{"id":48917,"date":"2020-10-27T14:39:00","date_gmt":"2020-10-27T13:39:00","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=48917"},"modified":"2020-11-05T16:27:34","modified_gmt":"2020-11-05T15:27:34","slug":"as-american-voters-head-to-the-polls-the-health-insurance-of-millions-hangs-in-the-balance","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2020\/10\/27\/as-american-voters-head-to-the-polls-the-health-insurance-of-millions-hangs-in-the-balance\/","title":{"rendered":"As American voters head to the polls, the health insurance of millions hangs in the balance"},"content":{"rendered":"<p class=\"standfirst\">The American voter\u2019s choice could not be starker, says Jamie Daw<\/p>\n<p><!--more--><span style=\"font-weight: 400\">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.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">At the center of the candidate\u2019s 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 <\/span><a href=\"https:\/\/www.commonwealthfund.org\/publications\/issue-briefs\/2019\/feb\/health-insurance-coverage-eight-years-after-aca\"><span style=\"font-weight: 400\">20% to 12%.<\/span><\/a><span style=\"font-weight: 400\"> Among the most <\/span><a href=\"https:\/\/www.healthaffairs.org\/doi\/abs\/10.1377\/hlthaff.2019.01420?journalCode=hlthaff\"><span style=\"font-weight: 400\">popular provisions of the law<\/span><\/a><span style=\"font-weight: 400\">, the ACA allowed dependents to stay on their parent\u2019s insurance plan up to the age of 26 and prevented insurers from denying coverage to people with pre-existing conditions.<\/span><\/p>\n<p><span style=\"font-weight: 400\">The Trump administration and Republican party propose \u201crepealing and replacing\u201d 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, <\/span><a href=\"https:\/\/www.kff.org\/health-reform\/issue-brief\/explaining-california-v-texas-a-guide-to-the-case-challenging-the-aca\/\"><span style=\"font-weight: 400\">the White House supports<\/span><\/a><span style=\"font-weight: 400\"> 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.\u00a0<\/span><\/p>\n<p><a href=\"https:\/\/jamanetwork.com\/channels\/health-forum\/fullarticle\/2761685\"><span style=\"font-weight: 400\">Legal experts<\/span><\/a><span style=\"font-weight: 400\"> 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 <\/span><a href=\"https:\/\/www.kff.org\/health-reform\/issue-brief\/potential-impact-of-california-v-texas-decision-on-key-provisions-of-the-affordable-care-act\/\"><span style=\"font-weight: 400\">far reaching consequences<\/span><\/a><span style=\"font-weight: 400\"> for the healthcare system. Amid a global pandemic and the <\/span><a href=\"https:\/\/www.bls.gov\/opub\/ted\/2020\/unemployment-rate-rises-to-record-high-14-point-7-percent-in-april-2020.htm?view_full\"><span style=\"font-weight: 400\">highest US unemployment rates on record<\/span><\/a><span style=\"font-weight: 400\">, millions of Americans could lose their health insurance.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Even if the ACA stands, a second Trump presidency is poised to continue efforts to undermine the law and erode coverage gains. In <\/span><a href=\"https:\/\/www.brookings.edu\/blog\/fixgov\/2020\/10\/09\/six-ways-trump-has-sabotaged-the-affordable-care-act\/\"><span style=\"font-weight: 400\">just the past four years<\/span><\/a><span style=\"font-weight: 400\">, 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.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">On the other hand, Vice President Biden presents a straightforward <\/span><a href=\"https:\/\/joebiden.com\/healthcare\/\"><span style=\"font-weight: 400\">message<\/span><\/a><span style=\"font-weight: 400\">: 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 \u201cObamacare\u201d insurance exchanges. Biden also supports <\/span><a href=\"https:\/\/jamanetwork.com\/channels\/health-forum\/fullarticle\/2767947\"><span style=\"font-weight: 400\">lowering the eligibility age for Medicare<\/span><\/a><span style=\"font-weight: 400\">\u2014the popular public program that covers American seniors\u2014from 65 to 60 years.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Biden\u2019s plan may appear as timid incrementalism, playing only at the edges of the ACA. Biden does not support the \u201cMedicare for All\u201d 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\u2019s push for health reform, after <\/span><a href=\"https:\/\/www.healthaffairs.org\/doi\/full\/10.1377\/hlthaff.2010.0363\"><span style=\"font-weight: 400\">strong opposition<\/span><\/a><span style=\"font-weight: 400\"> 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.<\/span><\/p>\n<p><span style=\"font-weight: 400\">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\u2019s incrementalism, it is at least a form of incrementalism that could send America on a path to universal coverage.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">The American voter\u2019s 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.<\/span><\/p>\n<p><b><i><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2020\/07\/jamie_daw.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\" wp-image-47984 alignleft\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2020\/07\/jamie_daw.jpg\" alt=\"\" width=\"137\" height=\"128\" \/><\/a>Jamie Daw\u00a0<\/i><\/b><i><span style=\"font-weight: 400\">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:\u00a0<\/span><\/i><a href=\"https:\/\/twitter.com\/jamie_daw\"><i><span style=\"font-weight: 400\">@jamie_daw\u00a0<\/span><\/i><\/a><\/p>\n<p><b>Competing interests<\/b><i><span style=\"font-weight: 400\">:\u00a0<\/span><\/i><span style=\"font-weight: 400\">None declared.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>The American voter\u2019s choice could not be starker, says Jamie Daw [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2020\/10\/27\/as-american-voters-head-to-the-polls-the-health-insurance-of-millions-hangs-in-the-balance\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":48912,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1357],"tags":[],"class_list":["post-48917","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-us-health-care"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - 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