By Adam Gaffney, M.D., M.P.H.
The Nation, July 31, 2024
President Bidenâs exit from the Democratic ticket and Vice President Kamala Harrisâs emergence as the presumptive nominee has, perhaps, escalated the stakes of the November election for healthcare. Trumpâs schemes are, of course, unchanged: A unified Republican government could shred the nationâs healthcare safety net, accelerate the (ongoing) privatization of Medicare, and further restrict or even ban abortion nationwide. In contrast, like a second Biden administration would have, a Harris administration might mostly mean continuityâallowing her to consolidate some real gains (like Bidenâs landmark Medicare drug negotiation reform) without confronting the broader injustices and galloping corporatization of US healthcare. But in some quarters, hopes are rising that a Harris administration could go a step beyond Bidenâand even open the door to a progressive shift on health policy.
Harris has been to Bidenâs left on abortion, supporting a measure in 2019 that would have gone beyond Roe by curtailing state-level abortion restrictions; she is also the first vice president to visit an abortion provider. As a California senator, she endorsed Senator Bernie Sandersâs landmark 2017 Medicare for All bill, a far more expansive reform than anything Biden has put his name on. Yet Harris backtracked on Medicare for All, and the political pressure her administration would face in any major reform effort from both right and center would be daunting, particularly without a powerful grassroots movement pushing the cause, once again, to center stage. Such a mobilization is precisely what we need regardless of the electionâs outcomeâto advance progressive reform if possible and to fight calamitous policies if necessary.
Forecasting the impact of a second Trump administration requires distinguishing his rhetoric from the reality of his rule. Recall that in the 2016 presidential primary, Trump ran on vaguely popularist promises to protect public health insurance programs, while maligning Obamacare and promising to replace it with something better. âTheyâre gonna cut Social Security, theyâre gonna cut Medicare, theyâre gonna cut Medicaid,â Trump said of his Republican primary competitors in 2015. âIâm the one saying thatâs saying Iâm not gonna do that!â He also famously accused pharmaceutical companies of âgetting away with murderâ in how they priced their products, causing pharma stocks to briefly tumble.
Given the popularity of Medicare and Social Security even among Republican voters, such claims may well have helped pave the road to the White House for Trump. But as we know, once in office, he governed as a hardened healthcare right-winger, joining congressional Republicansâ nearly successful campaign to dismember Medicaid and dismantle preexisting conditions protections. Even after the Obamacare repeal effort failed, Trumpâs budgets continued to call for devastating Medicaid cuts.
A second Trump administration could well give us something of a rerun. As in the past, Trump continues to deride Obamacare, but his platformâs healthcare provisions are reminiscent of his prior popularist claims. âFIGHT FOR AND PROTECT SOCIAL SECURITY AND MEDICARE WITH NO CUTS,â it promises, along with nebulous words about competition and transparency and some virulent threats to âprotectâ Medicare from immigrants. But if history is any guide, once in office, Trump will again serve as a right-wing standard-bearer on healthcare. Indeed, though he has distanced himself from the Heritage Foundationâs Project 2025 blueprint, his administrationâs actions seem more likely to be guided by this conservative wish listâwhose contributors include numerous members of his last administration, including six cabinet secretariesâthan by his hazy populism. The document calls for sweeping conservative change, including gutting cuts to Medicaid via block grants and lifetime caps on benefits (i.e., kicking people out of the program even if they remain poor) âto disincentivize permanent dependence.â The Center for American Progress estimated that as many as 18.6 million enrollees could be at risk of losing coverage if the latter provision were to become reality. Project 2025 also proposes making privatized Medicare Advantage the âdefault enrollment optionâ for seniors, which would no doubt be the death knell for public Medicare.
Yet if Trumpâs designs seem plain as day, the meaning of a Harris administration for healthcare seems underdetermined. âWe believe in a futureâŠwhere every person has affordable health care,â Harris said at a recent speech, without further details. The partyâs platform has yet to be released, and Harrisâs prior stances on healthcare issues have varied significantly. Her aforementioned cosponsorship of Sandersâs 2017 Medicare for All bill was no small thing; the senatorâs last single-payer bill prior to the 2017 bill was launched with precisely zero cosponsors. But the progressive energies unleashed by his campaign, years of single-payer activism, and the galvanizing effect of Trumpâs ascent to the White House (along with his attack on Obamacare) brought not just Harris but a historic 16 senators on board for the 2017 bill. (Similarly, Representative Pramila Jayapalâs 2019 Medicare for All bill, reintroduced last year, was ultimately cosponsored by two-thirds of House Democrats.) Yet, after endorsing Sandersâs bill, Harris backtracked, putting out her own plan that would give insurance companies a major role in providing universal coverageâan approach many of us criticized at the time for its accommodation of corporate interests. On Wednesday, a Harris spokesperson told NBC News that âThe VP will not push single payer as President.â
Those years were something of a high watermark for M4A: The arrival of the Covid pandemic and the end of the Democratic primaries saw the issueâs prominence fade. But as we look ahead to the November election, itâs critical to realize that the dynamics that drove it to the forefront of the national political discussion are no less pressing today. A Trump administration would cruelly degrade healthcare coverage for the sick and working class, while accelerating the corporate corruption of care. Yet, even without such a regressive shift, US healthcare remains deeply inequitable and under siege from corporate power: The number of uninsured fell during the pandemic but is predicted to rise 32.8 million by 2032; one in four adults go without needed medical care, and one in five without a prescription drug, because they cannot afford it; private equity firms are strip-mining the nationâs hospitals; private insurance companies are gobbling up Medicare; and vertically integrated insurer-pharmacy-provider behemoths like UnitedHealth are increasingly subordinating the healing mission of medicine to their corporate bottom lines.
Harris is no doubt aware of these issues: As attorney general of California, she helped block a merger between two massive insurance giants, and, though she backtracked, her endorsement of Medicare for All demonstrated that she was responsive to the progressive constituencies that mobilized behind it. A Trump victory, make no mistake, would be a deadly disaster for our nationâs healthâand something we must be prepared to fight. But it is important to be clear-eyed about a Harris victory: It will be an opening if and only if a progressive grassroots movement is able, once again, to put real universal healthcare back on center stage.
Dr. Adam Gaffney is a critical care physician and an assistant professor at Harvard Medical School, and past president of Physicians for a National Health Program.