Why health care is not a top issue in the U.S. presidential election

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It was an ambitious promise in Joe Biden’s successful 2020 presidential campaign: If elected, he would create a health care “public option” allowing all Americans to enroll in government-provided health insurance as an alternative to private coverage.

The measure was a compromise with Democratic Party progressives, who favoured what they dubbed Medicare for All, a single-payer model that would have replaced private insurance entirely.

But after Mr. Biden took office, the public option immediately fell off the radar for him. And now, sweeping health care change is barely on the agenda of this presidential election.

It’s a sharp contrast with previous elections over the past decade, in which Democrats ran on a range of expansive universal health care plans. The issue’s absence this time around makes it all but certain that medical care will remain onerously expensive, if not completely out of reach, for tens of millions of Americans.

Democratic nominee Kamala Harris, who once backed Medicare for All, is now campaigning only on a promise to preserve the Affordable Care Act, popularly known as Obamacare. The 2010 law expanded Medicaid, a government health program for the lowest-income people, and also made it easier to access private health insurance. Currently, it provides health care coverage to about 45 million people who otherwise would not have it.

Chuck Rocha, a Democratic political strategist who owns the consultancy Solidarity Strategies, said the availability of coverage under the Affordable Care Act has simply made health care less pressing politically.

“In all of the races I’m working on this cycle, it doesn’t poll as a top-three issue,” he said. “Obamacare has been such a success, health coverage is just not a top issue for voters.”

Republicans, who once campaigned relentlessly on demolishing Obamacare, now mostly steer clear of the issue.

Another factor may be the lack of a competitive primary on the Democratic side this year. This meant that there was no opening for a leftist candidate to put Medicare for All at the centre of the campaign, as Bernie Sanders did in the previous two elections.

Still, the U.S. remains the world’s only wealthy country not to guarantee health care to all its citizens. In 2023, according to the U.S. Census Bureau, 26.4 million Americans, or about 8 per cent of the population, did not have health insurance.

Even those who are insured often face hefty co-pays or deductibles – anywhere from US$1,000 to US$7,000 – to use their plans. A 2022 study by the Commonwealth Fund, a health care research group, found that 23 per cent of Americans, nearly 73 million people, are underinsured in this way.

Prescription-drug prices in the U.S. are also notoriously high, in some cases three times what they are in Canada and other high-income countries.

Rachel Nuzum, the Commonwealth Fund’s senior vice-president for federal and state health policy, said bringing down costs has supplanted expanding coverage as the central issue in U.S. health care.

“ ‘Underinsured’ is not a word that other countries use. This idea that you can have health care coverage but not afford to use it is a uniquely American feature. The amount of medical debt and medical-related bankruptcy – you don’t see that happening in other countries,” she said.

A public option would be, at least in part, aimed at tackling affordability. It would allow all Americans to buy into Medicare, the government health care plan for senior citizens – a less expensive option than getting private insurance.

In lieu of that, Mr. Biden pursued more narrowly targeted measures to reduce prices. He capped the cost of insulin, increased Obamacare subsidies for health care premiums and authorized Medicare to negotiate prescription drug prices.

Political consultant Rodell Mollineau said the decreased emphasis on Medicare for All or a public option is a matter of political pragmatism, given the country’s divided electorate and the perennially tight margins in Congress.

“With a divided House and Senate, and the presidency on the line, it does not surprise me that those who would advocate for that would take a beat and see what the numbers are like in the next Congress before trying to press the issue again,” said Mr. Mollineau of Rokk Solutions.

Implementing a public option would almost certainly involve regulating the prices that health care providers can charge, sparking a battle with hospitals, a powerful lobby group that would fight change in the same way that insurance companies fought against Obamacare. There is currently little such regulation, which helps explain the country’s disproportionately high health care costs.

A Commonwealth Fund study of 10 wealthy countries found that the U.S. spent 16.5 per cent of GDP on health care last year – by far the most out of the countries examined – but had the worst health care outcomes. By comparison, Australia, which had the best outcomes, spent 9.8 per cent of GDP.

In the absence of federal action, some states are acting on their own. Colorado last year created Colorado Option, which requires that insurers offer plans 15 per cent less expensive than 2021 prices and cover a specific range of health care services. The state government is achieving the reduction by ordering price cuts by both insurers and hospitals.

Colorado’s insurance commissioner, Michael Conway, listed a few reasons that the state managed to get the plan passed. One was that state public servants have for the past 15 years been issuing reports showing how much hospitals were driving up health care costs, keeping the issue front and centre for policy makers. Another was Governor Jared Polis making the issue a top priority. A third was consumer advocates pushing for the plan.

“There were a whole host of different entities we were taking on,” Mr. Conway said, “not just the hospitals but insurance companies and some specialists, concerned we were going to reduce their profitability.”