the United States’ ailing public health system to cope with it. And Joe Biden, the candidate favored to win the Democratic primary and face Trump, has a record of consistently undermining that health system. Despite pledging to “spend whatever it takes” to deal with the pandemic and the resulting economic fallout, Biden’s record is one of imperiling federal health programs and seeking to tie the government’s hands in a crisis, all for the sake of turning off the tap of government spending.

Biden’s Sunset After winning office as a New Deal liberal, by the late 1970s — with politics beginning to turn in a more conservative direction, and with one eye on his reelection in 1978 — Biden shifted sharply right. In 1977, he introduced the Federal Spending Control Act, one of two pieces of “sunset legislation” that year aimed at meeting the moment’s anti-government, anti-spending mood. Biden’s bill put all federal spending programs on the chopping block once every four years, mandating they be either reauthorized by Congress or automatically terminated, a harsh measure meant to force Congress’s hand. Some programs could be left out of the bill’s crosshairs “from time to time,” Biden explained to the Senate Committee on Rules and Administration, but only if the Senate passed a roll-call resolution doing so. “It is clear that there is growing sentiment around the country for less government, more efficient government, less costly government, and less intrusion into people’s lives by government,” Biden told the committee. “I do not believe that this sentiment is going to go away. In fact, I think it may get stronger. It is our responsibility, as I see it, to meet this feeling with action.” For Biden, this action involved putting specific spending limits on programs that were reauthorized, “not an open-ended amount.” “I realize that this poses problems, particularly for entitlement programs where the spending ceiling may depend upon economic or other circumstances,” Biden acknowledged, nonetheless insisting that Congress not create programs if it’s “not prepared to write into the law the cost of the program.” Needless to say, the idea drew objections. Calling Biden and Edmund Muskie’s bills “ill-advised proposals,” the AFL-CIO warned of their “dangerous potential as a means to delay, defer, and dismantle programs that are in the nation’s interest,” noting that programs like Social Security, Medicare, and Medicaid would be “in a constant state of confusion and uncertainty.” Senator Alan Cranston (D-CA), then chair of the Veterans’ Affairs Committee, warned of a “Darwinian struggle” among programs, where “the competitive edge would belong to powerful special interests to . . . kill the programs they dislike,” namely the “human benefit programs in such fields as health care” that had taken years of effort to create. Even those who testified in support noted concerns. An otherwise supportive statement from the Bar Association’s Commission on Law and the Economy acknowledged that “some people fear that sunset would adversely affect the government’s efforts to enhance public health and safety.” Common Cause, which gave qualified backing to the idea, warned that “an over-ambitious sunset proposal . . . could be invoked in ways to intimidate or abolish ‘people’ programs — those protecting consumer health and safety or human rights.” Biden’s bill didn’t go anywhere, but he did vote for Muskie’s bill in 1978, which put spending programs up for review once a decade. It cleared the Senate 87 to 1.

The Reagan Era Biden would get his chance to slash government programs just three years later, with an antigovernment conservative president in the White House. “In a strange way,” Biden said in November 1980, “the election of Ronald Reagan is more consistent with the budgetary thrust that a guy like me . . . has been going for the past few years.” Biden pointed to his sunset legislation as “the kind of area I think we can make some progress,” stressing that Reagan would “have my full, unbridled cooperation.” Biden wouldn’t end up getting his sunset legislation. But its overarching goal of shrinking the size and involvement of the federal government would be realized in Regan’s first two budgets, which Biden voted for. Political scientists Kenneth Meier and Deborah McFarlane would later charge that Reagan’s cuts had “assaulted the ethos of public health.” His budgets — the first of which the Washington Post described at the time as “the reversal . . . of two great waves of government intervention, the New Deal and the Great Society” — rolled numerous health programs, including community health centers and prevention programs like family planning, into a handful of block grants that it gave states discretion to spend. They also reduced the federal share of expenditure on Medicaid and gave states greater flexibility to decide who was eligible and what they would receive from the program, leading to cuts. The Washington Post estimated that various provisions in Reagan’s first budget would cut off medical aid to more than a fifth of the US population. “The decrease in funding of community health centers and migrant health programs is particularly disturbing,” Karen Davis, professor emeritus of health policy and management at Johns Hopkins University, wrote at the time, warning it “would have a devastating impact on the poor served by these programs.” Lauren Miller of the Coalition to Fight Infant Morality complained in 1982 that community health center funding had been cut by 25 percent, meaning dozens would have to close. (Over in Vermont, Biden’s current Democratic rival, Bernie Sanders, the newly elected mayor of Burlington, spoke at a protest over the budget Biden had voted for. Decades later, he would secure $11 billion of funding for such community health centers as part of Obamacare). Congress would eventually reverse some of these cuts, but combined with Reagan’s attacks on other social programs, the burden of reduced health care spending fell disproportionately on poor women and children. Meanwhile, the budgets’ devolution of power to the states meant conservative state governments had increasingly free reign to deny and defund health coverage. Despite voting for these budgets, Biden wanted to go further. While Reagan had left Medicare mostly untouched — older voters were more important than poor ones to his reelection – Biden had no such reservations. In 1984, he and a bipartisan group of senators put forward an unsuccessful budget freeze proposal that was nearly $100 billion larger than Reagan’s own plan, and eliminated scheduled increases for Medicare beneficiaries. More successful was the Gramm-Rudman resolution, which forced across-the-board spending cuts (exempting Social Security and Medicare) if the government failed to balance the budget by 1991, a clause so stringent and unpalatable that elected officials ignored and eventually replaced it. Biden’s determination to limit the government’s ability to spend, and to sacrifice vital social programs in the process, reflected the Reaganite mindset he had come to adopt from the 1980s, one that viewed even public health as a matter outside of the federal government’s powers. “Education is best left to the states,” he said in 1984. “You could make that case, I believe, for a whole range of areas where heretofore the federal government was involved . . . It will be involved in international drug questions, less involved in direct social questions like day care, education, or health.”

The Ghost of Herbert Hoover Biden spent much of the 1990s seemingly unsure of whether he wanted to cut Medicare or protect it. In October 1990, as President George H. W. Bush and Congress wrestled over how exactly to cut the deficit, Biden urged them to “freeze all government spending until we get it in order” and make cuts to everything, including Medicare; less than two weeks later, he voted against Bush’s package, which made cuts to the program. He called for billions of dollars of Medicare cuts in 1993 (his stance would “send people off the wall in Delaware,” he bragged), before deriding Republican budget plans to cut Medicare as a “bunch of malarkey” two years later. Where Biden was more consistent was in his votes for perhaps the most radical measure to limit the government’s ability to spend money: the balanced budget constitutional amendment, passage of which was one of the key planks of the new Republican House majority’s “Contract with America.” Though it came in different forms, the crux of the amendment was to make delivering a balanced budget a constitutional necessity. Some versions even made it prohibitively difficult to raise taxes to get it done, thus forcing drastic cuts to all manner of programs. Alice Rivlin, President Bill Clinton’s director of the Office of Management and Budget, warned it would “just exaggerate the boom-bust cycle” and that “recessions would tend to be deeper and longer.” Around 1,060 economists, including eleven Nobel Prize winners, repeated this warning, with one Nobel laureate cautioning it would “put the federal government into a fiscal straitjacket” during an economic crisis. Even Biden himself had, in 1994, said the measure would “make Herbert Hoover’s economic policy a constitutional mandate.” Though some versions insulated Social Security from cuts, Medicare and other public health programs were always imperiled by the amendment. Newspapers wondered if voter support for the measure would curdle once they saw the resulting cuts to areas like education, Medicare, and other health programs. Democrats themselves hoped such cuts would turn voters off. Clinton warned that “you don’t want to wind up with a Congress some day in a recession . . . throwing unemployed people off health care because they’re trying to get to a balanced budget.” From 1995 to 1997, Biden, despite acknowledging that the idea had “real flaws,” voted for the amendment each year. He was just one vote — and yet the measure fell short of passing the Senate by the smallest sliver: two votes short in 1995–96, and one vote in 1997. He had very nearly erected an insurmountable barrier to allowing the government to “spend whatever it takes” in a crisis like today’s, and one that would have led to the evisceration of programs dealing with public health and other areas. (Sanders, meanwhile, had warned the amendment would mean “the destruction of the Social Security system as we know it,” and “savage cuts in Medicare, in Medicaid.”) In 1997, having spent years insisting on the importance of balancing the federal budget above all else, Biden voted for the Balanced Budget Act (BBA), which reduced federal spending by $127 billion over the five years to 2002, with $112 billion coming out of Medicare (though bills passed in the years that followed restored some of this). It also contained the largest cutbacks in federal Medicaid spending since 1981, according to the Center on Budget and Policy Priorities. On the bright side, the law also created the State Children’s Health Insurance Program. On the other hand, the BBA added to the hardships faced by rural hospitals since the 1980s, with hundreds closing throughout the 1980s and 1990s. In a 2001 hearing, witnesses complained of the damage wracked on their state public health systems by the law. Dr. Mary Wakefield, director of George Mason University’s Center for Health Policy Research and Ethics, explained that rural hospitals had felt the sting more sharply than urban ones, due to their bigger reliance on Medicare payments. “It’s hard for any business to survive long with these kinds of margins,” she said, pointing to sharp drops in rural hospital revenues since the law’s passage. One administrator of a Mississippi county hospital testified that the BBA had “compounded severely” inequities in the reimbursement system that hurt rural hospitals. Another warned it was “jeopardizing the ability of rural providers . . . to ensure that high quality health care will be there when our community needs it.” “All hospitals, urban and rural, have been hammered by the Balanced Budget Act of 1997, which has had a far greater impact than anyone could have imagined when it passed,” said Thomas Scully, president and CEO of the Federation of American Health Systems. They were joined by Senators Dick Durbin (D-IL), Herb Kohl (D-WI), and Dianne Feinstein (D-CA), who said that “restoring Medicare and Medicaid cuts must be of the highest priority.” In the House, Sanders was one of just eighty-five to vote against the bill. BBA’s other lasting legacy was to expand the managed care program within both Medicare and Medicaid, encouraging the growth of the use of private plans. These plans, now known as Medicare Advantage, have had a mixed legacy: while those enrolled are generally happy with their plans, they’re also a bigger drain on taxpayer dollars, offer less choice and quality in health care providers, and put seniors at the mercy of plans that can drop or add providers at will. But that wasn’t all. As the Intercept reported earlier this month, Biden closed the decade out by voting to kill a 2000 amendment authored by current Democratic rival Bernie Sanders that took aim at the pharmaceutical industry. If passed, the amendment would have prevented price-gouging by pharmaceutical companies who develop drugs thanks to taxpayer money. Biden is now calling for the eventual coronavirus vaccine to be free of charge.