In advance of the 2024 presidential election, The Chronicle is breaking down each candidate’s stance on priority issues, examining their platform and political history to keep voters in the Duke and Durham community informed. This week, we take a look at health care:
Editor’s note: The Chronicle is dedicating separate Presidential Previews to examining the major candidates’ plans on reproductive rights and the opioid crisis.
While health care may not be a deciding factor in this election, it still ranks highly in terms of voters’ priorities.
One of the biggest health policy issues this election cycle is the high cost of care, with policies focused on lowering prescription drug prices and making insurance more affordable. The future of the Affordable Care Act — commonly referred to as Obamacare — is also in question this election cycle.
Republican nominee Donald Trump and Democratic nominee Kamala Harris have both framed their approach to health policy around making care more affordable, though they present distinctly different plans for doing so.
Health care remains a top priority for North Carolina, which has been recognized as “arguably the most innovative state in the country” in the field. A Sept. 11 poll conducted by WRAL and SurveyUSA found that health care was the top priority for Democrats and ranked highly for Republicans, though not the number-one issue.
However, the state faces significant challenges, with 9.4% of North Carolina residents uninsured in 2022 compared to 8% nationwide. Additionally, 1,090,000 adults — 13.4% of the state’s adult population — reported having medical debt between 2019 and 2021, well above the national average at the time of 8.6%. In August, North Carolina announced plans to leverage Medicaid through a first-of-its-kind program to relieve medical debt.
North Carolina has taken steps to provide health coverage to more people by expanding Medicaid under the ACA to cover nearly all nonelderly adults earning up to 138% of the federal poverty line (FPL) in December 2023, making it the 40th state to do so.
As a result of the expansion, over 500,000 additional North Carolinians have greater access to health care. The state has also seen substantial growth in health plan enrollment through the marketplace — a service mandated by the ACA that allows individuals or families without employer-sponsored health insurance to compare plans — with nearly 988,000 residents enrolling in 2024, a 118% increase since 2020.
Despite these advances, rural areas in the state face ongoing health care challenges, including lack of insurance, substance abuse and hospital closures. North Carolina has the second-largest rural population in the country after Texas, so addressing these issues could be crucial for securing the state’s 16 electoral votes.
Harris’ health care platform focuses primarily on making services more affordable by lowering prescription drug costs, strengthening Medicare and providing medical debt relief.
For her 2024 campaign, Harris is building on her record as a prosecutor in California, where she used antitrust laws to go after health insurance providers, hospitals and pharmaceutical companies that consolidated to raise costs. As the state’s attorney general from 2011 to 2016, she secured multimillion-dollar settlements from Quest Diagnostics and McKesson for overcharging consumers.
Later on as a senator, she co-sponsored the Medicare for All bill, which would have established a nationally mandated health insurance plan. Harris proposed a similar program as part of her 2020 presidential bid, though her version would not have eliminated private insurance entirely.
Many of the Democratic nominee’s current proposals expand upon initiatives already implemented by the Biden-Harris administration.
If elected this November, Harris’ approach to reducing the cost of care will rely largely on expanding the ACA by extending premium subsidies — federal assistance for health care costs — a stance she has backed since her 2020 presidential bid.
Under the American Rescue Plan Act, which was implemented in 2021 as part of a broader effort to provide economic relief during the COVID-19 pandemic, ACA Marketplace subsidies were temporarily increased and made available to a wider range of people. Tax credits increased for those with incomes up to 400% of the FPL, and those earning above that benchmark — who were previously ineligible for marketplace subsidies to reduce their health insurance premiums — had their health care plan contributions capped at 8.5% of household income.
The changes were designed to only be in effect for 2021 and 2022. However, the Inflation Reduction Act was passed in 2022, featuring provisions to extend the enhanced ACA subsidies through 2025.
The Democratic nominee has proposed to cap out-of-pocket prescription drug expenses for all Americans at $2,000 per year, a limit the Biden-Harris administration has already implemented for seniors. One of the administration’s key achievements, which Harris frequently highlights, is capping the monthly cost of insulin at $35 for Medicare beneficiaries — a cap that she promises to extend to all Americans if elected.
