The presidential election is bringing the Affordable Care Act back into the limelight

Health care is suddenly at the center of the final sprint before the presidential election, and the outcome will determine the Affordable Care Act and the coverage it will provide to more than 40 million people.

Aside from reproductive rights, health care remained a shadow issue for much of the campaign. However, recent comments from former President Donald Trump and his running mate, Ohio Sen. J.D. Vance, about possible changes to the ACA have opened Republicans up for closer scrutiny.

Recently, more than 1,500 doctors across the country issued a letter urging Trump to reveal details of how he would change the ACA, saying that information is needed so voters can make an informed decision. The letter came from the Health Care Advocacy Committee, a national group of doctors.

“It’s great that a decade and a half after the ACA was passed, we’re still debating these fundamental issues,” said Larry Levitt, executive vice president of health policy at KFF, a nonprofit health organization that includes KFF Health News. “Democrats want to protect people with pre-existing conditions, which requires money and regulation. Republicans have sought to reduce federal regulation, and the byproduct has been fewer protections.”

The two parties’ tickets have starkly different goals for the ACA, the sweeping law passed under former President Barack Obama that sets minimum payment standards, makes more people eligible for Medicaid and ensures that consumers with pre-existing conditions cannot be denied health care.

Vice President Kamala Harris, who previously supported universal health care, wants to expand and strengthen the health care law known as Obamacare. It supports the creation of permanent temporary increased subsidies that reduce the cost of premiums. And she is expected to push Congress to expand Medicaid coverage to more people in the 10 states that have not yet expanded the program.

Trump, who has repeatedly tried and failed to repeal the ACA, said during the September presidential debate that he has a “concept plan” to replace or amend the law. While the audio clip drew laughs because Trump has promised an alternative health insurance plan many times during his administration and never followed through, Vance later provided more details.

He said the next Trump administration would deregulate insurance markets, a change that some health care analysts say could provide more choice but weaken protections for people with pre-existing conditions. He appeared to adjust his stance during the vice presidential debate, saying the ACA’s pre-existing condition protections should be left in place.

Such health care policy changes could come as part of a major tax measure in 2025, Sen. Tom Cotton (R-Ark.) told NBC News. It could also open the door to changes to Medicaid. Conservatives have long sought to overhaul the health insurance program for low-income or disabled people from the current system, in which the federal government pays a percentage of states’ total Medicaid spending based on a formula, to one that caps federal spending through block grants or cap on funding per capita. Supporters of the ACA say it would shift significant costs onto states and force most or all states to eventually opt out of expanding the program.

Democrats are trying to turn the comments into a political liability for Trump, with Harris’ campaign running an ad saying Trump has no health care plan to replace the ACA. The Harris campaign also released a 43-page report:The Trump-Vance “concept” for health care,” arguing that her opponents “would take coverage away from people with pre-existing conditions and raise costs by millions.”

Republicans have stumbled in the past when they unsuccessfully tried to repeal the ACA. Instead, the law became more popular, and Democrats were helped by the risk Republicans took to protect the status quo. take control again house in 2018.

In a KFF survey last winter, two-thirds of the population said it was very important maintain the statutory ban on charging more for health insurance or denying coverage to people with health problems.

“People in this election are focused on issues that affect their families,” said Robert Blendon, professor emeritus of health policy and political analysis at Harvard. “If people believe that Trump will affect their insurance, that could make a difference.”

Vance in a September 15 interview on NBC’s Meet the Press program tried to minimize this influence.

“You want to make sure that pre-existing coverage — conditions — are covered, you want to make sure that people have access to the doctors they need, and you also want to implement a program of deregulation so that people can choose the health plan that’s right for them “, he said.

Vance went on to say that the best way to ensure that everyone is covered is to promote more choice and not put everyone in the same pool of insurance risks.

Risk pools are fundamental to insurance. They refer to a group of people who share the burden of health care costs.

Under the ACA, participants generally belong to the same pool regardless of health status or preexisting conditions. This is done to control premium costs for everyone, using the lower costs incurred by healthy participants to control for the higher costs incurred by unhealthy participants. Segregating sick people into their own pool could lead to higher costs for people with chronic conditions, which could put coverage out of reach for them.

The Harris campaign seized on the threat, saying in a recent report that “insurance companies will go back to discriminating based on how healthy or unhealthy you are.”

But some critics of the ACA believe there are ways to separate risk pools without undermining coverage.

“It’s not surprising that it has been inflated for political purposes,” said Theo Merkel, a former Trump aide who is now a senior fellow at the Paragon Health Institute, a right-wing organization that focuses on health research and market-based policy proposals. .

Adding short-term plans to the coverage options would not hurt the ACA market and would give consumers more affordable options, said Merkel, who is also a senior fellow at the Manhattan Institute. The Trump administration increased the maximum duration of these plans, then Biden returned it to four months.

People who qualify for subsidies are likely to buy ACA comprehensive plans because — with financial assistance — they will be affordable. That way, the ACA’s marketplace and its preexisting condition protections will continue to function, Merkel said. But offering short-term plans would also provide a more affordable option for people who don’t qualify for subsidies and who are more likely to buy plans that don’t qualify.

He also said that in states that allowed people to buy plans not compliant with the ACA off-the-shelf exchanges have performed better than in states where it is prohibited. Another option, Merkel said, is a reinsurance program similar to the one in Alaska. Under the plan, the state reimburses insurers for covering very expensive health claims, helping to keep premiums affordable.

But supporters of the ACA say that separating sick and healthy people into different insurance risk pools would make health coverage unaffordable for people with chronic conditions, and that allowing people to buy short-term health plans for longer terms would have the opposite effect.

“It doesn’t protect people when they get sick,” said Leslie Dutch, executive director of Protect Our Care, which advocates for the health care law. “There is no reason to do this. This is reckless and does not make economic sense. They will hide behind the words ‘we do it better,’ but it’s not true.”

Harris, meanwhile, wants to keep the temporary expanded subsidies that helped more people get health insurance at a lower cost under the ACA. Those expanded subsidies, which help about 20 million people, are set to expire at the end of 2025, setting the stage for a bitter battle in Congress between Republicans who want them to end and Democrats who say they should be made permanent.

In September, Democrats introduced a bill to make them permanent. One challenge: Congressional Budget Office It is estimated to increase the federal deficit by more than $330 billion over 10 years.

Ultimately, the ability of any candidate to significantly expand or change the ACA depends on Congress. Polls show that Republicans are in a good position control of the Senateand the result in the Chamber is unknown. However, the margin is likely to be small. In any case, many initiatives, such as expanding or limiting short-term health care plans, can also be pushed through executive orders and regulations, as Trump and Biden have done.