As American voters head to the polls, the health insurance of millions hangs in the balance

The American voter’s choice could not be starker, says Jamie Daw

Next week, American voters will choose between one of two very different visions for their healthcare system. In the wide gulf between the health policy plans of the 2020 presidential candidates, access to health insurance for millions of Americans hangs in the balance. 

At the center of the candidate’s disagreement is the Affordable Care Act (ACA), a complex law with tentacles that touch almost every aspect of the US healthcare system. Of most practical importance to the lives of everyday Americans, the ACA made health insurance coverage more accessible and more affordable, reducing the percentage of uninsured Americans from 20% to 12%. Among the most popular provisions of the law, the ACA allowed dependents to stay on their parent’s insurance plan up to the age of 26 and prevented insurers from denying coverage to people with pre-existing conditions.

The Trump administration and Republican party propose “repealing and replacing” the ACA. However, in the four years of the Trump presidency, no replacement plan has been revealed. While President Trump publicly claims that his plan would protect people with pre-existing conditions, the White House supports a constitutional challenge to overturn the ACA. The oral arguments for this lawsuit are scheduled to be heard by the US Supreme Court only a week after the November election. 

Legal experts from across the political spectrum argue that the case against the ACA is weak. Democrats warn, however, that the imminent confirmation of Judge Amy Coney Barrett to the Supreme Court would solidify its conservative majority and increase the likelihood of the ACA being struck down. Without a plan and legislative pathway to replace the law, such a decision would have far reaching consequences for the healthcare system. Amid a global pandemic and the highest US unemployment rates on record, millions of Americans could lose their health insurance. 

Even if the ACA stands, a second Trump presidency is poised to continue efforts to undermine the law and erode coverage gains. In just the past four years, the Trump administration has reduced outreach for enrollment, loosened regulatory requirements for insurers, promoted Medicaid waivers that impose burdens on low income enrollees, and created barriers for immigrants to enroll in coverage. 

On the other hand, Vice President Biden presents a straightforward message: we need to maintain and build on the success of the ACA. Some of his proposals are important but not transformative. For example, modest increases in subsidies would make private insurance more affordable for individuals on the “Obamacare” insurance exchanges. Biden also supports lowering the eligibility age for Medicare—the popular public program that covers American seniors—from 65 to 60 years. 

Biden’s plan may appear as timid incrementalism, playing only at the edges of the ACA. Biden does not support the “Medicare for All” plan of other Democratic primary candidates, which would overhaul the current system and provide universal coverage through a single payer public insurance system. However, one feature of his plan should be recognized as incredibly ambitious: the creation of a public insurance option that any American could choose to buy into. A more limited version of the public option was lost in President Obama’s push for health reform, after strong opposition from the healthcare and health insurance industries and a failure to garner support among moderate Democrats. A Biden White House committed to the public option with a Democratic majority in Congress could result in a different outcome.

A public option could allow the federal government to leverage its bargaining power to lower prices and provide a less expensive insurance option for patients. If a public option is administered effectively to provide high quality, lower cost coverage, its success is likely to compound on itself. More Americans would buy in, which, in turn, would further drive bargaining power and reduce prices, encouraging more buy-in. While some progressives may be less inspired by Biden’s incrementalism, it is at least a form of incrementalism that could send America on a path to universal coverage. 

The American voter’s choice could not be starker: support a Trump plan likely to reduce the accessibility and affordability of insurance for millions of Americans, or support a Biden plan that will, at the least, protect the status quo, and at the most, offer a route to a healthcare system where no American is uninsured.

Jamie Daw is an assistant professor of health policy and management at Columbia University Mailman School of Public Health. She studies health insurance and access to care in the US and Canada. Twitter: @jamie_daw 

Competing interestsNone declared.