When President-elect Joe Biden is sworn in next month, he will inherit a public health disaster in a pandemic that has already killed almost 320,000 and infected just under 18 million. While addressing the impact of COVID-19 may be the most pressing issue for Biden — and one he has vowed would be a top priority — it isn’t the only health care problem he plans to tackle. 

As a candidate, he pledged to undo many of the regulations enacted by his predecessor, particularly those that scaled back protections for abortion and contraceptive care. He also promised to expand access to health care by building on the Affordable Care Act, a law that disproportionately benefited women and other gender minorities.

But Biden will face an uphill battle. It’s still unclear which party will control the U.S. Senate. And even if Democrats pick up two seats in the January Georgia elections, the chance of enacting many of the sweeping policies Biden has championed — for instance, codifying the abortion protections guaranteed in Roe v. Wade, adding a public insurance option to extend ACA coverage, or simply helping public schools safely reopen — are longshots.

All together, experts said, it’s clear that for women, both physical and mental health will be areas in dire need of support next year. But whether that support will come is still anyone’s guess.

“Congress is clearly going to be key. That’s why they’ve thrown millions and millions at this Georgia election,” said Alina Salganicoff, a senior vice president and director of women’s health policy at the Kaiser Family Foundation (KFF), a nonprofit health care think tank and research group. “There’s a lot riding on that.”

The coronavirus will cast a shadow over other elements of Biden’s health care agenda, experts agree, dictating any early policy efforts. But it’s hard to say what impact that will have, and whether efforts to curb the pandemic might also fuel efforts to tackle other gender-based health disparities. 

“The prioritization question is going to be tough. They just have so much to do,” said Katie Keith, a health law expert at Georgetown University. 

Beyond the pandemic, issues such as reproductive health – where executive action could shape access to care — and pregnancy-based death are  also expected to emerge as major priorities next year.

Pandemic fallout

In a December press conference, Biden vowed to use his first 100 days in office to mandate masks in many public places, get 100 million doses of coronavirus vaccines administered, and curb the spread of infection enough to safely reopen most American schools. 

Those changes would particularly benefit women, who are disproportionately represented among the frontline workers eligible for early access to COVID-19 vaccines, who work as teachers navigating the challenges of pandemic education, and who have shouldered the burden of supervising children’s remote learning. 

Women have reported higher rates of anxiety and depression over the past year, with 45.7 percent reporting symptoms of at least one of those conditions by the start of December. Transgender people have also faced higher rates of both conditions, research suggests.

Experts say the disparity stems in part from the heavier parenting burdens women have faced, and the fact that women and other gender minorities have been hit harder by the economic downturn caused by the pandemic. Addressing concerns like school closure and mitigating the spread of the virus could go a meaningful way toward stemming that mental health crisis.

“Controlling the virus inherently is an important issue for women,” said Cynthia Cox, a vice president at KFF. 

But the federal government has limited power in determining if school districts — which are run on more local levels — do in fact reopen. And curbing the virus’s spread will require buy-in from state and local governments, as well as money from Congress, whether for vaccine distribution, supporting businesses that temporarily close their doors, or for providing schools with protective gear and resources to revert to in-person learning.

“How much can you do without states like Texas, and Congress actually funding this stuff? I hope they’re thinking about it,” Keith said. “What are the contingency plans if you don’t get the cooperation that we all know you have to have?”

And still, even achieving all of those goals won’t undo the mental health challenges that have burdened women and LGBTQ+ people for almost a year. The nation already doesn’t have enough mental health professionals to treat people. And when it comes to psychological burdens, vaccinations and schools are only part of the picture. 

Over the past year, women have faced greater job losses in the recession and have regained work at a slower pace. Mothers, and especially single mothers, have been more likely to experience food insecurity. The pandemic also appears to have contributed to an increase in domestic violence — including homicide — a public health crisis that disproportionately harms women and transgender people.

Those all have exerted a deep psychological toll that won’t disappear overnight, or even over a few months. 

