How the 2024 Election Will Determine the Future of America's Health Crises

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As the 2024 presidential election approaches, the relentless rise in health care costs, from insurance premiums to prescription drugs, continues to stretch household budgets, especially for low-income families. Authors recently published in NEJM argue that any effective reform must tackle both the skyrocketing costs and the structural inequities in the current system.¹

Data show profound disparities in the burden of crises currently impacting Americans. Black Americans experience maternal and firearm-related mortality rates more than 2.5 times higher than those of non-Hispanic Whites. Deaths from synthetic opioid use are concentrated among individuals without a college education, while childhood obesity disproportionately affects lower-income families.

"Ideological differences between presidential candidates Kamala Harris and Donald Trump would lead to differing policies, which would affect these epidemics and related inequities," Aslan, et al. wrote. "...Policy responses to health differences are steeped in some rationale of their root cause, and Harris and Trump seem to endorse divergent explanations: structural barriers and privilege versus individual merit and grit. Recent executive orders reflect their ideologies."

Recent executive actions reflect these ideological rifts. President Biden’s executive order on racial equity, championed by Harris, reversed Trump’s ban on federal training around “divisive concepts” related to systemic racism, underscoring a commitment to addressing structural barriers. Should Harris win, the article states that her policies would likely continue expanding governmental services and oversight to improve health outcomes. At the same time, a Trump administration would likely reduce federal interventions, promoting individual choice as the path to health improvement.

Health Insurance and Social Safety Nets

The Biden-Harris administration has proposed expanding health insurance coverage to mitigate health inequities, suggesting a payroll tax increase on high-income earners to extend Medicare’s solvency by 25 years. Harris would likely continue these efforts by supporting the Affordable Care Act (ACA) and maintaining Medicaid waivers that fund programs addressing social determinants of health. In contrast, Trump’s track record indicates he would likely aim to destabilize the ACA, a move critics argue could worsen disparities by reducing access to care and increasing financial burdens for the uninsured.

Harris has also pledged to tackle medical debt—a key factor in financial insecurity for low-income Americans—by canceling billions of dollars of debt, potentially easing the economic strain on vulnerable families. Trump’s administration has focused more on reducing federal regulations, prioritizing a smaller government role in health care access and financial support.

Affordability Requires Protection, Systemic Reform

As McWilliams et al. highlight in another NEJM article, affordability hinges not only on direct out-of-pocket expenses but also on the broader sacrifices families make to meet rising health care costs.² This often means forgoing essential needs, particularly for low-income households that lack sufficient protections against high medical expenses. A truly affordable system requires substantial subsidization for these households to prevent devastating financial consequences when health issues arise, the article stated.

On a systemic level, affordability is also impacted by the high aggregate cost of health care in the US, which now consumes a growing share of the economy. As spending outpaces economic growth, more households struggle to maintain coverage or access necessary care. With subsidies struggling to keep up with these rising costs, there is a pressing need to evaluate where health care dollars can be spent more effectively, especially by addressing inefficiencies and unnecessary profit margins that fail to contribute to public well-being.

This approach calls for a careful balance: policies that control excess costs, especially by limiting market power abuses among provider organizations, insurers, and pharmaceutical companies, could prevent funds from being diverted away from other essential sectors. Price caps, for example, could restrain exorbitant health care charges without disrupting competition, while enhancing affordability for millions. For pharmaceuticals, continued regulation of drug prices and strategic negotiation rights, as established by recent legislation like the Inflation Reduction Act, could further alleviate the cost burden on both individuals and public payers.

The Role of the Courts and the Limits of Presidential Power

Regardless of who takes office, the conservative-leaning Supreme Court and the potential lack of a congressional majority could limit the next president’s influence on health policy.¹ Recent judicial decisions, like the overturning of the Chevron doctrine, restrict federal agencies’ regulatory power, curtailing executive initiatives on health.

"Nevertheless, the president retains the power to nominate federal judges and agency heads, and to frame issues such as whether observed health disparities should be attributed primarily to systemic failures, necessitating government intervention, or to personal preferences, requiring behavior modification," Aslan et al. concluded.

References

1. Alsan M, Yearby R. Health equity in the 2024 U.S. presidential election. N Engl J Med. 2024;391(15):1374-7. doi:10.1056/NEJMp2410598
2. McWilliams JM, Dusetzina SB. Affordability of health care in the United States — old problems awaiting a new administration. N Engl J Med. 2024;391(15):1372-4. doi:10.1056/NEJMp2410638