Health care is a critical issue for voters, according to an April poll by the Kaiser Family Foundation. About 6 in 10, 63%, of voters surveyed said it was a "very important" issue in deciding their vote for president, while 60% said the economy was a very important issue.
Health care is top of mind for Americans for a number of reasons. The repeal of the Affordable Care Act would directly affect Americans' monthly costs, for example, says Elisabeth Rosenthal, author of "An American Sickness: How Healthcare Became Big Business and How You Can Take It Back."
"Health care is, of course, a health issue, but for many Americans it is first a pocketbook issue, and that's not right," she says.
For voters, the two top concerns regarding health care is increasing access to health care and the cost of health care, according to Kaiser. Here's how the election and the potential repeal of the ACA could affect both of those concerns.
The week after the election, the Supreme Court will hear a case that will decide whether the Affordable Care Act, otherwise known as the ACA or "Obamacare," is unconstitutional, and the ruling could result in the act being repealed.
President Donald Trump has said he wants to repeal the ACA and has pressed the Supreme Court to do so. On Twitter in September, he promised that "Obamacare will be replaced with a MUCH better, and FAR cheaper, alternative," though he has not as yet unveiled details of a substitute plan.
Most of the president's health-care actions have taken the form of executive orders, several of which he issued in the last couple months.
However, executive orders don't allocate funding, says physician-turned-financial-advisor Carolyn McClanahan, director of financial planning at Life Planning Partners in Jacksonville, Florida. So unless Congress acts, the president's power is limited: "He can't spend money through an executive order, so he can't really do anything that costs money."
Former Vice President Joe Biden says he wants to enhance and expand the ACA. Many of Biden's initiatives can be found in the Biden-Sanders Unity Task Force Recommendations document. His running mate, Senator Kamala Harris, is known for protecting consumers from rising medical care prices by opposing the consolidation of institutions in the health-care industry.
Coverage of preexisting conditions is one critical aspect of health-care access. If the ACA is repealed, 133 million people with preexisting conditions would see premiums go up or lose access altogether, according to a 2017 report by the Department of Health & Human Services. Of those 133 million, an estimated 54 million Americans have conditions that would allow insurers to deny them coverage if the ACA were not in effect, according to a 2019 Kaiser Family Foundation analysis.
"Costs would go up for unhealthy people but may go down for healthy people," McClanahan says. "There are 100 million people with preexisting conditions and they will definitely see their costs go up."
Republican leaders say the administration will protect those with preexisting conditions. In late September, Trump signed executive orders as part of what the president calls his "America First" health-care plan, which involves urging Congress to act.
The effects of these executive orders is unclear, though, Nicholas Bagley, a professor at University of Michigan's law school, told Reuters. "Unless there's a law that prohibits the conduct in question, or unless the president is exercising a power that's been delegated to him by Congress, his statements have no more legal weight than a tweet," he said.
The president also signed an executive order in August that focuses on Americans in rural areas getting more health facilities and access to doctors.
"The President is now directing HHS to keep charging ahead on giving Americans better access to the doctors of their choice, including via telehealth," the U.S. Department of Health and Human Services said in a statement. "The President's executive order on rural health will help transform care for forgotten Americans who deserve better healthcare and better access to their doctors."
But whether this order will translate into concrete action is also unclear.
Biden also plans on "doubling investments in community health centers and rural health clinics," according to the Biden-Sanders Unity Taskforce Recommendations.
"Pocketbook-wise, in some ways the ACA's biggest disappointment is in its branding," Rosenthal says. "For many people, the Affordable Care Act policies have proven to be unaffordable." This is true in many cases for both premiums, or what you pay for health insurance every month, and for deductibles, or what you pay for your health services out of pocket before your plan begins to cover the costs.
Obamacare offered subsidies for low-income Americans, however, that income cap after which you cannot receive a subsidy is $49,960 for a single person and $103,000 for a family of four, according to HealthInsurance.org.
Those who earned just over this income cap felt alienated and frustrated, Rosenthal says: "The people who got stuck tended to be middle-class people who made too much money to make any of the Obamacare subsidies but too little to be able to afford the policies on offer."
One way Obamacare attempted to keep premium prices down was to enact a federal tax penalty for those who didn't want to but could afford to pay for health insurance. But during the Trump administration, Republican legislation made that penalty $0. The repeal of the so-called individual mandate bumped up premiums, according to a Kaiser Family Foundation report, and contributed to declining marketplace enrollment.
Biden says he will bring back the federal tax penalty, according to NBC News, by using executive orders and congressional legislation to expand the ACA.
Trump signed an executive order in September called the "Most Favored Nation" order which calls for Medicare to pay the same price for drugs as other developed countries. "Little movement has been made" to enact this order, according to CNN.
This is not totally dissimilar from Biden's plan, which will "empower Medicare to at last be able to negotiate prescription drug prices for all public and private purchasers — for families and businesses, as well as older Americans — no matter where they get their coverage," according to the Biden-Sanders Unity Task Force Recommendations.
"The assumption is that Medicare rates will somehow trickle down," Rosenthal says. "Some would question that but it's likely to have a chilling effect on the rise of drug prices," meaning prices would go down.
In general, both Biden and Trump argue that they will keep drug prices down. Neither, according to Rosenthal, have yet shared sufficiently detailed plans.
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