President Biden wants to do at least two big things in health care: crush the pandemic and cover the 30 million Americans who remain uninsured.

History, however, suggests that he may get only one chance to do them. The reason? As President Obama’s experience with the Affordable Care Act (ACA) demonstrated, health care is so politically fraught and complex that it inevitably exhausts enormous political capital. It can even break a presidency. New presidents who want to go big on health care have to go full bore early in their first term when their influence is at its height.

What will Biden do? By reading the tea leaves from the president’s $1.9 trillion rescue package, we can see that he has taken on the pandemic. But his proposed commitments on coverage seem much less robust.

The rescue package includes coverage expansion through an increase in the subsidies people may use to purchase private insurance on Affordable Care Act marketplaces. Together with executive actions already underway, these initiatives could extend coverage to the estimated 2 million Americans who are caught in the Medicaid coverage gap – too poor for marketplace subsidies and ineligible for their state’s Medicaid. But a full-throated effort to cover all Americans would require additional legislative action including:

  • allowing eligible adults in states that didn’t expand Medicaid to access ACA tax credits during the COVID-19 public health emergency
  • increasing federal Medicaid matching payments to encourage states that have not expanded Medicaid to do so.

In theory, Biden could return to these initiatives in his promised follow-on recovery package. But by then, his agenda will likely be crowded with other challenges – climate change, infrastructure renewal, economic recovery, tax reform – that will make major health care battles much less appealing and achievable. His hard push on the pandemic package will have tested the loyalty of many allies within his fragile Senate majority, let alone potential supporters among the few Republican Senate moderates.

Biden’s decision to go all in on the pandemic is understandable. History will judge his presidency first and foremost by whether he conquers COVID-19.

But he may be able to have his cake and eat it, too. He and his congressional allies could potentially add coverage expansion provisions to a reconciliation bill without jeopardizing pandemic assistance. In other words, his one big thing in health care may be a rescue package that takes on both COVID and coverage. Regardless, one thing is clear: If he wants to significantly expand coverage during his presidency, now is the time to do it.