Health care affordability is a top issue for voters this year, second only to the economy, according to a February 2024 poll from the Kaiser Family Foundation.

Both candidates attempted to lower health care costs during their time in office. At the end of his tenure in 2020, Trump passed a flurry of measures to lower health care costs. He signed the No Surprises Act, protecting people with private insurance from some unexpected bills from out-of-network providers. (Medicare and Medicaid plans already offered similar protections.) The act also requires health care providers and facilities to give uninsured people a good faith estimate of costs before delivering services.

Trump also issued an executive order seeking most favored nation pricing so Medicare would pay drugmakers the same prices as other high-income countries for certain medications. This rule sparked a number of legal challenges and was rescinded in the early days of the Biden Administration due to procedural complaints about how the rule had been made.

As part of the Biden administration, Harris worked to pass the Inflation Reduction Act. The plan—which is the largest investment in climate action and green energy in U.S. history—also includes health care components, which includes capping insulin at $35 per month for seniors, giving Medicare the power to negotiate lower prices for prescription drugs, and capping the cost of prescription drugs at $2,000 for Medicare recipients by 2025. 

On the Inflation Reduction Act’s two-year anniversary on August 14, 2024, Harris reaffirmed her commitment to its principles. She has also committed to expanding on other health care affordability measures implemented by the Biden Administration, such as cancelling medical debt and lowering prices for even more prescription drugs.

It’s possible that much of the upcoming conversations about health care affordability may focus on pharmacy benefit managers (PBMs). These middlemen companies negotiate rebates between drugmakers and health plans, pocketing most of the profits. Trump tried to enact a rule that would end these rebates, but Biden delayed its implementation due to procedural and budgetary issues until at least 2027.

Right now, there are multiple pieces of bipartisan legislation in Congress about the role of these middlemen that could change the PBM model and make it less profitable.

For over 50 years, Medicare and Medicaid have offered affordable health insurance coverage to older and low-income Americans. Medicare is a national program that primarily serves Americans ages 65 and older and younger people with disabilities, whereas Medicaid is a state-administered program for people with very low incomes. Medicaid income criteria varies by state, with some states limiting adult coverage to parents and caretakers making less than half the federal poverty level (FPL).

In 2010, former President Barack Obama signed the Affordable Care Act (ACA) while Biden was vice president. The ACA established insurance marketplaces with financial aid. Originally, the ACA required states to provide Medicaid coverage to people making up to 138% of the FPL. But several states sued over this provision, and the Supreme Court ruled that Medicaid expansion should be voluntary. Nonetheless, the law seems to have successfully expanded access to coverage: By 2023, the national uninsured rate has fallen from about 15% to 7.7%.

Trump led an unsuccessful crusade to repeal the ACA. However, he oversaw the repeal of the ACA’s individual mandate, which would have imposed a tax penalty on uninsured people. He has mentioned looking for “alternatives” to the ACA, but hasn’t specified what those alternatives might be.

The Biden-Harris administration increased the ACA’s health care subsidies (tax credits) through the American Rescue Plan Act of 2021 and the Inflation Reduction Act of 2022. But these are set to expire at the end of 2025.

Harris is likely to extend the ACA’s health care subsidies if elected. She previously supported the Medicare for All Act and included a similar plan in her 2020 presidential campaign, however it is not a central part of her agenda in 2024.

Georgia is one of 10 states that didn’t expand Medicaid under the ACA. It currently covers low-income children and pregnant and postpartum people, as well as parents making only a few thousand dollars per year.

Instead of expanding Medicaid, Georgia launched an alternative program: Georgia Pathways to Coverage. Launched last year, this program provides Medicaid coverage to adults making up to 100% of the FPL (about $15,000 per year for a single adult), as long as they can prove that they work, volunteer, or attend school for at least 80 hours each month.

Georgia is currently the only state to tie a work requirement to Medicaid coverage. The requirement presents a major barrier to care, according to Anna Newton-Levinson, PhD, assistant professor of behavioral, social, and health education sciences. Her research, which focuses on reproductive health care access, has shown that many people, including those who are full-time caregivers or have informal jobs, struggle to provide proof of income.

