Health Care Reform and the 2024 Elections

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Bill Haskell
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Health Care Reform and the 2024 U.S. Elections — Low Visibility, High Stakes.

by Jonathan Oberlander, Ph.D.

New England Journal of Medicine

Exploring the what-ifs in healthcare and the ACA in an election year. What if Trump wins the presidency and Repubs control the House and the Senate. The author discusses the alternatives also.

Abortion and reproductive health have emerged as a major focus in the 2024 U.S. presidential campaign. The 2022 Supreme Court decision overturning Roe v. Wade, and the ensuing spread of abortion bans and restrictions in many states, has propelled the issue to the forefront of American politics. Beyond the presidential contest, 10 states have measures to protect abortion rights on the ballot this year, including Nebraska, which also is considering a measure to restrict such rights.¹

While reproductive health has drawn the spotlight, less attention has been paid to other health policy issues such as the uninsured and underinsured populations, health care costs, and Medicare. Medicaid, too, has drawn scant notice, despite seeing disenrollment of more than 25 million people since 2023 owing to the expiration of the continuous-coverage provision of the Families First Coronavirus Response Act of 2020.

Issues such as the economy and immigration are predominant, reducing the visibility of health care (apart from abortion). But there is another explanation for why neither Democrats nor Republicans have offered sweeping reform plans: the success of the Affordable Care Act (ACA), which was strengthened by policies adopted during the Biden administration. In the ACA’s shadow, both parties lack a clear plan for future health care reform. U.S. health politics has, for now, returned to incrementalism, with proposals that promise small changes rather than transformation — and if the election produces divided party control of the White House and Congress, the prospects for transformative change will be further constrained.

Repealing Obamacare was a centerpiece of Donald Trump’s first campaign for the White House in 2016, and as president, he supported congressional Republicans’ 2017 efforts to roll back the law. Those efforts ultimately failed, and the GOP’s controversial repeal-and-replace drive actually made the ACA more popular while helping Democrats regain a majority in the House of Representatives in the 2018 elections. In 2024 — with higher enrollment in ACA insurance plans and more stability in the law’s insurance marketplace, more states having adopted Medicaid expansion, more favorable public opinion, and longer public exposure to popular benefits such as protections for persons with preexisting conditions — the ACA is stronger politically. Twenty-four million Americans are enrolled in Medicaid as a result of the ACA’s expansion, another 21 million obtain insurance through its insurance marketplace, more than 60% of Americans view the law favorably, and in recent years the uninsured rate fell to record lows.²

Trump has therefore not made ACA repeal a priority in this year’s campaign. Still, he has given mixed signals — on the one hand expressing regret that congressional Republicans had not voted to “terminate” Obamacare and indicating an openness to alternatives, and on the other hand declaring that he is not “running to terminate the ACA” but wants to make it “much better.” If Trump wins the presidency and Republicans gain majorities in the House and Senate, what would they do? It could be tempting for Trump to unravel Barack Obama’s signature legacy by renewing ACA-repeal efforts. But not only would that be perilous politically, Republicans lack consensus on any replacement for the ACA — a problem that helped doom their past repeal efforts (and one underscored by Trump’s acknowledgment that he has only “concepts of a plan”). Seared by the fallout from those misadventures, Republicans may forgo sweeping plans to dismantle Obamacare.

The GOP could instead attempt to eliminate specific ACA policies or weaken its insurance market regulations. Another option would be to take administrative actions to undermine the ACA, such as reducing outreach efforts designed to boost insurance enrollment — a strategy the Trump administration employed after legislative repeal failed in 2017. Republicans could also undermine the ACA simply by doing nothing: the enhanced subsidies enacted during the Biden administration that make insurance plans in the marketplace more affordable for consumers are set to expire in 2026 unless Congress acts. But letting those subsidies expire — which would increase premiums for many people and thereby reduce health insurance coverage — could trigger a political backlash.

