What COVID-19 and the Nomination of Joe Biden Mean For Health Care in the 2020 Presidential Election
-Jarrett Lewis and Bill McInturff
(This commentary originally appeared in JAMA Health Forum on 7/13/20).
Before mid-March, health care was the issue of the 2020 election cycle. Voters consistently ranked it at the top of the list of most important issues facing the country. Democratic primary voters ranked it as the number 1 issue in every single primary contest.
The 2020 election was shaping up to be a robust debate regarding the future of the US health care system, with Medicare for All as the central theme. Both sides were confident that voters would support their position. As Mollyann Brodie, PhD, pointed out in this forum in February, Medicare for All was a central tenet of the candidacy of Vermont Senator Bernie Sanders, helping position him as the frontrunner when primary contests began in February. In fact, in 22 of 23 exit polls of Democratic primary contests held through the middle of March, most Democratic primary voters expressed support for a Medicare for All system.
Republicans were equally hungry for this debate because they believed a conversation about overhauling the entire medical system worked to their advantage. Multiple surveys conducted during the last few years have shown that most of the more than 160 million US residents who receive health insurance coverage through an employer like their coverage. The debate was set.
Then, within a span of 10 days, former Vice President Joe Biden emerged as the Democratic frontrunner, much of the United States went on lockdown due to the coronavirus disease 2019 (COVID-19) pandemic, and health care was displaced as the top issue. Ironically, a global health event pushed health care down the issue agenda. Since the third week in March, more than 45 million US residents have filed initial unemployment claims, while tens of millions more have had a reduction in their income. The economy is likely to be the top issue in November.
Looking back a decade, the unemployment rate was 6.6% in October 2008 and 7.8% in October 2012. In each of those elections, voters overwhelmingly ranked the economy as the top issue facing the country (63% in 2008 and 59% in 2012). The unemployment rate is currently 13.3%, and while many expect it will improve by November, it is also expected to be greater than the rates in 2008 and 2012. In terms of the economy as an issue, a recent NBC News/Wall Street Journal survey found a plurality of voters believe President Trump would handle the economy and lower the unemployment rate better than Joe Biden (economy: 48% vs 37%; unemployment rate: 48% vs 35%).
Other issues have also drawn voters’ attention away from health issues. Racial equality is top of mind for voters, as more than two-thirds of Americans say racism is a big problem in today’s society, the highest number registered for CNN/Kaiser Family Foundation polls dating back to 1995. Voters believe Joe Biden would be better on the issue of race relations than President Trump by 63% to 31%.
While it may not be the top issue, health care will still have an important role in 2020. The choice of former Vice President Joe Biden as the Democratic presidential nominee shifted the health care debate from Sanders’s overhaul of the system to incremental change. Recent comments from Massachusetts Senator — and potential vice presidential candidate — Elizabeth Warren, who has retreated from her long-standing position on Medicare for All, suggest that the country’s focus should instead be on “strengthening the [Patient Protection and] Affordable Care Act.”
With Medicare for All fading from the picture, other health policies are receiving increased attention. Central to Joe Biden’s health plan is a public health insurance program, sometimes referred to as a public option. During the past few years, the public option has received support from approximately two-thirds of US residents because some view the plan as more moderate than a Medicare for All system. We anticipate an aggressive Republican response aiming to disqualify the public option using the same antigovernment messages that would have been mobilized against Medicare for All.
Another key (and more recent) feature of the former vice president’s plan is lowering the Medicare age from 65 to 60 years. There is little polling data available on whether US voters support lowering the Medicare-eligible age, although more than three-quarters support allowing individuals aged 50 to 64 years to purchase coverage through the Medicare program. However, our experience with health care reform is that ideas poll well until they are seriously considered for implementation. Once the policy details for lowering the Medicare eligibility age are explained, support will likely drop.
On the Republican side, voters have shown an increase in support for short term programs that ensure that those who have lost coverage due to COVID-19 can either maintain that coverage with some financial assistance or access coverage through a government program. Accordingly, Republicans may choose to focus on ways to protect and strengthen private health insurance coverage by promoting temporary policies that increase insurance portability and guardrail protections, such as providing federal assistance and tax credits to those who have lost their jobs to maintain their employer-provided insurance through continuation coverage (ie, COBRA).
In terms of whom voters trust to handle health care issues, a plurality of voters believe Joe Biden would handle the issue of health care generally better than President Trump (49% vs 34%). For the COVID-19 pandemic specifically, 48% believe Biden would handle it better than Trump, with 37% stating that Trump would handle it better.
Health care was the top issue in the 2018 midterm election. It was widely expected to be the top issue of the 2020 election. It took a global pandemic and a national debate about racial equality to displace it. However, with the health care industry serving as the largest sector of the US economy and continued public support for improving and strengthening the health care system, it will undoubtedly play an important role this November.
