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Charles Krupa/The Associated Press

What’s at stake in the U.S. election: The Globe and Mail has asked a group of writers to offer their opinions. Scroll to the bottom for links to the full series.

No matter how you slice it, the health policy challenges facing a new U.S. president are daunting. More than 10 per cent of Americans still lack health insurance, making COVID-19 tests and especially treatments hard to access. Millions more have lost their employer-sponsored insurance. Even those with health insurance face shockingly high hospital costs and surprise US$50,000 ambulance bills. Our drug prices are the highest in the world, and COVID-19 treatments are no different. The long-standing racial disparities in American health care have turned deadly during the pandemic. African-Americans are five times as likely to be hospitalized because of COVID-19 and more than twice as likely to die from it.

Making everything more complex is the potential discontinuation of the Affordable Care Act by a conservative, or even reactionary, Supreme Court. If this happens under a Republican president or Senate, it could take the U.S. health care system from bad to catastrophic. If the Democrats win the White House and Senate, there is an easy legislative fix: They can just pass a bill separating the individual mandate from the rest of the ACA that would render moot a forthcoming case challenging the Act.

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But the bigger question is what can we expect after the presidential election in 10 days?

If President Donald Trump wins re-election, we can expect no serious effort at addressing any of these challenges. Republicans have promised a replacement for the ACA for a decade, but they have never produced a feasible alternative. The few proposals offered by Republicans, such as short-term insurance plans that do not have to cover essential benefits, would end protections for people with pre-existing conditions. This idea is a non-starter when the long-term effects of COVID-19 could become a pre-existing condition.

Mr. Trump’s promises to lower costs ring hollow. He promised international reference pricing and action on surprise medical bills just ahead of the 2018 midterms. Nothing came of it. The administration only focused on repealing the ACA through the courts – backing legal challenges to invalidate the law. The only reasonable expectation of a Trump presidency is fewer protections for those with illnesses, not a serious effort at expanding coverage, controlling costs, or addressing disparities.

A better, but still evolving, picture emerges if Joe Biden wins and Democrats take control of the Senate. Mr. Biden is committed to expanding coverage, but he is opposed to sweeping approaches such as Medicare for All. He has proposed a collection of coverage policies, such as lowering the age of Medicare eligibility to 60, offering public option on the exchanges that is open to all Americans, and increasing subsidies to buy insurance on the exchanges. While less comprehensive than Medicare for All, these proposals could insure millions more Americans. But they will not get the United States to universal coverage.

Mr. Biden also takes health care costs seriously. He would continue the Obama administration’s policies of moving physicians and hospitals away from the wasteful fee-for-service model toward value-based systems incentivize more efficient, higher quality. He is in favour of regulating drug prices. He is demanding legislation to combat surprise medical bills.

Will Mr. Biden’s proposals get enacted? The ability to adopt comprehensive reforms on coverage and cost depends on the political environment. History shows that most presidents have about two years to enact a handful of major laws. After that, Congress is unwilling to take risks during election season. Consider Lyndon Johnson, who won a landslide victory in 1964. As a former senator and master legislative dealmaker, he enacted many major pieces of Great Society legislation in his first year of office, including Medicare, Medicaid, and the Civil Rights and Voting Rights Acts. He knew he had a limited window, and he seized it. That speed and sweep was historically unprecedented.

If elected, Mr. Biden will have to prioritize legislation quickly. After years of feckless administration, the U.S. confronts many dire needs: building a solid safety net including mandatory paid family leave and sick days for all workers; infrastructure including roads, bridges, ports, and airports; shifting to green energy; COVID-19 economic relief; and good-governance reforms are all high priority. It isn’t clear if universal coverage will make the cut.

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But even if universal coverage is too big a lift, there is room for optimism. Many of the smaller initiatives Mr. Biden is committed to are politically popular, long overdue, and will significantly improve health outcomes and reduce disparities. In addition to legislative fixes to the ACA and actions focused on the health care system, many social policies will address the disparities in health outcomes. If a Biden administration can raise the minimum wage, expand food stamps, make prekindergarten universal and help students pay for college, there will be not just profound improvements in Americans' economic situation, but in their health outcomes – reducing rates of chronic conditions and increase life-expectancy for minorities and low-income families.

The problem a Biden administration would face isn’t finding policy fixes to the U.S.'s problems. As with everything in the era of COVID-19, it will be a question of triage.

Ezekiel J. Emanuel is the vice-provost for Global Initiatives and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. He is also a senior fellow at the Center for American Progress. His most recent book is Which Country Has the World’s Best Health Care?

More from the series



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