Three medical issues at issue in the presidential election: Shots

As the 2024 election heads into its final weeks, the direction of policy that will affect the health of millions of Americans is at stake.

The next president and Congress will have the power to influence major health care programs like Medicare and Medicaid, which together cover nearly 150 million Americans. They will be able to direct resources to how the United States combats the drug overdose crisis and prepares for the next pandemic.

A recent survey found that two-thirds of Americans say the presidential election should focus more on health care, making them the most important health care policy the next president will face in his first year in office. There are several choices. Here are the candidates' views on the three issues:

1. What does the future hold for Medicare drug price negotiations?

The Biden-Harris administration has scored a historic victory by giving Medicare the power to directly negotiate the prices of some of the most expensive prescription drugs. Federal health officials say the first 10 negotiated prices will go into effect in 2026, saving patients and Medicare a combined $7.5 billion.

Some senior Republicans in Congress want to abolish that authority, arguing that lower profits for drug companies would reduce their incentive to develop the next breakthrough treatments. Several drug companies are also suing the federal government, arguing that Medicare's negotiating powers are unconstitutional.

President Trump has not said whether he supports repealing the law or whether he will continue to defend it in court. Stacey Dusetsyna, a health policy professor at Vanderbilt University Medical Center, said Medicare's new powers remain fragile.

“Once you give improved benefits to Medicare beneficiaries, it's very difficult to take them back,” Dusetsyna acknowledged. “But the negotiated price doesn’t go into effect until 2026, so I don’t think anyone will miss it[if it is repealed].”

Harris said during her campaign that she wants Medicare to “accelerate negotiations so we can lower prices on more drugs faster.” Experts believe this will likely mean negotiating more drug prices, or starting negotiations earlier in a drug's lifespan. Both moves would require parliamentary approval.

Harris' campaign says it will invest the additional savings in new policy proposals, such as expanding Medicare coverage for home health care. However, a recent report from the Congressional Budget Office estimates that such efforts would generate minimal additional funding.

Dusetsyna said it is also unclear whether Harris' plan will slow down the pipeline of new drugs.

“I think it’s worth being a little bit cautious about how big and broad we go right away,” she said. “I want to know what that means for drug development? What does that mean for patient access?”

President Trump has not explained how his administration will proceed with negotiations. Medical experts say the rule tells Medicare which drugs it chooses to negotiate with and sets the minimum discounts the government must seek, making it difficult for the Trump administration even if the law survives. It points out that its ability to weaken the law is limited.

2. Should Congress extend the Affordable Care Act's enhanced subsidies?

For people who buy their health insurance on the ACA Marketplace, the federal government pays a portion of the monthly health insurance premiums that many people pay. In the original law, lawmakers capped aid to individuals making up to 400 percent of the federal poverty level, which now stands at about $125,000 for a family of four.

Congressional Democrats lifted income limits and expanded the size of the subsidies in 2021. According to KFF, a nonpartisan health research group, the cost of insurance premiums for consumers has been cut by almost half. Since the subsidy increase, the number of people insured under the ACA has nearly doubled to more than 21 million.

These enhanced subsidies, so-called “subsidies”, are scheduled to expire at the end of 2025. If that happens, KFF estimates that monthly premiums for people with subsidized ACA plans will double in many states, and the Congressional Budget Office estimates that more people will enroll in the ACA. . The number of subscribers will fall by 7 or 8 million. (CBO estimates that about half of these people obtain insurance through work.)

Vice President Harris has said she wants to make these subsidies permanent, which would cost Washington an estimated $335 billion over the next 10 years. Former President Trump has not taken a position, but many Republicans, including former Trump officials, say the benefits should expire.

Many Republicans believe that a report released this year by the conservative Paragon Health Institute found that up to 5 million people have falsely declared their income to deceive the government into qualifying for $0-premium health insurance. It points out that there is a possibility. Paragon says the activity has cost taxpayers up to $26 billion.

Other health policy experts say there are less sinister explanations. KFF Vice President Cynthia Cox said annual income can be very difficult to predict, especially for people who work in many low-wage jobs. Even if it looks suspicious on paper, your best guess could be wrong in reality.

“It may depend on how much you get tipped, how many rides you pick up, how many shifts you work,” Cox said. “So I think there are important nuances to consider, like whether this is really a scam or not.”

Cox added that the law has provisions that force citizens to pay back all or part of their subsidies if the subsidy estimates are incorrect.

Michael Cannon, director of health policy at the libertarian Cato Institute, blames the subsidies for encouraging other forms of fraud by insurance brokers. Federal health officials have received 275,000 complaints this year about brokers buying people's Obamacare insurance without their consent. Brokers receive a commission for each person who signs up for insurance, but consumers who don't have to pay monthly premiums may be less likely to notice changes to their insurance.

“If more enrollees had to pay at least a small amount of money to enroll in these plans, a lot of this unscrupulous behavior by brokers would be stopped,” Cannon said. .

Federal regulators suspended 850 brokers, proposed new rules to crack down on bad brokerage practices, and resolved nearly all complaints.

3. Is medical abortion still available?

Currently, nearly two-thirds of abortions in the United States are medication abortions, which typically require a medication regimen of two pills: mifepristone and misoprostol. In June, the U.S. Supreme Court rejected an attempt by abortion opponents to overturn the Food and Drug Administration's years-long approval and expanded access to mifepristone. But depending on the election, the FDA's new leadership could move to restrict (or even expand) access to medical abortion.

Under the Biden-Harris administration, the FDA allowed doctors to prescribe mifepristone to any patient through telemedicine, instead of requiring patients to see a health care provider in person. Now, one in five people in the United States can obtain an abortion through telemedicine prescriptions, and Harris has made protecting and expanding access to abortion a central part of her campaign.

Trump flipped out. The former president at times said he would not restrict access and at other times said he would accept federal restrictions. Project 2025, a conservative governance plan written by former President Trump officials and other allies, calls on the FDA to withdraw its approval of mifepristone.

“I think a lot of people don't know if we can be trusted because what he says is consistently different,” said Edellina Ko, an associate professor at Pacific University's School of Law.

Even if the Trump administration restricts or blocks access to mifepristone, people will still be able to obtain medication abortion using only one other pill, misoprostol. Although misoprostol is safe and effective when used alone, it can cause more side effects.

Uncertainty surrounding President Trump's health care policy

Harris' position on these three issues is clear. She supports expanding ACA enhancement subsidies. She supports medical abortion and wants to get serious about Medicare drug negotiations.

It's even harder to predict what will happen to health policy under a second Trump administration because he has not taken public positions on many major issues.

“When former President Trump describes his plans, his words are often so general that it's difficult to understand,” said KFF's Cox.

For example, until recently, one of President Trump's clearest positions on prescription drug prices was the “most-favored-nation” policy he launched late in his first term. That would force drug companies to sell certain drugs to Medicare at rates paid by other countries.

Within the past few weeks, the Trump campaign told Politico and Stats that the former president had no intention of reinstating the policy in his second term.

Ben Ippolito, a health economist at the conservative American Enterprise Institute, said it's “a little hard to predict” how President Trump will approach health care beyond the policies that have now been repealed.

This article is from the health policy news organization Tradeoffs. Ryan Levi is a reporter and producer on the show, and a version of this story first appeared. You can listen here: