Oct. 1, 2024, 7:49 p.m.
As the nation enters the final weeks before the election, key questions remain around the health care agendas for both Vice President Kamala Harris and former President Trump.
Reproductive health, particularly abortion and IVF, has been the dominant health-related issue during the election cycle, with Trump and Harris sparring on the topic during the sole presidential debate last month.
But health-policy experts who spoke with National Journal still want to know about the plethora of other health care issues either candidate will have to take on if elected: the future of Medicaid, corralling America’s high health costs, and what to do next with Obamacare.
“It would be nice to know what’s the priority or priorities if they have two or three,” said Sean Creighton, managing director at the consulting firm Avalere. “Just in my experience, what really drives the agenda is when things are prioritized.”
Stephen Patrick, who served as policy adviser to the White House Office of National Drug Control Policy in 2021 and 2022, said there has not been a “substantial conversation around health policy, and that’s unusual—it’s really missing from this election cycle.”
The future of Medicaid
Multiple health-policy experts raised questions about the future of Medicaid, the public health insurance program for low-income Americans that is jointly funded by the federal and state governments.
Patrick, who is the professor and chair of the Health Policy and Management Department at Emory University’s Rollins School of Public Health, said, “Kids don’t vote, so we don’t talk a lot about programs that serve them, including Medicaid.”
The program has gone through substantial changes in the last decade, with a majority of states expanding it to cover people earning 138 percent of the federal poverty level. Lawmakers have also provided the option of expanding coverage 12 months postpartum for pregnant women.
But as of Sept. 12, more than 25 million people have been disenrolled from the program, according to KFF. These disenrollments are part of the renewal process states have been undertaking after enrollment was largely frozen during the COVID-19 pandemic. The requirement to freeze disenrollments ended in March 2023, when enrollment in the program stood at more than 94 million, per KFF.
By the end of 2023, at least 4 million children were disenrolled from Medicaid and the Children's Health Insurance Program, according to a Georgetown University report.
“Medicaid has become an increasingly critical program throughout the U.S.,” Patrick said. “We’ve seen millions of children in particular have lost Medicaid coverage with redetermination that occurred. ... I think the role of Medicaid and what it will look like is important.”
The Democratic National Committee platform mentions Medicaid multiple times in relation to home- and community-based services, maternal health, and reproductive health rights. The platform says Democrats would push for “Medicaid-like” coverage to people in the last 10 states that didn’t expand the program. The platform also backs a plan by President Biden to only require families to submit paperwork every three years for children under the age of 6. The platform accuses Republicans of wanting to “gut” the program.
The Republican National Committee platform, which Trump backs, doesn’t mention Medicaid.
Joan Alker, executive director of the Center for Children and Families at Georgetown University, said she is worried that cutting Medicaid would be a priority if Trump wins. “Former President Trump has said that he will protect Medicare and Social Security,” she said. “If we take him at his word—OK, so that leaves Medicaid and the [Affordable Care Act] subsidies as the two big targets.”
Project 2025, which was organized by the Heritage Foundation and lays out a conservative agenda, floats changing the financial structure of the program to allow for block grants or caps. Multiple former Trump officials contributed to the plan, although Trump has tried to create distance between himself and this agenda.
The Republican Study Committee plans for the 2025 budget recommend turning Medicaid, Obamacare, and the Children’s Health Insurance Program into five block grants for states to cover low-income children, older Americans, people with disabilities, and pregnant women. The fifth block grant would be available to provide guaranteed insurance coverage, including funding for high-risk pools.
“What cuts might either candidate make to Medicaid, and would they commit to defending the current financing structure?” Alker asked.
High health costs for Americans
Some experts want more concrete plans on how Trump or Harris will help Americans facing massive health care costs.
“What will you do to improve the problems that we have in U.S. health care, where those problems are continued increasing high cost that makes health care unaffordable for the government, for employers, and for individuals and individual families?” asked Dennis Scanlon, distinguished professor of health policy and administration at Penn State.
Scanlon said more specific questions would deal with reforms to antitrust regulation to address unchallenged mergers and acquisitions in the health care sector and high prices of pharmaceutical drugs, two big focuses on Capitol Hill.
The RNC platform commits to promoting transparency, choice, and competition, as well as access to new affordable health care and prescription-drug options—without much detail. There has been speculation about what a Trump administration could mean for the Medicare drug-price-negotiation authority provided under the Inflation Reduction Act, which many Republicans blast as “price controls.”
The Trump administration was active on anticompetitive practices, but it also allowed one of the biggest health care mergers in history between CVS Health and Aetna, KFF noted in an analysis of both candidates’ health-policy histories and campaigns. Trump's administration also moved to eliminate drug rebates in Medicare Part D—which is expected to raise premiums, so the policy has been delayed until 2023—and to tie the price of some drugs to the prices in other countries, a move which was rescinded by the Biden administration, according to KFF.
Harris says she wants to expand Inflation Reduction Act drug-pricing policies to the commercial market, including the $35 cap on insulin and the $2,000 out-of-pocket cap for drug costs. Currently, these apply only to Medicare. Harris also wants to expand the Medicare drug-price-negotiating power to include more medications.
Ashley Flint, a principal at Avalere, said expanding the IRA policies to the commercial market will come “with some pretty big price tags."
"I think that often something that’s not confronted is some of the trade-offs and choices that have to be made with these policy decisions, how things are going to be paid for, and what’s going to fall lower on the list accordingly,” Flint said.
The DNC platform says Democrats want to expand protections so Americans don’t get slammed with unexpectedly high medical bills after using an ambulance in a health emergency. They also want to use antitrust laws to curb mergers of hospitals, insurance, and pharmaceutical companies that they argue increase health prices. Additionally, Democrats want to get medical debt excluded completely from credit scores.
Pointing to the credit-score proposal, Creighton asked: “How about you can’t force people into ginormous amounts of debt because they have a medical emergency or need a drug that’s very expensive? How about that for a policy instead?”
Creighton said he isn’t seeing proposals from either candidate to help households with health care affordability and debt. “What are you actually going to do to address not just the debt issue, or the national burden of health care, but what are you actually going to do for families and individuals to bring these costs down and make them containable?” he asked.
Where to go next on Obamacare
Harris has openly committed to preserving and expanding the Affordable Care Act, while Trump as president tried to repeal the health care law multiple times.
When the issue was raised during the presidential debate earlier this month, Trump said he is looking for different ways to potentially replace Obamacare. Pressed on whether he had a plan, he said he had “concepts of a plan” and would change the law only if there was another plan that was “better and less expensive.”
No matter who wins in November, the next president will likely have to confront the expiration of the more-generous premium tax credits for individuals buying coverage on the marketplaces. The tax credits, initially enacted under the American Rescue Plan Act and extended by the IRA, lifted the income cap so more people could qualify for assistance and made the tax credits more generous for lower-income people. These credits are set to expire at the end of 2025.
Trump has not provided clear signals about the premium tax credits specifically, but a spokesperson for his campaign told The Washington Post last week that they were poorly designed and benefit insurers more than patients.
The Republican Study Committee 2025 budget proposal says the subsidies “will only perpetuate a never-ending cycle of rising premiums and federal bailouts,” and it calls for eliminating them.
If they are allowed to expire, the Congressional Budget Office estimates that enrollment in the ACA marketplace will drop by 7 million people. Expiration of the subsidies would mean steep increases in premium costs for enrollees, particularly for low-income people, according to an analysis by KFF.
“The concern is, will there be action to continue them in Congress and by the next president, or will the decision by policymakers in D.C. be to let those expire and have people face huge premium shock?” said Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities.
But to extend them comes at a steep price. Harris has called for making these tax credits permanent. CBO estimates this would increase the deficit by $335 billion over the next 10 years.
Creighton said extending the tax credits is “huge, and it is expensive,” and, like the other policy proposals, implies "some kind of funding and some kind of trade-off.”
