In a week of hand-wringing and finger-pointing over what Democrats might have done differently in this year’s presidential election, one big topic has been absent from the conversation: Health care reform and public health. It’s a surprising omission given how 2020 was largely a referendum on pandemic response—a referendum Trump failed. The issue remains highly salient: At least eight in 10 voters said it was “very important” for the 2024 presidential candidates to talk about the affordability of health care.
But beyond Harris’s promise to maintain the Affordable Care Act and introduce some moderate reforms to drug pricing and medical debt, the issue felt like an afterthought. As of October, two-thirds of U.S. adults said they didn’t think the presidential campaigns were paying enough attention to health care.
The issues of health care and the Covid-19 pandemic are still front of mind to large swaths of voters and, in some ways, inextricable. President Biden owed his 2020 win in part due to his promise that he would do better than his predecessor in handling the pandemic; that unlike Trump, he would “follow the science.” And at first, he did. But once it became clear that new variants would arise and vaccines would not prevent all Covid cases—though they did limit hospitalizations and deaths—the Biden administration went way off course. Rather than following the science and ramping up rapid-test production, covering testing and new vaccines, and upholding commonsense safety measures like masking in health care, his Covid czar, a corporate executive, chose to pretend Covid was a thing of the past.
As new variants surged, Biden followed directives from consultants, corporations, and vibes. The Democrats’ current Covid-19 prevention playbook barely differs from that of Republicans, even though the World Health Organization has said this year that we are still in a pandemic.
But the Biden administration did not just stumble in following the science, it also lost its way in terms of capitalizing on its own successful policies, which taught broad lessons in the value of breaking from a broken health care status quo. Since Biden declared the end of the state of emergency in May 2023, tens of millions have lost benefits that they had gained in 2020—including Medicaid expansion, paid sick leave, increased unemployment benefits, and coverage for Covid testing and vaccines. Losing these benefits while inflation soared, income stagnated, and poverty increased certainly played a role at the ballot box.
“Pandemic social programs enjoyed broad support,” said Dr. Lucky Tran, a public health and science communicator based in New York. “However, when countries like the U.S. declared the end of the public health emergency, these programs were allowed to expire, despite Covid continuing to surge throughout the year and the long-term impacts on people’s health and economic well-being.”
Both campaigns seemed to view discussing Covid-19 itself as a “toxic” political issue, as Tran put it, but the Biden administration’s public health failings certainly didn’t help the cause of the Democrats, who had come into office promising a different approach. Disabled and immunocompromised people—who constitute a quarter of the population—feel betrayed by an administration unwilling to protect them.
The expansion of the social safety net that came with the pandemic—which included Medicaid expansion, unemployment benefits, child tax credits, rent freezes, and paid sick leave—was undoubtedly popular. As it happened, voters cut across partisan assumptions in three red states (Alaska, Missouri, and Nebraska) to vote to increase sick leave benefits. Trump has promised not to cut Medicaid, though it never pays to trust him. During his last administration, he cut funding to programs that helped users navigate the complicated ACA system as well as ad spending.
During the state of emergency, some 23 million Americans gained health care coverage through Medicaid, thanks to a provision that halted Medicaid disenrollments. Typically, Medicaid enrollees have to prove their eligibility every year or their coverage will be removed; that means going through an onerous process involving forms, income verification, and bureaucracy in order to prove their income is low enough to grant them Medicaid. Medicaid eligibility was also expanded in several states during that time and its coverage was broadened to include things that made health care more accessible, like telehealth. The end of the state of emergency meant the end of the Medicaid disenrollment provision, and since then those tens of millions who gained coverage have lost it.
As Bryce Covert put it in The New York Times last March, “The message received is that the government could have done these things all along but had chosen not to—and has chosen once again to withdraw that kind of security.”
Jeff Reese, a bartender in Colorado, was one of the millions of people who lost Medicaid under Biden: “The Covid measures to help get us through, such as expanded Medicaid, food stamps, and unemployment benefits, were critical in getting me through the early part of Covid,” he told me. “Having access to health care was really good since I’m now in my fifties. I did have some preexisting conditions diagnosed, and I started treating and monitoring them, adopted a plant-based diet, and generally was able to improve my health.”
When the Covid emergency was declared over, he lost his coverage. This February, Reese suffered a serious e-bike accident that put him in the hospital for weeks, and he had to turn to GoFundMe to pay for intensive physical therapy. He says now that he owes $100,000 in medical bills, which he negotiated down from almost half a million with the hospital. He hasn’t been able to find an ACA plan that works for him yet, so he remains uninsured.