“You're putting a lot of burden on folks who are already juggling multiple things in their lives, working multiple jobs. And then trying to provide all of that documentation just to get health insurance is a lot,” she says.

From July 2023 to March 2024, about 3,500 people signed up for coverage through Georgia Pathways. In comparison, over 1.3 million Georgia residents used the ACA marketplace to enroll in other plans during the 2024 open enrollment period, including zero-premium subsidized plans. That's an 181% increase since 2020, the third-highest increase in the country. The other states with the biggest enrollment spikes, all of which are in the South, haven’t expanded Medicaid either.

Politicians disagree on the reasons for the enrollment increase. Some say it’s because people are losing Medicaid coverage as COVID-era protections expire, driving them to sign up for low-cost plans subsidized through the American Rescue Plan Act and Inflation Reduction Act. Meanwhile, Gov. Brian Kemp credits the increase in coverage to the launch of Georgia Access, an online portal linking to the ACA marketplace and brokers.

One critical issue that hasn’t seen a lot of attention this election cycle is how to address health care deserts. These “deserts” are areas, often rural or low-income, that lack health care. A number of factors play a role in the creation of health care deserts, but the biggest might be workforce shortages.

“We have this growing labor shortage of primary care physicians, nurses, and health care professionals in general,” says Kenneth Thorpe, PhD, Robert W. Woodruff Professor of Health Policy. “This challenge cuts across different sectors of health care.”

For instance, over 1 million additional direct care workers, including home health aides and nursing assistants, will be needed by 2030 compared to 2015.

“We are in a crisis already,” says Regina Shih, PhD, professor of epidemiology. Because of the rapid increase in the older adult population, coupled with the increased participation of women in the workforce and smaller family sizes, there are not enough people to take care of older adults. Shih stresses, “We don't have enough family caregivers. We don't have enough formal caregivers.”

She explains that a direct care worker is “somebody who takes care of your loved one sometimes 24 hours a day, providing very personal care like helping them to go to the bathroom, feeding them, changing their clothes.” Despite that, “they are underpaid and under-recognized. And if we don't help them get better pay and compensation, we will not have sufficient paid services.”

Shih says that better pay and training would help retain home care providers, who see 77% turnover each year. The home care workforce is already experiencing shortages, and openings are projected to grow more than any other occupational category. In 2021, Biden proposed investing in Medicaid home and community-based services as part of the American Jobs Plan, which would have been the biggest-ever expansion of direct care. Harris, as vice president, supported this plan, but the bill was never passed.

On the other end of the age spectrum, children are suffering from a shortage of mental health care professionals, according to Janet Cummings, PhD, professor of health policy and management. The shortage, which is especially pronounced for children enrolled in Medicaid, is driven by low pay and compounded by high, complex caseloads.

Cummings says a major part of the solution would be to increase Medicaid reimbursement rates. At present, low reimbursement rates translate into low salaries for mental health providers serving Medicaid-enrolled children. This leads to high turnover rates and staffing vacancies, particularly at safety-net clinics.

As a result, providers can make more money by running cash-only practices. In the past, this would require moving to a wealthy area where people could afford to pay in full. But the advent of telehealth, while increasing access for some patients, means that mental health providers can run a cash-only practice from anywhere and still have a statewide pool of willing payers.

“People on both sides of the aisle love to talk about child mental health, but there has been little action on addressing the low Medicaid reimbursement rates for mental health,” says Cummings.

Other forms of mental health are also fraught with access challenges. For example, Stephen Patrick, MD, chair of the Department of Health Policy and Management, has seen pregnant people travel hours for opioid treatment. Even then, in some states up to 60% of providers are cash only. Patrick’s research has shown that cash-only practices are more common in urban areas, although the reasons for this remain unclear.

One widely touted solution for increasing rural health care access is telehealth. Although it existed previously, it became commonplace during the height of the COVID-19 pandemic, when Medicare began to cover remote services. Other insurance companies quickly followed. Medicare coverage for telehealth sunsets at the end of this year, but there’s bipartisan support for its renewal.

