Professor Robert Coulam shares his thoughts on the state of health policy in light of the 2020 Presidential election.
Healthcare policy affects fundamental, intimate interests — it’s not surprising that health policy choices are controversial! This is especially true when the two major parties offer distinctively different visions of how to govern the health system. While the actual results of the 2020 election are impossible to predict, it is fairly clear how the different visions of the two parties might affect three basic choices in health policy.
Should the government ensure that all Americans have access to affordable health coverage?
The most basic political issue concerning health policy, and one separating the parties, is whether the government should ensure affordable coverage for all, in some fashion. All current Democratic candidates for President agree that this is a critical responsibility of government.
While there are dissenters within the party, Republicans in Congress and state legislatures do not support government responsibility for health coverage except at a very reduced level — a majority appear to believe what Sen. Orrin Hatch said when he likened ACA coverage to being “on the dole,” which government shouldn’t encourage. President Trump would agree with Hatch on this.
Regardless of the outcome of the next election, disagreements will continue in Congress over particular plans, this or that way of doing things, but those fights over plans are generally masks over the fundamental disagreement as to whether the government must ensure affordable access to healthcare. President Trump and a Democratic president would move in very different directions, assuming Congress lets them.
Assuming some level of responsibility for access to healthcare, how should the government carry it out?
One of the most catalytic issues on the Democratic side of the current campaign has been the call for Medicare for All. Actually, this is a variety of proposals. The common core among them is an expansion of Medicare to at least some of the non-senior population and a reduction in the role of private insurance in the system. That position is only one of many possible ways to provide insurance coverage to more Americans. Another is to expand ACA, which many Democrats prefer.
By contrast, Republicans would like to reduce the government role in the healthcare system, perhaps through some kind of voucher system in a system less regulated than currently under ACA (e.g., with respect to pre-existing health conditions). To date, President Trump and Congressional Republicans have been unable to repeal ACA or to develop a compelling substitute plan of their own. Failing that, the Trump Administration has tried to chip away at ACA in large ways (in court) and small ways (through regulatory actions that gradually weaken the framework of ACA). Expect that to continue if President Trump is reelected. Expect a Democratic president to try to strengthen ACA and possibly to introduce some kind of public option health plan.
Will the government support women’s access to abortion and other reproductive health services?
The Trump Administration and Republican-controlled state governments have worked in a variety of ways to restrict women’s access to abortion and other reproductive health services (though a number of Democratic-controlled states are acting to protect or in some cases expand access). The Republican efforts are extensive. For example, in October, the Trump Administration appealed to the Supreme Court to allow the administration to implement an expansive rule on religious exemptions — the effect of which would be to restrict access to birth control otherwise guaranteed by ACA under employee health plans.
On this, as other women’s health issues, the judiciary is critical to the Administration’s efforts. Most important, in 2020, the Court will consider its first major abortion rights cases since two Trump appointees were confirmed — the Roe decision itself could well be overturned by the current Supreme Court, no matter who is elected president or to the Congress. Meanwhile, judges who oppose abortion and other reproductive rights are more likely to sanction what the Trump Administration is trying to do to limit those rights. If President Trump is reelected, he will continue to appoint such judges in his second term — and he will succeed, if Republicans continue to control the US Senate. If Democrats control the Senate, a second-term Trump would be blocked in such judicial appointments.
Democratic candidates are consistently opposed to these efforts by the Administration, and would appoint judges likely to be sympathetic to reproductive rights — although those appointments might have some trouble being confirmed if Republicans continue to control the Senate.
It’s at least clear that this area is likely to remain a battleground, whichever party wins in 2020, and that the Senate is as important as the Presidency, in determining the direction of the judiciary.
There are many other health policy issues currently being contested that will be affected by the election — perhaps most conspicuously, the need for government action to control pharmaceutical costs. However, the three issues above point to more fundamental divisions between the parties on healthcare. A vote next November for President and Congressional races will do much to determine which vision leads the country in the next four years.