After the ACA Expanded Health Care Access, 2024 Elections May See Voters Demand Affordability

Amid a rancorous election season already showing partisan divides in perceptions of the economy, foreign policy, and the candidates themselves, one potential area of common ground is that Americans are frustrated with the unaffordability of health care. However, sweeping legislation is likely not on the horizon regardless of who’s elected, according to speakers at the spring conference of the New Jersey Health Care Quality Institute, held in Princeton, NJ, on May 14, 2024.

Linda Schwimmer, JD, president and CEO of the Quality Institute, kicked off the event by reminding the audience that New Jersey voters will face many choices at the ballot box over the next 18 months, with federal, statewide, and gubernatorial elections coming up, and these elections will have a profound impact on health care policies. To discuss these issues from a national vantage point, she introduced the event’s keynote speakers, Christopher Whaley, PhD, and Anand Parekh, MD, MPH.

Whaley, who is an associate professor in the Department of Health Services, Policy, and Practice at Brown University School of Public Health, took the stage to explain how health care affordability is increasingly driving political pressure. In the US, health care prices are high, variable across the nation, maddeningly opaque, and not linked to quality, which “drives a lot of the current frustration with the US health care system,” he said. Deductibles and premiums have far outpaced both wages and inflation, leaving households struggling to pay for care.

The resulting importance of the health care affordability conundrum elevates it to where 39% of voters say they would cross party lines to vote for a candidate who makes it their top priority.¹ In fact, at an employer conference Whaley attended the day prior, 2 senators with diametrically opposite political stances—Mike Braun (R, Indiana) and Bernie Sanders (I, Vermont)—both received an award for their work on price transparency illustrating that “these health care affordability issues are creating very strange bedfellows, but actually, that’s the area where there’s a lot of encouragement and a lot of stuff getting done.”

Another driver of frustration is that the cost of care depends on the market and setting where the care is delivered, Whaley said. For instance, research he coauthored in the April issue of The American Journal of Managed Care^® found that prices are higher for hospital-based outpatient surgery than at freestanding surgery centers—without any link to better quality.² And while it’s not yet top of mind for voters, the accelerating trend of mergers, vertical integration, and private equity acquisitions will contribute to even more growth in costs over the coming years, so policy makers will need to better regulate competition, Whaley noted. Prospects for that may be brighter at the state level, considering the seeming impossibility of getting major legislation through Congress, even though the frustration with unaffordability is bipartisan and touches every state.

“There’s not a clear political way to actually resolve these issues, and so in many cases, we see dysfunction in terms of both sides without any resolution,” Whaley concluded. “And so if we are going to address health care affordability, that’s going to require important compromises.”

Parekh, the chief medical advisor at the Bipartisan Policy Center, agreed that health policy and affordability will surface during the 2024 election, both in voters’ concerns and campaign messaging. He highlighted several topics that will likely arise.

1. Prescription drug costs: Democrats will tout the Inflation Reduction Act, which ushered in the largest Medicare policy changes of the past 4 years, including insulin price caps, limits on out-of-pocket spending, and a framework for drug price negotiation—although it’s not clear whether voters are aware.³ Expect Republicans to counter with concerns about how the provisions may stifle research and development of new pharmaceuticals.
2. Reproductive health: With the 2022 overturn of Roe v Wade continuing to send shockwaves through American politics, state and federal laws are coming into conflict, and some of these thorny questions are reaching the Supreme Court. Democrats will campaign on ensuring access to abortion at the federal level, while Republicans are either pressing for a federal ban or calling to leave the decision up to individual states. Reproductive rights “will continue to be a potent issue,” Parekh emphasized.
3. COVID-19 and public health: Republicans and independent presidential candidate Robert F. Kennedy Jr will stoke sentiment around government overreach during the COVID-19 pandemic, ranging from school closures to mask and vaccine mandates, whereas Democrats will emphasize that the Biden administration brought the pandemic to an end.
4. Drug overdoses: Polls reveal that voters rank drug overdoses as the top threat to public health, and Republicans will try to link illegal immigration and border policy to the presence of fentanyl in the US. Democrats will counter with the administration’s work with China to reduce the influx of precursor ingredients for fentanyl production.

These issues are likely to grab the spotlight on the campaign trail, Parekh said, but a more existential health policy question may go unanswered: “How healthy of a nation do we want to be?” Without dedicating more resources to addressing prevention, public health, and primary care, they will not be national priorities.

“These are areas where we probably won’t hear a lot from either side or from candidates. We ourselves may or may not be asking these questions, but if you really want to improve health, these are the types of issues that we as a country need to be focused on,” Parekh concluded.

In a discussion moderated by Ben Dworkin, PhD, director of the Rowan Institute for Public Policy, the speakers agreed that the US is unlikely to see an “ACA 2.0” type of legislation that would address the affordability crisis since there just isn’t the political appetite or path to passage. A more realistic scenario, Parekh said, would be “more incremental…one sector at a time, one policy at a time,” like site-neutral policy, surprise medical billing, or consolidation.

Trust will also be a key issue as voters head to the polls this fall, the speakers said. While people generally trust their individual clinician, there’s a gigantic amount of distrust in the health care system as a whole, Whaley said. For instance, a patient might do the legwork of finding an in-network hospital for a surgical procedure, but if they get a surprise medical bill for $5000 from an out-of-network anesthesiologist, “that’s another way to build distrust.”

References

1. Fioroni S. The high cost of U.S. healthcare is on voters’ minds. Gallup. October 20, 2022. Accessed May 15, 2024. https://news.gallup.com/poll/402941/high-cost-healthcare-voters-minds.aspx
2. Robinson JC, Whaley CM, Dhruva SS. Prices and complications in hospital-based and freestanding surgery centers. Am J Manag Care. 2024;30(4):179-184. doi:10.37765/ajmc.2024.89529
3. Caffrey M. Independent voters favor Biden on most health care issues, but not controlling costs, KFF poll finds. AJMC. May 15, 2024. Accessed May 15, 2024. https://www.ajmc.com/view/independent-voters-favor-biden-on-most-health-care-issues-but-not-controlling-costs-kff-poll-finds