However, the growth of telehealth may have some unintended drawbacks. Cummings is concerned that by enabling the growth of cash-only clinics, telehealth could ultimately exacerbate the shortage of mental health providers that serve children with public or private insurance.

Many rural Georgians face significant barriers to health care, but the situation is particularly bleak for those seeking reproductive care. “One-third of counties have no OB-GYN, and many more have way too few,” says Newton-Levinson.

“Abortion bans and other restrictive policies make states like Georgia less attractive to work in,” she adds. “We're now seeing trainees electing not to come to these states to get their medical training.” She expects that this will reinforce workforce shortages, as providers often stay in the state where they were trained.

Workforce shortages, coupled with low reimbursement rates, have contributed to the widespread closure of rural hospitals. Many rural hospitals primarily serve people who are on Medicare or Medicaid, or who don’t have any insurance. This means that most of their revenue ultimately comes from federal reimbursements.

Rural clinics and hospitals are “having to make decisions about staying afloat and staying competitive amid increasingly costly environments,” says Newton-Levinson. Their closures are symptomatic of broader issues related to health care volume and costs. But they also fuel growing health care inequities.

Newton-Levinson states that in the case of reproductive health, the solution must be two-fold: policies that expand access to care and better supports for the workforce, particularly in rural areas. These changes could take the form of incentives, loan repayment programs, telehealth expansion, better provider education about working with publicly-insured populations, and improved reimbursement rates.

The Biden Administration recently dedicated $11 million to establish residency programs in rural communities. However, none of the organizations that received funding are in Georgia.  

“Over the last 20 years there has been a rise in deaths from opioids, and that really escalated during the pandemic. Now, more than 100,000 people per year die of an overdose,” says Patrick.

As a result, there’s been broad bipartisan support for ending the crisis, even if people disagree on the methods. “We've seen multiple pieces of legislation and initiatives that have happened over the last eight years. Everything from the declaration of a national emergency to the SUPPORT Act,” says Patrick.

Patrick would know. He testified at the Senate to help inform the creation of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act in 2018. This legislation provided funding for community-based treatment and recovery services, and it also required Medicaid to cover medications for opioid use disorder.

The Biden-Harris administration has used a very intentional harm reduction approach, explains Patrick. Harm reduction techniques like clean needle programs and the distribution of overdose reversal kits serve people who want to use substances more safely. For example, the Food and Drug Administration made overdose reversal kits available over-the-counter in 2023, albeit at a high sticker price.

Harris has a strong record of action to fight the opioid crisis. As vice president, she met with state attorneys general to discuss federal and state-level action against illicit fentanyl and expanding access to treatment for people at risk of overdose. During her tenure as California attorney general, she filed a lawsuit against pharmaceutical companies to lower the cost of opioid addiction treatment.

On the other hand, Trump is focused on tackling the issue from the supply side. He plans to declare a “war” on cartels, designate them as terrorist organizations, and levy military action and embargoes against them. He would collaborate with neighboring governments to destroy the cartels and expose corruption.

Patrick points out that the drug market is complex. Not all drugs come from cartels across the border, and some even enter the country legally. Plus, drugs like fentanyl can be made synthetically. “It's not like the days where you had to grow a crop,” he says.

Historically, the focus on eliminating drug supply has simply led people to switch to other drugs. “The opioid crisis is a great example of that,” explains Patrick. “We had a prescription opioid crisis, so then we enacted policies that tried to decrease the supply. And what we saw were higher prices on the street for prescription opioids.” As a result, people turned to heroin, which was cheaper, and then fentanyl, which was even cheaper.

“We have a long history in the U.S. of fighting a drug war and that was largely ineffective,” Patrick says. What’s more, it villainized people who used substances, especially people of color.

“We know that public health approaches rather than criminal justice approaches are more effective,” Patrick adds. “There is no question that we have to do a better job of limiting the supply of illicit fentanyl in the U.S., but that can't be the only solution. We need vast expansion in treatments. We need harm reduction. We need a comprehensive approach that really does have to be grounded in public health.”

Story by Deanna Altomara
Designed by Linda Dobson
Illustration by John Jay Cabuay