Presidential election puts the Affordable Care Act back in the bull’s eye

Health care is front and center in the final presidential election race, and the outcome will shape the Affordable Care Act and the protections it provides to more than 40 million people.

Aside from reproductive rights, health care has been a non-issue for most of the campaign. However, recent comments from former President Donald Trump and his running mate, Ohio Sen. JD Vance, about possible changes to the ACA open to Republican scrutiny.

More than 1,500 doctors across the country recently released a letter calling on Trump to reveal details about how he will change the ACA, saying the information is necessary for voters to make a decision. The letter was from the Committee to Protect Health Care, a national advocacy group of physicians.

“It’s amazing that a decade and a half after the ACA passed, we’re still debating these fundamental issues,” said Larry Levitt, senior vice president for health policy at KFF. which is a non-profit organization that includes KFF Health News. “Democrats want to protect the disadvantaged, who need money and control. Republicans are looking to cut government regulations, and the product is less protection.”

The bipartisan bills have very different goals for the ACA, the sweeping law passed under former President Barack Obama that set lower benefit standards, made more people eligible for Medicaid and to ensure that customers with health conditions will not be denied health benefits.

Vice President Kamala Harris, who previously supported the health care plan, wants to expand and strengthen the health law, known as Obamacare. He supports the provision of temporary enhanced subsidies that lower the cost of payments. And he is expected to press Congress to expand Medicaid coverage to more people in the 10 states that have not yet expanded the program.

Trump, who has tried several times and failed to repeal the ACA, said in a presidential debate in September that he has “ideas for a plan” to replace or change the law. Although that sound bite became a laughing stock because Trump had promised an alternative health insurance plan many times during his administration and never delivered , Vance later provided additional information.

He said the next Trump administration would eliminate the insurance marketplaces — a change that some health experts say would provide more choice but undermine coverage for people with pre-existing conditions. He appeared to change his position during the vice presidential debate, saying the ACA’s coverage for pre-existing conditions should be waived.

Such health policy changes could be developed as part of a major tax measure in 2025, Sen. Tom Cotton, R-Ark., told NBC News. That could also open the door to changes to Medicaid. Conservatives have long sought to roll back the health insurance program for low-income or disabled people in the current system, in which the federal government contributes a percentage based on states’ Medicaid payments. which reduces federal fees through block grants or. personal income limits. Advocates of the ACA say that would shift large costs to states and force many or all states to scale back the program’s expansion over time.

Democrats are trying to turn the sentiment into a political liability for Trump, with the Harris campaign running ads saying Trump does not have a health plan to replace the ACA. The Harris campaign also released a 43-page report, “The Trump-Vance Concept on Health Care,” asserting that his opponents would “remove coverage from people with pre-existing conditions.” and raise costs for millions.”

Republicans stumbled in the past when they unsuccessfully tried to repeal the ACA. Instead, the law became more popular, and the Republican threat to protect the status quo helped Democrats retake control of the House in 2018.

In a KFF survey last winter, two-thirds of the public said it was very important to maintain a legal ban on charging people with health problems for health insurance or denying them coverage. see.

“People in this election are focused on issues that affect their families,” said Robert Blendon, a distinguished professor of health policy and political analysis at Harvard. “If people believe their insurance is going to be affected by Trump, that could be an issue.”

Vance, in a September 15 interview on NBC’s “Meet the Broadcaster,” tried to minimize this influence.

“You want to make sure that the pre-covered conditions – the conditions – are covered, you want to make sure that people have access to the doctors they need, and you want to implement other plans of control so that people can choose a health care plan that suits them,” he said.

Vance went on to say that the best way to ensure that everyone is covered is to encourage more choice and not put everyone in the same insurance risk pool.

Accidents are important to insurance. They refer to a group of people who share the burden of health costs.

Under the ACA, enrollees are generally in the same pool regardless of their health status or pre-existing conditions. This is done to control premium costs for everyone by using the lower costs caused by healthy participants to save the higher costs caused by unhealthy participants. Separating the sick from their pool can lead to higher costs for people with chronic health conditions, and that can make them less able to access financial services. .

The Harris campaign has seized on that threat, in its recent report that “health insurers will go back to discriminating based on how healthy or unhealthy you are.”

But some critics of the ACA think there are ways to divide risk pools without reducing coverage.

“Unsurprisingly, it has been abolished for political purposes,” said Theo Merkel, a former Trump aide who is now a senior researcher at the Paragon Health Institute, a right-leaning organization. who produces health research and market-based policy recommendations. .

Adding short-term coverage options plans would not disrupt the ACA market and would give consumers cheaper options, said Merkel, who is also a senior fellow at the Manhattan Institute. The Trump administration extended the duration of these projects, and Biden returned it to four months.

People who qualify for subsidies are more likely to buy ACA comprehensive plans because — with financial assistance — they can afford it. So, the ACA market and its coverage for pre-existing conditions will continue to work, Merkel said. But offering short-term plans, too, would provide a cheaper option for people who don’t qualify for subsidies and who might be more likely to buy illegal plans.

He also said that in states that allow people to buy non-ACA-compliant plans off the exchanges, the exchanges are doing better than states that prohibit them. Another option, Merkel said, is a reinsurance program similar to the one operating in Alaska. Under this plan, the government pays insurers to cover more expensive health claims, which helps keep premiums down.

But ACA advocates say that separating sick and healthy people into different insurance risk pools will make health coverage unaffordable for people with chronic conditions, and that letting people buy short-term health plans for the long-term will backfire.

“It doesn’t insure people when they get sick,” said Leslie Dach, executive chairman of Protect Our Care, a health law advocacy group. “There is no reason to do this. It has no conscience and no economic sense. They will hide behind saying ‘we are improving,’ but that is not true.

Meanwhile, Harris wants to preserve the expanded temporary subsidies that helped more people get affordable health coverage under the ACA. These extended grants, which help about 20 million people, will expire at the end of 2025, setting the stage for a bitter battle in Congress between Republicans who want to let them expire and Democrats. he said they should be done forever.

Democrats in September introduced a bill to make them permanent. One challenge: The Congressional Budget Office has estimated that doing so would increase the federal deficit by more than $330 billion over 10 years.

Ultimately, the candidate’s ability to expand or change the ACA is largely limited by Congress. Polls suggest that Republicans are well positioned to take control of the Senate, and a result in the House is very much up in the air. However, the seeds will be very hardy. However, many initiatives, such as expanding or restricting short-term health plans, can also be improved through executive orders and regulations, as Trump and Biden have done.

KFF Health News is a national news site that produces in-depth journalism on health issues and is one of the main programs operating KFF-an independent source of health policy research, polls and journalism . Learn more about KFF.