Health care and public health loom large today, on the eve of the presidential election. From COVID-19 to the Affordable Care Act (ACA), this is now clearly a public health election. Let’s review what’s on people’s minds and what’s at stake.
Where are voters on health issues? 
In February of this year, health care was the single most important issue among registered voters in the presidential election. By October, health care appeared to have fallen in importance. The public health issue of COVID-19 had understandably superseded it. And, relatedly, the economy had become the top issue. By stalling economic growth and causing job losses, COVID-19 was almost certainly what drove concerns about the economy to the top.
The economy, in a sense, has become a health issue.
Whether and how government should respond to these issues is clearly on the ballot. President Trump for example, has left much of the COVID-19 response to the states. Vice President Biden has argued for a more centralized coordinating role. A survey asked registered voters whether the government should play a major role in “effectively handling threats to public health.” The results revealed a 22-point divide between Democrats (at 90%) and Republicans (68%). And on “ensuring access to health care” specifically, there was a 43-point divide (85% to 42%).
The public tends to trust Biden over Trump to have the better approach to most health care and public health issues. From reproductive health to lowering prescription drug prices, Biden consistently outpolls Trump.
Where are the campaigns on health issues?
While Trump has generally avoided health care or COVID-19 in his advertising, Biden has made both a central theme. In his final major online national ad, the campaign describes “the 6 things” on his agenda. Having a pandemic plan (#2) and expanding access to health care coverage and lowering costs (#6) are sandwiched in between climate change (#3), education (#1) and jobs (#5). In his final 30 online ads, Biden’s campaign has featured COVID-19, climate change and health care 30% of the time.
Public health issues were featured just four times in the 30 most recent online ads for President Trump. Three argued Vice President Biden would “lock down the economy” due to COVID-19. And one described Biden’s clean energy agenda as an “energy ban.” President Trump has regularly discussed protecting pre-existing conditions and lowering prescription drugs costs, but neither are major features of his campaign ads.
Health care and public health are also top issues in US senate races. In speaking to voters through advertising, health care was the single most common issue among all pro-Republican ad airings (included in over 33% of all ads). Forty-four percent of pro-Democratic ads included health care. Democrat senate candidates also included advertising on COVID-19 (25% of ads) and prescription drugs (15% of ads).
COVID-19
Today, the US has seen more than 9.2 million confirmed coronavirus cases and 231,000 deaths. By my calculation, ~3% of all US residents have now tested positive for COVID-19. It will likely be the third-leading cause of death in the US in 2020. With these numbers, it is not surprising that Dr. Anthony Fauci, the nation’s leading infectious disease expert, has said “You could not possibly be positioned more poorly” as we enter winter. The US is not “rounding the turn,” as Trump has suggested.
In comparing approaches to COVID-19, there are larger differences between the two candidates than is immediately obvious. President Trump has primarily touted the success of his travel ban, which indeed happened early in the pandemic (announced Jan. 31, 2020). But these travel restrictions were already in place in many other countries, and most major airlines had already suspended flights to and from China. This makes the US rather late to the game.
Trump deserves, among other things, credit for launching Operation Warp Speed to fund COVID-19 vaccine research. There is some progress, though a vaccine is still no guarantee. Even so, a declining number of US residents say they are willing to accept a vaccine. Only 49% of Americans say they would get a vaccine, a troubling statistic.
Biden’s approach–analyzed in detail by Time magazine–would expand testing, where Trump has been reluctant. Biden’s plan includes building a national contact tracing workforce, a process that has been currently left to the states. He would encourage mask wearing by working with governors to enforce mandates. And Biden would re-establish the White House office that monitored global health risks (disbanded during the Trump administration) and would quickly rejoin the World Health Organization.
The Affordable Care Act at Risk
The US Supreme Court will hear another challenge to the ACA after the election. California v Texas will be argued on November 10. There are two main questions. First, is the individual mandate with a $0 penalty still constitutional? Second, if not, should the rest of the law be invalidated with it? The impacts of an invalidated law are unimaginable at this point, but tens of millions would lose coverage.
Voters have no say in the Supreme Court decision. But presidential and legislative responses to the decision are what counts. And candidates have staked out vastly different positions. The Trump administration has tried unsuccessfully to repeal the law in full, and successfully repealed the mandate penalty. There is no evidence of a Republican plan to replace the law, meaning there would almost certainly be no quick action while millions lost their coverage.
Like many Democratic presidential contenders, Biden, in contrast to Trump, has said he would expand the ACA. He has proposed adding a public plan option (a government health insurance plan that some people could select). He would provide more Medicaid funding to states during the economic crisis, and proposes to reduce the age at which people qualify for Medicare from 65 to 60 years.
A different set of options unfolds if the law is struck down and Democrats hold power. A President Biden and Democrat-controlled Congress could potentially pass the law again without a mandate. They could also add other fixes needed to meet the constitutionality concerns of the current court. It may also give them a ripe opportunity to expand the law further.
KFF Health Tracking Poll: Public’s View on the ACA
Regardless of who is in power, the public now rather firmly supports the law. The past few months have recorded perhaps the broadest level of favorability for the ACA (55% favorable vs. 39% unfavorable in October) in its 10-year history (see figure). Favorability has grown for Democrats and independents, reaching their highest levels in October (89% and 58% respectively). Just 18% of Republicans support the law, little changed over time.
On the eve of a public health election
As of today, about 97 million people have already voted. This puts the 2020 election firmly on track to reach as many as 150 million voters, considerably more than the 2016 election. Health care and public health are very much on the minds of the campaigns and voters. The final results will tell us much about the preferred direction of the country on these issues.
Gregory Stevens