“This is not going to be flipping a switch and having people vaccinated, and we’re going to get back to where we were,” Salganicoff said. “It’s a little like PTSD. You’re out of the war, but these issues are still there.”

The nation’s crisis of pregnancy-related deaths could emerge as an area that the Biden administration could deliver on campaign promises made last fall no matter who controls the Senate.

Bipartisan consensus could be emerging when it comes to at least some of the potential government strategies to help address pregnancy-related deaths. The United States has markedly worse pregnancy-related outcomes than other wealthy nations, with Black and Native people at especially heightened risk of dying. 

Biden and Vice President-elect Kamala Harris both highlighted the issue on the campaign trail, and President Donald Trump’s outgoing Health and Human Services administration in December put out its own recommendations to address the crisis.

This fall, the House of Representatives unanimously voted for legislation to fund states that want to extend Medicaid insurance — which covers almost half of all the nation’s births — to cover people for a year after giving birth. Currently, that coverage ends 60 days postpartum, though about a third of all pregnancy-related deaths occur somewhere between a week to a year after birth, per the Centers for Disease Control and Prevention. The Medicaid and CHIP Payment and Access Commission, which advises Congress on how to run the program, is expected to endorse that policy change come January. 

Some observers think that change could also find bipartisan support in the Senate.

But still, insurance is only one part of pregnancy-related health. Research has also indicated that implicit bias plays a major role in poor birthing outcomes, as does mental health treatment, and access to structural factors like housing, nutrition and transportation. 

In theory, there are bills in Congress that could address some of those issues — including the so-called “Momnibus” that Harris backed as a Senator, which would institute a slate of policy changes, including implicit bias training for medical professionals, and funding community-based organizations that support Black pregnant people. But in practice, it’s harder to see if those kinds of legislation have a viable path forward, especially if Democrats lose the Georgia elections.

“I think the Biden administration will certainly give this a lot of attention, but they’re going to be limited in terms of what they can do,” Salganicoff said.

Reproductive health

The Trump administration rolled out a slew of executive orders meant to undercut abortion funding, contraception access and health care protections for transgender people. Biden has suggested he would undo many of those orders, though it may take time to see the results.

Several Trump regulations — including efforts to block Planned Parenthood from federal funding, to expand reasons employers can decline to provide insurance that covers birth control, and to eliminate Obama-era rules that prohibit health plans or medical providers from discriminating based on gender identity — are still undergoing legal challenges. Courts are also weighing how to rule on Trump’s so-called “conscience protections,” which allow medical providers to refuse to provide treatment such as abortion, contraceptive coverage and gender-affirming care. 

Pending legal judgement could put pressure on Biden’s new Justice Department to move quickly and stop defending Trump-era regulations before judges weigh in. The administration would then have to roll out new regulations, which must go through the federal approval process before they can take effect. 

Beyond undoing Trump’s regulations and issuing his own, Biden likely won’t be able to move the needle on other signature campaign promises, such as his vows to codify the abortion protections enshrined in Roe v. Wade or repealing the Hyde Amendment, which prohibits using federal funds to pay for most abortions. Both of those would likely require stronger legislative majorities that Biden won’t have, no matter how the remaining Senate elections go.

“The Biden administraiton will see the abortion policy that they can control is pretty limited without Congressional action,” Salganicoff said.

But outside of Washington, abortion policy in particular will likely emerge as a major issue, health policy experts agreed, adding that they anticipate seeing more states moving to enact restrictions on people seeking the medical procedure. 

That’s especially more likely because of Trump’s legacy of appointing federal judges. As of December, almost 230 federal judges had been confirmed under Trump, and three of the nation’s nine Supreme Court justices are Trump picks. This fall’s confirmation of Amy Coney Barrett to the Supreme Court cemented a more conservative court majority, and one far friendlier to abortion restrictions. 

“The courts and the direction of the courts have made establishing abortion protections much harder for states than trying to establish abortion restrictions,” Salganicoff said.