Whether Trump clings on or Biden wins the US election after the prolonged agony of one of the world’s least efficient and democratic electoral systems, and the seemingly inevitable involvement of courts and lawyers, the incoming President will face a whole mountain of problems over health care.

The issue is of real immediate concern to millions of Americans, 72% of whom, according to a poll published by – of all people – Fox News, “strongly” or “somewhat” favour the option of changing to “a government-run health care plan”.

This of course is close to the ‘Medicare for All’ policy popularised by Biden’s main challenger for the Democratic nomination, Bernie Sanders, but rejected by both Trump and Biden, along with many of the more conservative layers of Democrats. (Medicare is the publicly-funded healthcare for seniors, and the plan would create a “single-payer, national health insurance program to provide everyone in America with comprehensive health care coverage, free at the point of service,” with “No networks, no premiums, no deductibles, no copays, no surprise bills.”)

The issue of health care has come to the fore in the US, with the Covid pandemic, which was far and away the biggest concern of voters in the Fox News poll. Almost 27 million Americans lost their employer-based insurance in the first two months of the Covid pandemic, and now face the grim prospect of paying through the nose for personal or family insurance policies, or the risk of financially crippling medical bills if they require any treatment.

But the commercial provision of healthcare also means that the costs are prohibitive. Insurance costs are inflated by hospitals charging private insurers an average of 240% of the fees they charge the publicly-funded Medicare system for the same care, according to a recent survey. If private health plans paid hospitals using Medicare’s payment rates, the total payments to hospitals would have been reduced by $19.7 billion from 2016 to 2018.

US hospitals run as businesses have been closing down, or putting staff on furlough during the peak of the pandemic – because there was no profit to be made from treating Covid patients – while hospital chains owned by three already profitable private equity firms picked up a staggering $2.5 billion in cheap government loans and handouts designed to help struggling businesses get through the Covid crisis.

The most significant Democratic Party effort to address the problems of the ruinously expensive and unequal US health care system was President Obama’s half-baked Affordable Care Act (ACA), negotiated with the insurance industry, which imposed an unpopular “individual mandate” requiring Americans not covered by workplace insurance to buy an individual policy, or face a penalty.

The ACA led to the creation of a whole slew of low-value, relatively low-priced “Bronze” insurance policies, which carried hefty deductibles (the “excess” level, up to which no pay out would be made) and co-payments (the share of any remaining bill to be paid by the beneficiary), leaving many people effectively uninsured except for the most catastrophic health bills.

This has been compounded by Trump’s sponsoring of even lower-cost and less useful policies which would not meet the standards of the ACA: “My Administration increased the availability of renewable short-term, limited-duration healthcare plans, providing options that are up to 60 percent cheaper than the least expensive alternatives under the Patient Protection and Affordable Care Act (ACA) and are projected to cover 500,000 individuals who would otherwise be uninsured.”

Trump has boasted of having ‘terminated’ the individual mandate, although Congress has only removed the penalty for not taking out insurance, not scrapped the mandate. Republican state attorney generals are due to argue in the conservative-led Supreme Court for the ACA to be overturned on November 10.

However Trump has become aware of the popularity of one key aspect of the ACA – the prevention of insurance companies from barring subscribers or charging them extra on the basis of pre-existing health conditions. In September he signed an Executive Order which declares: “It has been and will continue to be the policy of the United States … to ensure that Americans with pre-existing conditions can obtain the insurance of their choice at affordable rates.”

But as Kaiser Health News notes “there is nothing in the order — or in the broader outline — to ensure that would be the case if the ACA were struck down.” In other words Trump has committed to scrap the legislation that underpins one of his key pledges – but has made no clear proposals for any alternative legislation. This would pose immediate and serious problems to at least 135 million Americans with pre-existing conditions, plus a significant number of the 3.9 million adults aged under 59 who have contracted Covid and may have on-going health problems.

Despite repeated promises to repeal the ACA in his first hundred days, and that a new plan was just about to surface, the Republicans have legislated only the 2017 American Health Care Act (AHCA), which kept in place some of the more popular provisions of the ACA, and which some Republicans refused to support, dismissing it as “Obamacare-lite”.

In June last year Trump said in an interview with ABC News “We’re going to produce phenomenal health care. And we already have the concept of the plan. And it’ll be much better health care.” Similar claims have been repeated several times in 2020, but never followed up by a plan.

In September came Trump’s Executive Order, replete with typically vacuous Trumpish rhetoric: “my Administration has taken monumental steps to improve the efficiency and quality of healthcare in the United States.”

But Kaiser Health News points out that few Republicans actually want a Trump plan to revamp health care: “Not having a replacement plan for the Affordable Care Act may be just fine with many of his supporters and conservatives. Most Republicans don’t want the federal government to remake the nation’s health system, said Grace-Marie Turner, of the conservative Galen Institute.”

Biden too is unlikely to make the bold moves on health care that even the Fox News poll shows the large majority of Americans are crying out for. The Democrats are deeply divided on these questions, with many politicians caught up with the powerful lobbying power of the “medical industrial complex” that defeated Bill Clinton’s efforts at health reforms, and led to the dilution and effective neutering of Obama’s proposals.

Even if he himself favoured it, it’s also clear that Biden will not have control of the Senate, which is essential to be able to push through any radical change.

A poll for Kaiser Health News found that most voters preferred Biden’s limited policies on health to Trump’s. But having rejected the bolder proposals of Medicare for All, he has limited his offer to capping price increases for already over-priced brand name and some generic drugs, and giving consumers subsidies and tax credits to help pay exorbitant premiums, with an option to purchase a public insurance plan (which would be free for the poorest, based on need).

In June the Democrats in Congress passed a proposal to cap insurance costs at no more than 8.5% of income, but were not able to agree on much else of substance, leaving Biden and party candidates mouthing promises not far different from Donald Trump, pledging to “strengthen and improve our health care system to make it cheaper and easier for everyday Americans to get the care and coverage they need.”


The Covid-19 pandemic triggered a “precipitous” drop up to 50% in hospital admissions of non-Covid medical patients in the US, according to a study of almost a million medical admissions published in Health Affairs.

While some of this fall resulted from hospitals postponing or delaying elective surgery and non-critical medical services, there were also “puzzling” declines in admissions for serious conditions that require hospital care – such as pneumonia (-44%), chronic obstructive pulmonary disease/asthma (-40%) sepsis (-25%), stroke and heart attacks.

Similar studies indicate that outpatient appointments and surgical admissions were also sharply reduced.

Non-Covid admissions were most reduced in patients from majority Hispanic neighbourhoods and higher for patients from majority Black neighbourhoods.

The authors suggest the explanation may be that many patients with acute medical illness were more afraid of contracting Covid-19, or concerned that they might not be able to get in to hospitals swamped with Covid-19 patients.

They warn that in addition to the “implications for hospital solvency,” falling hospitalisation of people who need it “could portend substantial harm to public health if patients defer care for life-threatening conditions.” They suggest health system leaders and public health authorities need to focus upon “how best to ensure that patients with conditions that require hospital care obtain it during the pandemic.”


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