In the run-up to the 2024 U.S. presidential election, healthcare reform is poised to be one of the most consequential yet under-discussed issues on the national stage. While hot-button topics like abortion and reproductive rights often capture the headlines, other critical aspects of healthcare policy, particularly those pertaining to Medicare and Medicaid, remain largely absent from the public debate. Jonathan Oberlander, a professor at the University of North Carolina, delves into these under-the-radar yet high-stakes issues in his insightful article in the New England Journal of Medicine (NEJM).
The ACA’s Incremental Success
Widespread Coverage Gains
The Affordable Care Act (ACA) has dramatically expanded healthcare coverage across the United States, with 24 million Americans enrolled in Medicaid and another 21 million purchasing insurance through its marketplace. This significant increase in healthcare coverage has led to a broad shift in public opinion, with over 60% of Americans now viewing the ACA favorably. Because of the ACA’s success and its popularity, neither major political party is keen on proposing broad, sweeping reforms that could prove disruptive. Instead, both Republicans and Democrats are turning to incremental changes that adjust and refine the existing system.
For example, the Democratic Party under the Biden Administration has made considerable efforts to build on the ACA’s foundations. Their improvements include extending premium subsidies and undertaking initiatives aimed at further closing coverage gaps, particularly in states that haven’t expanded Medicaid. These focused actions are far less contentious than sweeping overhauls and offer a pragmatic path forward in a deeply divided political landscape. They also ensure that the health coverage gains made under the ACA are preserved and expanded without provoking contentious political battles.
Shifting Political Strategies
Faced with the reality that the ACA has embedded itself into the fabric of American healthcare, Republicans have moved away from the goal of full repeal. The political risk of stripping millions of Americans of their healthcare coverage is too significant. Instead, their strategies will likely target specific components of the ACA, such as loosening insurance market regulations and allowing premium subsidies to lapse when they expire in 2026. Reinstating federal work requirements for Medicaid enrollees and reducing federal Medicaid funding are on the GOP’s agenda, particularly under a potential Trump Administration.
Similarly, Medicare’s newfound ability to negotiate prescription drug prices, a landmark achievement under recent Democratic leadership, could find itself under threat if Republicans gain control. The GOP’s priorities often center on reducing federal spending and deregulating markets, even if that means potentially rolling back some of the progress made under the ACA. This approach highlights the sharp partisan divide that persists in U.S. healthcare policy, making the 2024 elections especially critical for the future of healthcare reform.
Potential Health Policy Directions
A Second Trump Administration
Should Donald Trump regain the presidency and the GOP secure majorities in Congress, the healthcare landscape could shift dramatically. Even if an outright repeal of the ACA is unlikely, the Trump Administration would focus on dismantling specific ACA provisions. This approach would include loosening insurance market regulations, which could make it easier for insurers to offer plans that do not comply with ACA standards. The potential rollback could exacerbate coverage gaps and lead to increased costs for consumers with pre-existing conditions.
Another significant target would be the premium subsidies that make marketplace insurance affordable for millions of Americans. These subsidies are currently set to expire in 2026, and without Congressional action to extend them, millions could see their premiums soar. Additionally, Trump and the GOP could push to reinstate Medicaid work requirements, a move aimed at reducing the number of people eligible for Medicaid but one that also risks leaving many without necessary healthcare coverage. If implemented, these policies could significantly undermine the coverage gains and protections established by the ACA.
A Harris Administration’s Approach
In contrast, a potential Harris Administration would likely take steps to not only preserve but also expand upon the ACA’s successes. Kamala Harris and the Democratic Party would prioritize efforts to control prescription drug costs, building on recent legislation that allows Medicare to negotiate prices for certain medications. This initiative aims to alleviate the financial burden on seniors and the broader population who face exorbitant costs for essential medicines.
Other priorities could include medical debt relief initiatives designed to help Americans struggling with high healthcare costs, effectively reducing one of the primary sources of financial strain for many families. Harris’s administration would likely seek to address coverage gaps, especially in states that have resisted Medicaid expansion. Extending the premium subsidies, ensuring they do not lapse in 2026, and potentially making them permanent could also feature prominently in her healthcare agenda. These measures not only aim to solidify the ACA’s gains but also ensure more Americans have access to affordable healthcare.
The High-Stakes Nature of Incrementalism
The Quiet but Significant Battle
While healthcare reform may not dominate the headlines in the same way as other contentious issues, its implications are far-reaching and deeply significant. The stakes are incredibly high, not just for the millions of Americans relying on ACA provisions for coverage but for the broader trajectory of U.S. healthcare policy. Jonathan Oberlander notes that the apparent shift to incrementalism reflects the challenges and complexities of enacting large-scale reform in a polarized political environment. Both parties are cautious about proposing drastic changes that could provoke backlash, opting instead for smaller, carefully calibrated adjustments.
This incremental approach may lack the drama of sweeping reform but can be just as impactful over time. By focusing on targeted improvements and adjustments, policymakers are able to address specific issues within the healthcare system without the upheaval that accompanies major overhauls. This strategy ensures progress continues, albeit more slowly, maintaining and enhancing the gains made under the ACA while avoiding the political pitfalls that can derail comprehensive reform efforts.
Partisan Divide and the Future
The sharp partisan divide over healthcare policy underscores the importance of the 2024 elections. The outcome will determine the direction of healthcare reform for years to come. Republicans aim to scale back federal involvement and reduce spending, which could lead to significant rollbacks in ACA protections and coverage. Democrats, on the other hand, seek to build on the ACA’s foundation, expanding coverage and providing more robust protections for Americans.
As Oberlander highlights, the future of healthcare reform hinges on these electoral outcomes. A GOP-led government would likely focus on deregulation and spending cuts, risking increased gaps in coverage and higher costs for many Americans. Conversely, a Democratic administration would aim to strengthen and expand the ACA, striving for broader coverage and lower costs for consumers. The 2024 elections may not prominently feature healthcare reform in their debates and advertisements, but the eventual policy outcomes will have profound and lasting impacts on the American healthcare system.
Oberlander’s analysis underscored that even though the spotlight was not often on healthcare reform during election seasons, the stakes could not have been higher. Incremental changes proved to be strategic approaches by both parties, adapting to the enthusiasts and critics of the ACA while tackling targeted issues within the system. It was evident that the 2024 elections would shape the future of U.S. healthcare, making each vote crucial in determining whether ACA gains would be preserved or rolled back. For more comprehensive insights, Oberlander’s full article in NEJM offered an in-depth exploration of these critical healthcare issues.