Harris also hopes to strengthen the federal government’s ability to negotiate lower drug prices. The IRA included a provision allowing the Centers for Medicare and Medicaid Service to negotiate the prices of certain drugs directly with pharmaceutical companies. Ten drugs have been selected for the first round of Medicare price negotiations, with agreements reached on new, lower prices that will take effect in 2026. These medications are among the most expensive and widely used in the Medicare program, treating conditions ranging from heart disease and diabetes to arthritis and cancer.
A Harris presidency would likely continue to strengthen protections against high out-of-pocket health care costs and medical debt.
In March, the Biden-Harris administration implemented a rule reinstating restrictions on short-term health insurance plans, which often put people at risk of inadequate coverage when they are used longer than intended. Harris also played an active role in the administration’s proposal to remove medical debt from consumer credit reports.
In line with her continued effort to highlight women’s issues, Harris also aims to combat rising maternal mortality rates. As vice president in 2022, she announced the White House Blueprint for Addressing the Maternal Health Crisis, which outlined 50 federal actions to improve maternal health care. She also called upon states to extend Medicaid postpartum coverage from two months to 12 months — which 46 states now do — and supported an over-$500 million award from the Department of Health and Human Services to improve maternal health.
During his Sept. 10 debate with Harris, Donald Trump famously stated that he had “concepts of a plan” for health care reform should he secure a second term, leaving the actual details undefined.
Trump’s past record on health care policy is somewhat mixed.
As president in 2017, he led an unsuccessful attempt to repeal and replace the ACA, which would have resulted in over 50 million Americans becoming uninsured. However, in recent years, Republican support for repealing the ACA has diminished.
Trump has since revised his stance, no longer seeking to dismantle the law entirely but instead pledging to improve it. In a video posted on his social media platform Truth Social, he promised to make the ACA “much better, stronger and far less expensive.”
One of Trump’s notable health care achievements during his first term was the signing of the bipartisan No Surprises Act in December 2020. The law protects patients from unexpected medical bills when they receive out-of-network care, such as during emergencies or when treated by out-of-network specialists in in-network hospitals.
The Republican nominee’s 2024 platform promises to make health care more affordable by “increas[ing] transparency [and] promot[ing] choice and competition.” He also promises to “protect Medicare” as part of his larger plan to support seniors.
Trump’s running mate, Ohio Sen. JD Vance, has since provided more insight into what a second Trump administration’s approach to health care policy could look like.
In a September interview, he advocated for more personalized “risk pools” that lump individuals with similar levels of health risk together in one insurance market to calculate their premiums. Unlike the current system under the ACA, which established one risk pool designed to have healthier individuals help subsidize the costs of those with more complex medical needs, this approach isolates higher-risk individuals into their own insurance pool.
The new model would likely result in lower premiums for healthier individuals, but those with chronic conditions could see significantly higher costs, as their insurance pools would consist of higher-risk patients in need of more care. As costs rise, healthier individuals may opt out of the pool, leaving behind only the sickest individuals, which would drive premiums even higher. Critics argue that this approach could make comprehensive coverage prohibitively expensive and that lower-cost plans would offer minimal benefits, reducing meaningful coverage options for everyone.
Another key issue Trump may revisit is imposing work requirements for Medicaid recipients. Under this policy, individuals would need to meet specific employment or community service criteria to maintain their coverage. When work requirements were previously attempted, such as in Arkansas in 2018, the policy led to substantial coverage losses, drawing criticism from health care advocates.
Independent candidate Cornel West has emphasized his commitment to improving Black maternal health and advocates for the “nationalization of health care industries” as a means to “prioritize people’s welfare over corporate profit margins.” His health platform features a proposal titled “Beyond Medicare for All,” though the specific policies remain unclear.
Libertarian Party candidate Chase Oliver advocates for reducing government regulation in health care. He supports alternatives to employer-provided insurance and calls for lowering the “regulatory burden on the pharmaceutical industry.” Oliver also seeks to end practices like evergreen patents, which he argues keep drug prices artificially high.
Green Party nominee Jill Stein supports a universal health care system, calling for a “National Improved Medicare for All” program. She also proposes canceling all medical debt and expanding funding for federal health agencies.
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