Every four years, we are told that the forthcoming presidential election will be the most important of our lifetimes. This one may live up to the billing, including for health care.
If former Vice President Joseph R. Biden Jr. is elected president, and especially if the Democrats also take control of the Senate and maintain control of the House, 2021 may be the year when the U.S. puts in place the policies needed to achieve health coverage for all. Mr. Biden has proposed to build on the Affordable Care Act by giving every American the ability to enroll in a publicly funded plan, guaranteed by law, or in private insurance that meets rigorous federal standards. (This could possibly lead to a single-payer system, if most people choose a public plan, although Mr. Biden has said that he wants to maintain a role for private insurance.)
To achieve guaranteed coverage for all, the federal government would need to regulate prices, eligibility, benefits, scope of practice, billing, documentation, quality, measurement, privacy, and workforce policies to a greater extent than ever before. Higher taxes would be required to fund coverage, although the evidence shows that public coverage can lower overall spending far more effectively than our current market-based, profit-driven system, as has been seen in most other industrialized countries.
Many will welcome such increased federal regulation, insisting that everyone has a right to health care. Many will fiercely oppose it, calling it “big government” or even socialism. Pharmaceutical companies, hospitals, and insurers have already launched a well-funded effort, the Partnership for America's Health Care Future, to oppose a public option, falsely calling it a “one-size-fits-all” approach that would lower quality and restrict access to physicians.
Mr. Biden would also strive to guarantee women's reproductive rights against state and court challenges, restrict access to firearms for those likely to harm themselves or others, protect and create a pathway to citizenship for DACA (Deferred Action for Childhood Arrivals) recipients, and limit carbon emissions to mitigate climate change. He has said he will defer to science and scientists on testing, social distancing, vaccine development, and therapies to mitigate and end the COVID-19 pandemic.
If President Donald J. Trump is re-elected, and if Republicans keep the Senate, and especially if the GOP takes control of the House, he will be able to advance policies that he was only able to partly accomplish in his first term. This would include trying again to repeal the Affordable Care Act or overturn it in the courts, eliminate federal benefit mandates and protections for pre-existing conditions, replace Medicaid with state block grants while capping the federal contribution, ease federal regulation of private insurance, restrict health care for immigrants, limit women's reproductive rights and access, make it easier to obtain access to firearms, and end efforts to slow and mitigate climate change. He can be expected to continue to push public health and regulatory agencies to approve vaccines and treatments for COVID-19, as well as for states, schools, and businesses to reopen as quickly as possible, even if scientists don't recommend it and the virus is not under control.
A House or Senate controlled by the Democrats, should that be the outcome, would seek to put the brakes on many of these policies, but a re-elected President Trump would be emboldened to pursue them through executive orders, federal agency rulemaking, and litigation and by ignoring congressional intent and even statutory requirements, an intensification of his “try to stop me if you can” approach to governing.
The future of race relations is also on the ballot. What will be done to acknowledge and address systemic racism in health care, in medical education, in law enforcement, in education, and in criminal justice? To address violence and unrest?
Also consider this: Whoever wins can be expected to make several Supreme Court appointments and hundreds of lower court appointments, which will determine the willingness of the courts to support an expanded role for the federal government in health care, as well as the future of women's reproductive rights, climate change, regulation of firearms, and immigration policy, for decades to come.
The stakes of the election could not be higher. But this election will just be the beginning of a conflict over the future of American health care. It will be akin to the battles that preceded enactment of the Affordable Care Act in 2009 and 2010, and the continuing conflicts since then over its fate, but on steroids.
ACP will be there to ensure that policies to support patients and their physicians are paramount. Our lodestar will be “Better Is Possible: ACP's Vision for the U.S. Health Care System,” a series of four interrelated and comprehensive policy papers, released in January 2020. While these papers were written before ACP knew that a global pandemic was developing and soon would affect millions of us, reading them shows their prescience in identifying what needs to be done to make American health care better.
ACP called for enacting universal coverage, eliminating cost-sharing for high-value care, investing in primary care, lowering excessive prices, making health information technologies work for clinicians and their patients, eliminating unnecessary administrative burdens, moving away from fee-for-service to prospective global payments for care by physicians and their clinical care teams, increasing funding for public health, understanding and addressing social determinants of health, and ending discrimination and racism in health and in society.
Just imagine how much better U.S. health care would have been if these, and other policies in the paper, were in place when COVID-19 arrived. Imagine how much better off our country will be in 2021, and the years after, if ACP's vision becomes reality.
There is no question better is possible. But it will take determination, perseverance, and toughness to make ACP's vision a reality, no matter who is in the White House (and which party controls Congress) in January.