What’s at stake for health care reform in the US election?

While abortion and reproductive health care are in the spotlight during the 2024 United States presidential campaign, other health policy issues, including Medicare and Medicaid, have drawn less attention. Despite this low visibility, the election will have significant implications for the future of health care reform, according to health policy expert Jonathan Oberlander, Ph.D.

In the New England Journal of Medicine, Oberlander tackles these policy issues in a new Perspective piece titled “Health Care Reform and the 2024 U.S. Elections—Low Visibility, High Stakes.” Oberlander is a professor and chair in UNC’s Department of Social Medicine and a professor of health policy and management at the UNC Gillings School of Global Public Health.

Due to the prominence of other issues, such as the economy and immigration, as well as the success of the Affordable Care Act (ACA), neither Democrats nor Republicans have offered sweeping reform plans for health care in their presidential campaigns. Oberlander says that health care policy has returned to incrementalism, with a focus on small changes rather than broad transformation.

The ACA has been both successful and popular, with 24 million Americans enrolled in Medicaid thanks to the ACA’s provision for Medicaid expansion and 21 million who have obtained insurance through the ACA’s insurance marketplace. More than 60% of Americans now view the law favorably.

Oberlander lays out some potential health policy paths that Republicans could take if Donald Trump wins the presidency and the GOP gains Congressional majorities. Pursuing full repeal of the ACA would be politically risky. Instead, Republicans could seek to eliminate specific ACA policies and loosen insurance market regulations.

A Trump administration could also choose not to extend premium subsidies for ACA plans that are due to expire in 2026. Republicans could additionally pursue plans to reduce federal funding for Medicaid, revive work requirements for Medicaid enrollees and repeal Medicare’s ability to negotiate some drug prices.

In contrast, if Kamala Harris is elected president, Oberlander says her administration would seek to build on the ACA. It could pursue policies to control prescription drug costs and provide medical debt relief.

Democrats could also seek to close the coverage gap for low-income persons living in states that have not expanded Medicaid and extend the ACA’s enhanced premium subsidies. During the campaign, Harris has not embraced two reforms that Democrats have previously proposed: creating a new government insurance plan (a “public option”) and lowering Medicare’s eligibility age from 65 to 60

While health care reform has not received much attention in this election, Oberlander says the stakes remain high and a partisan divide persists over whether to continue building on the ACA’s success or adopt policies that would jeopardize its coverage gains.