Though he begrudgingly voted for Harris in the election, many of his peers did not. “I haven’t been too keen on [the Democrats’] ability to see to my interests for a while,” he said. Reese said that he would have felt more enthusiastic in his vote had the Democrats presented a more comprehensive plan on health care. He said it was Barack Obama mentioning single-payer health care during his campaign that led him to vote Democrat for the first time after voting third party since 1992. According to a Gallup poll, a majority of Americans think the government should ensure that everyone has health care coverage.
To the extent that Harris addressed health care, it was largely to voice support for abortion rights or highlight Trump’s threats to unravel the ACA. In October, Harris ran some ads on health care and talked up her efforts to lower prescription drug costs. In a town hall on Univision, Harris faced criticism when answering a question from a Latina voter, Martha, about her problems qualifying for disability despite her debilitating long-Covid symptoms. Harris responded by talking about her support for medical debt relief, sidestepping the crux of the question.
Meanwhile, disability claims jumped by over a million between 2020 and 2023, largely attributable to long Covid, according to the Center for American Progress. Martha, who was left homeless and uninsured due to her struggles with long Covid, and who referenced “Make America great again” in her question, did not seem satisfied by Harris’s response.
At the last minute, Harris added expanding Medicare to cover some home care and addressing the high costs of ambulance rides, into her platform. But it was too little, too late. (Notably, Harris backed Medicare for All during her 2020 campaign.)
“I think the result of elections around the world have shown that ‘back to normal’ messaging was ineffective, with many incumbent governments losing office in large part due to a failure in acknowledging people’s pain and providing real plans to help people in the long term,” said Tran.
Trump’s brand of economic populism appealed to voters who are hoping for something different. But if things were already bad when it comes to health care, public health agencies, and health research, they are bound to get worse over the next four years.
“A second Trump presidency will erode essential public health and health care infrastructure, increase distrust in science and public health, and will put many people at greater risk of death and serious illness,” Tran warned.
Though Trump is no longer saying he necessarily wants to repeal the ACA—and is in fact now taking credit for “saving” it (um, OK), he can still do a ton of damage to this important health insurance program. For example, Democrats are worried about a looming expiration to ACA deductible subsidies, which make coverage possible for many, and fewer protections for people with preexisting conditions (that is to say: most people) who could not get health care before Obamacare outside of employer-sponsored plans.
Beyond that, Trump says he’ll let Robert F. Kennedy Jr. “go wild on health” and plans to give him a high-level Cabinet role, perhaps leading the Department of Health and Human Services. Kennedy, who has zero health experience (and who once suffered from a literal brain worm) is a notorious anti-vaxxer—so much so that his views got him kicked off Facebook. An HHS under his watch would surely limit access to vaccines, leading to outbreaks of diseases we thought we left behind in the twentieth century. Even if he is unable to outright ban vaccines, his efforts would surely stigmatize and discourage them. In a time when we still need a durable, variant-proof Covid vaccine and bird flu threatens to become a new pandemic, the outcome will be devastating.
“All of the policies which make the U.S. more vulnerable to Covid will also make the U.S. less prepared for future pandemic threats like bird flu because to prevent them we need health agencies that are competent, objective, and transparent; wide access to prevention and treatment tools; and strong trust in science and public health information, all of which will be under attack by the new administration,” said Tran.
Kennedy has also pledged to cut funding to the Food and Drug Administration, the Centers for Disease Control, and National Institutes of Health, which means more public health disruptions such as listeria outbreaks, as well as inaccurate or absent public messaging about current and future diseases, and less funding for biomedical research to help us understand and treat diseases affecting millions of Americans.
Some of the NIH’s biomedical research is going into things like long Covid, which affects some 20 million Americans and counting, as people are repeatedly reinfected. After a wobbly start, this research was finally showing promising signs under new NIH leadership and a $515 million grant, as I wrote a few weeks ago. We can probably wave goodbye to any further funding at the federal level.
Meighan Stone, who leads the Long Covid Campaign, says it’s critical to allocate NIH funding for Covid research as quickly as possible, before Trump takes office. “[Long Covid] is impacting force-readiness for the military, it is impacting the number of Americans who are having to apply for disability, it is affecting the economic strength of the United States,” she told me last month. “This is a significant public health issue, and it’s growing. We’re getting to the level of disease burden of other concerns like strokes, heart attacks, cancer,” she continued. “This is not a red state or blue state problem, this is a problem that’s impacting all Americans.”
It is clear that health care reform is urgently needed in this country, as numerous attempts in previous campaigns have attested. Democrats and Republicans alike take the blame for empowering insurance companies to call the shots and set the prices for this basic human right. As millions lost the pandemic-era health care benefits that provided much-needed immediate assistance, as well as pointing to the potential of a better future, the two parties—having staked out meaningful differences with one another—ended up reconverging on their approach to public health. We may never know how many decided to stay home this election because they felt disaffected at the sight of their presidential candidates abandoning following science and sensible policy. Now we will all witness what it looks like to go from bad to far, far worse.