Beyond the ACA’s insurance marketplace, Republicans could expand use of health savings accounts. They could also pursue large reductions in federal funding for Medicaid, given their concerns about Medicaid’s expense and enrollment growth and the need to offset the costs of proposed tax cuts in order to satisfy congressional budget rules.³ As Republicans discovered in 2017, however, Medicaid is a popular program with sympathetic beneficiaries — pregnant women, children, persons with disabilities, older Americans — and an influential political constituency, including hospitals and governors, that opposes funding cuts that could substantially increase the uninsured population. A Republican Congress could additionally seek to revive work requirements for some Medicaid enrollees, another policy that was promoted by the Trump administration. On Medicare, the GOP could seek to accelerate enrollment in private Medicare Advantage plans. Republicans also have called for repealing the provisions allowing Medicare to negotiate some drug prices that Democrats enacted in the 2022 Inflation Reduction Act — though any increase in Medicare beneficiaries’ drug costs would be deeply unpopular.

Meanwhile, Democrats are formulating their own incremental agenda. When Kamala Harris ran in the 2020 Democratic presidential primary, she proposed extending Medicare — including private insurance plans offered through the program — to all Americans. Harris has subsequently retreated from that plan, and she has not made enactment of a new Medicare-like public insurance option or lowering of the Medicare eligibility age to 60, reforms backed by Joe Biden in 2020, a centerpiece of her current campaign. Instead, Harris has spoken of efforts such as curbing prescription-drug costs, building on provisions of the Inflation Reduction Act, and providing medical debt relief. The political appeal of such policies lies in their promise to make health care more affordable for Americans, including those with insurance. But they do not constitute an ambitious reform agenda.

The Harris campaign may want to avoid the controversy that bolder plans could spark. Democrats’ caution also reflects a lack of consensus on where health reform should go next and how to address the persistent problems of millions of U.S. residents who cannot afford medical care even if they are insured or who lack health insurance altogether (and large-scale Medicaid disenrollment may be increasing the uninsured rate). Whatever its substantive appeal, Medicare for All remains a politically daunting aspiration. One alternative, the public option, can come in myriad shapes (some with roles for private insurers) and sizes (with varying eligibility criteria); Democrats have not coalesced around a single plan. Moreover, enactment of a public option, which is opposed by much of the health care industry, is challenging.

So what would a Harris administration do in health care policy if it had Democratic majorities in Congress? In addition to measures related to prescription-drug costs and medical debt relief, it could seek to pass legislation to close the coverage gap for low-income persons living in states that have not expanded Medicaid eligibility under the ACA. Democrats would also prioritize extending the ACA’s enhanced premium subsidies. In addition, a Harris administration could consider reviving Democratic plans to improve Medicaid coverage of in-home and community-based services and expand Medicare to cover dental, hearing, and vision benefits.

Notably, neither Democrats nor Republicans have had much to say about a range of other important issues — such as the implications of climate change for health, the opioid crisis, and consolidation in health markets.

Despite the predominance of incrementalism, there remains a stark partisan divide on whether U.S. health policy should build on the ACA’s successes or pursue policies that would jeopardize its coverage gains. Though health care reform has garnered only limited visibility in this campaign, the stakes of the 2024 elections for its future are high.

1. KFF ballot tracker: status of abortion-related state constitutional amendment measures for the 2024 election. KFF, August 23, 2024 (https://www.kff.org/womens-health-policy/dashboard/ballot-tracker-status-of-abortion-related-state-constitutional-amendment-measures/).

2. KFF health tracking poll: the public’s views on the ACA. KFF, May 15, 2024 (https://www.kff.org/interactive/kff-health-tracking-poll-the-publics-views-on-the-aca/#?response=Favorable–Unfavorable&aRange=twoYear).

3. Park E. GOP push to make Trump tax cuts permanent makes Medicaid top target for draconian cuts. Georgetown University, September 4, 2024 (https://ccf.georgetown.edu/2024/09/04/gop-push-to-make-trump-tax-cuts-permanent-makes-medicaid-top-target-for-draconian-cuts/).