Healthcare in America's Future: Trump versus Biden

Presidential candidate Donald J. Trump has renewed his pledge to repeal the Affordable Care Act (ACA), which now provides health insurance to 45 million plus Americans and has gained greatly in popularity since it was passed in 2010. The latest (February 2024) poll of the Kaiser Family Foundation (KFF), a non-partisan think tank, shows 59% of polled Americans supporting the ACA and only 39% opposing it.

Thanks to the ACA, medically uninsured Americans now represent only 8% of the population. In 2023, 21 million people signed up through the ACA to buy personal healthcare insurance, the highest number ever. Another 25 million previously uninsured people have received Medicaid due to the ACA.

The Republican Study Committee (RSC), a conservative group of the U.S. House of Representatives (80% of the Republicans), published a budget proposal that, if enacted, would not only end the ACA but would also dramatically change Medicare, Medicaid, and the federal tax incentive for employers to provide health insurance for their workers.

One RSC objective is to repeal federal protections the ACA provides for people with pre-existing conditions, turning this matter over to the states. (We have seen how that is working out with the issue of abortion!) Other changes would include the transformation of Medicare to a voucher system. Seniors would be given a stipend to purchase private health insurance. The federal entitlement to Medicaid would end. The program would be bundled into a block grant for states along with a separate federal program that covers children. The authority Biden won for Medicare to negotiate lower drug prices would end.

In a similar project endorsed by Trump, a consortium of conservative groups including the Heritage Foundation created Project 2025, Presidential Transition Project. It embraces most of the same ideas as the RSC proposal. Larry Levitt, executive vice president for health policy at KFF, explains, "At the root of a lot of these Republican Study Committee proposals is reducing what the federal government spends on healthcare, and putting the risk back on individuals, employers, and states." (KFF research shows that the government now funds nearly half of all U.S. healthcare spending.)

The massive cuts resulting from the RSC plan ($4.5 trillion less in healthcare spending for those under 65 over the next 10 years and $1.2 trillion from Medicare over the next decade) would mean millions more Americans without health insurance but also tremendous chaos for healthcare providers, including major reductions in their revenues.

Ironically, the biggest losers would be older white adults, a major part of the Republican voting contingent. Also, large cuts to Medicaid would doom many hospitals in red rural communities, and a reversal in ACA's insurance reforms would raise costs and erode access for those with greater health needs.

Supporting the RSC plans, Michael Cannon, director of health-policy studies at the libertarian Cato Institute, states: "Pervasive government is the main reason why health-care spending is out of control." Len Nichols, a health economist and emeritus professor at George Mason University, calls this view "naïve and unrealistic." He believes that a free market of very large healthcare systems and health insurers will NOT lower prices and improve quality. Free markets will not solve this issue.

President Biden's accomplishments and plans. According to KFF's Levitt, Biden's vision includes a country in which government pays the majority of healthcare bills and therefore has more control in how the system works.

Biden's achievements thus far include providing significant subsidies to help people buy private health insurance and lowering pharmaceutical costs for older Americans. Medicare now can negotiate lower prices on prescription drugs, insulin expenses are capped at $35/month, and seniors have a $2,000 maximum on their total annual spending on drugs. All of this was made possible by the passage of the COVID rescue plan of 2021 and the Inflation Reduction Act of 2022.

Biden proposes to make permanent the health insurance subsidies that otherwise will expire at the end of 2025. For the ten Republican-controlled states that still refuse to expand access to Medicaid under the ACA, he proposes to fund coverage for those states' residents who are now unable to afford health insurance. Biden would also instruct Medicare to negotiate lower prices on 50 drugs a year (now 10) and to place an annual $2,000 maximum on the pharmaceutical costs of all Americans.

Trump and the RSC proposals challenge the foundations of federal healthcare policy over the last several decades. If we are complacent, as we were with the fate of Roe v. Wade, we could be in the same predicament with our gains in healthcare.

Please consider these issues before you vote. Otherwise, you could be voting against your own best interests.