3 health issues at stake in the presidential election: Shots

Presidential candidates Vice President Kamala Harris and former President Donald Trump differ on how they would address several health issues, including drug pricing.

Charles Rex Arbogast/AP

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Charles Rex Arbogast/AP

As the 2024 election enters its final weeks, the direction of policies impacting the health of millions of Americans is at stake.

The next president and Congress will have the power to put their stamp on major health care programs like Medicare and Medicaid, which together cover nearly 150 million Americans. They will be able to provide resources for how the United States is combating the drug overdose crisis and how the country is preparing for the next pandemic.

A recent poll found that two-thirds of Americans believe health care should receive more attention during the presidential campaign, and that the next president will likely face several key health policy decisions in his first year. Here are the candidates' views on three topics:

1. What is the future of Medicare drug price negotiations?

The Biden-Harris administration scored a historic victory by giving Medicare the power to directly negotiate prices for some of the most expensive prescription drugs. According to federal health authorities, the first ten negotiated prices will come into force in 2026. Patients and Medicare will collectively save $7.5 billion.

Some senior Republicans in Congress want to repeal that authority, arguing that reducing drugmakers' profits would reduce their incentive to develop the next blockbuster therapy. Several pharmaceutical companies have also sued the federal government, claiming that Medicare's bargaining powers are unconstitutional.

Trump has not said whether he supports repealing the law or whether he would continue to defend it in court. Stacie Dusetzina, a professor of health policy at Vanderbilt University Medical Center, says Medicare's new authority is still vulnerable.

“Once you give people on Medicare improved benefits, it's really hard to take them away,” Dusetzina admitted. “But I think because the negotiated prices don’t come into effect until 2026, no one will miss them (if they are repealed).”

Harris said on the campaign trail that she wanted Medicare to “accelerate the speed of negotiations so that the prices of more drugs come down more quickly.” Experts say that would likely mean either negotiating the price of more drugs or starting to negotiate earlier in a drug's lifespan. Any move would require congressional approval.

Harris' campaign says she would invest any additional savings into new policy proposals, such as expanding Medicare coverage for home health care. However, a recent report from the Congressional Budget Office estimates that additional funding from such an effort would be minimal.

Dusetzina said it was also unclear whether Harris' plan would slow the pipeline for new drugs.

“I think it's worth being a little careful about how big and wide you go right away,” she said. “I want to see what does this mean for drug development? What does this mean for patient access?”

Trump has not explained how his administration would conduct the negotiations. Health experts note that a Trump administration would have limited ability to undermine the law if it remained in effect, since the rules dictate which drugs should be chosen for negotiation by Medicare and set minimum rebates the government must seek.

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

For people who buy their own health insurance on the ACA marketplaces, the federal government covers a portion of the monthly health insurance premiums that many pay. Under the original law, lawmakers limited that assistance to people making up to 400% of the federal poverty level — today that's about $125,000 for a family of four.

Democrats in Congress lifted the income cap in 2021 and increased the amount of subsidies. According to the nonpartisan health research organization KFF, consumers' share of their premiums has been cut almost in half. Since the subsidy increase, the number of people signing up for ACA insurance has nearly doubled to more than 21 million people.

These so-called extended subsidies expire at the end of 2025. KFF estimates that if this happens, monthly premiums for people with subsidized ACA plans would double in many states, and the Congressional Budget Office estimates that the number of ACA enrollees' insurance coverage would double by 7 to 8 million people go back. (The CBO estimates that about half of these people would receive coverage through work instead.)

Vice President Harris says she wants to make these subsidies permanent, which would cost Washington an estimated $335 billion over the next decade. Former President Trump has not made a case, but many Republicans, including former Trump officials, argue that the benefit should be phased out.

Many Republicans point to a report released this year by the conservative Paragon Health Institute that found as many as five million people misreported their incomes and may have tried to defraud the government and sign up for health insurance plans with zero premiums US dollars qualify. According to Paragon, this activity cost taxpayers up to $26 billion.

Other health policy experts say there is a less nefarious explanation. Cynthia Cox, vice president of KFF, said it can be very difficult, especially for people in many low-wage jobs, to forecast their annual income. What looks shady on paper may actually be a misjudgment.

“It could depend on how many tips you get, how many rides you do or how many shifts you work,” Cox said. “I think there are some important nuances that need to be considered, such as: Is this really a scam or not?”

Cox added that the law contains provisions that force people to pay back all or part of their subsidies if their estimate was incorrect.

Michael Cannon, director of health policy at the libertarian Cato Institute, blames the subsidies for encouraging another form of fraud – perpetrated by insurance brokers. Federal health officials have received 275,000 complaints this year about brokers signing people up for Obamacare insurance without their consent. Brokers receive a commission for each person they add to coverage, and consumers who don't have to pay a monthly premium may be less likely to notice a change in their insurance.

“Having more participants pay at least a small amount to enroll in these plans would put a stop to much of this unscrupulous behavior by brokers,” Cannon said.

Federal officials have suspended 850 brokers, proposed new rules to combat unscrupulous broker behavior and resolved nearly all complaints.

3. Will abortion with medication still be possible?

Nearly two-thirds of abortions in the United States are now medication abortions, which typically involve treatment with two pills – mifepristone and misoprostol. In June, the U.S. Supreme Court rejected an attempt by abortion opponents to revoke the Food and Drug Administration's longstanding approval and expansion of access to mifepristone. However, depending on the election, new FDA leaders could take action to restrict (or further expand) access to medication abortion.

Under the Biden-Harris administration, the FDA has allowed doctors to prescribe mifepristone to any patient via telemedicine, rather than requiring patients to see a doctor in person. Telemedicine prescriptions now enable one in five abortions in the U.S., and Harris has made protecting and expanding access to abortion a centerpiece of her campaign.

Trump flip-flopped. On some occasions, the former president has said he would not restrict access, and on other occasions that he was open to federal restrictions. Project 2025, the conservative government bill written by former Trump officials and other close advisers, calls for the FDA to withdraw approval of mifepristone.

“I think a lot of people don't realize that we can trust his statements because they're always different,” said Ederlina Co, an associate professor of law at the University of the Pacific.

If a Trump administration restricted or blocked access to mifepristone, people would still be able to have medication abortions using only the other pill, misoprostol. Using misoprostol alone is safe and effective, but it may have more side effects.

Uncertainty about Trump's health care policy

Harris' position on these three issues is clear. She supports expanding expanded ACA subsidies. She supports medication abortion and wants to put her foot down in the Medicare drug negotiations.

It is harder to estimate what would happen to health care policy under a second Trump administration because he has not made public statements on many important issues.

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

For example, until recently, one of Trump's clearest positions on prescription drug prices was the “most favored nation” policy he advocated late in his first term. This would have forced drug manufacturers to sell certain drugs to Medicare at the prices paid by other countries.

Within the last few weeks, Trump's campaign team announced Politico And Stat that the former president would not revive the policy in a second term.

Beyond that now-abandoned policy, Ben Ippolito, a health economist at the conservative American Enterprise Institute, said it was “a little harder to predict” how Trump would approach health care.

This story comes from the health policy news organization Tradeoffs. Ryan Levi is a reporter/producer on the show, which features a version of this story appeared for the first time. You can listen here: