When Donald Trump stammered at the recent presidential debate that he had “concepts of a plan” for Americans’ health care, he came across like a child who had forgotten his homework. But thanks to his campaign and his running mate JD Vance, we know now the Republican ticket really does have some “concepts.” Those concepts are bringing health care into the election — and presenting a tremendous opportunity to Vice President Kamala Harris.
Last Sunday, Vance raised the eyebrows of anyone familiar with health care policy when he told NBC’s Kristen Welker about Trump’s “deregulatory agenda.” “A young American doesn’t have the same health care needs as a 65-year-old American,” he told Welker. “We want to make sure everybody is covered. But the best way to do that is to actually promote some more choice in our health care system and not have a ‘one size fits all’ approach that puts a lot of people into the same insurance pools, into the same risk pools, that actually makes it harder for people to make the right choices for their families.”
Vance confirmed that Trump wants to revive one of the worst aspects of American health care before the Affordable Care Act.
It wasn’t clear in the moment whether Vance’s views matched Trump’s. As is often the case, the former president didn’t mention any specifics in his nonanswer at the debate, and Vance has run ahead of Trump before. When asked at the debate about Vance’s claim that Trump would veto a national abortion ban, the latter responded, “Well, I didn’t discuss it with JD.”But it soon became clear that Trump and Vance are singing from the same hymnal. In a story from Semafor published Wednesday, a Trump spokesman refused to provide specific details but “did tell Semafor that the president and Vance were broadly aligned on health care policy.” That afternoon at a campaign stop in North Carolina, Vance reiterated the proposed overhaul. “If you only go to the doctor once a year, you’re going to need a different health care plan than somebody who goes to the doctor 14 times a year,” he argued, “because they’ve got chronic pain, or they’ve got some other chronic condition. That’s the biggest and most important thing that we have to change.”
In other words, Vance confirmed that Trump wants to revive one of the worst aspects of American health care before the Affordable Care Act.
Unlike the U.S., other developed countries’ health care systems run the gamut from government-run single-payer programs to private, heavily regulated insurers. As journalist Jonathan Cohn notes in his book chronicling the ACA’s conception and passage, these varied systems share several features: “Most importantly, everybody pays into these systems, and everybody gets coverage from them, so that money from the young and healthy effectively covers bills for the old and sick.”
The American system developed differently. Beginning in the 1930s, employers offered their workers insurance plans, which allowed some pooling of risk. But for individuals who had to buy coverage directly, insurers could charge them based on so-called pre-existing medical conditions and risk factors like their age, where they worked and their family history. “By the late 1950s, in large swaths of the country,” Cohn writes, “people at high risk of medical expenses had no realistic way to get comprehensive insurance.” When Democrats, notably President Harry Truman, sought to establish a national insurance program, it was blocked by an alliance of Republicans, conservative Southern Democrats and business lobbies.Lyndon Johnson’s presidency chipped away at this state of affairs via the establishment of Medicaid and Medicare. (To oppose the latter program, the American Medical Association enlisted actor Ronald Reagan, who predicted that Medicare’s passage would herald the end of an America “when men were free.”) But by the time Barack Obama became president, millions of Americans again could not afford insurance. Millions more were stuck with plans that were either incredibly expensive or provided little actual coverage — or both.
The ACA addressed these issues by prohibiting discrimination against people with pre-existing conditions. It required all plans to offer certain “essential benefits” and limited premium increases based on age.
Americans don’t want to go back to the pre-ACA system.
The Trump-Vance proposal would undo all of this. If you’re old or sick, you’d pay more, likely much more. If you’re young and healthy, you’d pay less in the short term — until you inevitably become old and/or sick. The only way to keep the high-risk pools from falling apart would be massive government subsidies, which Republicans oppose.Few voters want to return to the pre-ACA system. More than 60% of Americans now hold a favorable view of the law. The protections for pre-existing conditions are its most popular aspect, with majority support even among Republicans. No wonder then that for nearly a decade, Trump has promised to replace the Affordable Care Act with “something terrific” — without having articulated a single program in all that time.
“The Harris campaign had already scheduled a week of events focused on Trump’s debate comments and past record on health care” before Vance’s comments, reports The Washington Post. So this proposal to go back to the days before the ACA is a gift to the vice president, who has made “not going back” a mantra of her campaign. Obamacare is more popular than ever, voters trust Harris more on health care, and most voters still remember the many deficiencies of the pre-ACA system. She can even point out its echoes of a Project 2025 proposal, which would “separate the subsidized ACA exchange market from the nonsubsidized insurance market.”
And health care’s salience as an issue goes beyond the electioneering of the campaign’s final six weeks. Health care may not be voters’ top concern anymore, but the cost of living is. The ACA, for all its positives, did not change the fact that Americans still pay more than citizens of peer nations for health care, only to have worse outcomes to show for it. Harris herself knows much remains to be done, having proposed a universal coverage plan when she ran for president in 2020.
The groundwork for the next great, overdue reform of American health care starts now.