When American voters are asked to name their top issues in this year’s election, they say health care second only to the economy. And with good reason — despite spending the most on health care, the United States has the shortest life expectancy, the highest rates of avoidable deaths, and the highest health care costs of any country.
Voters understand that policy changes made by the next administration and Congress will profoundly impact our health care system, shaping its affordability, access, and equity.
Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System — a new report from the Commonwealth Fund — reveals that the U.S. consistently ranks last among 10 nations on key measures of health equity, access to care, and outcomes. This is in largely because millions of Americans face significant barriers getting and affording health care. The U.S. is the only nation in the study without universal health coverage. Despite gains made by the Affordable Care Act, 26 million Americans are uninsured and nearly a quarter of all working-age Americans cannot afford their health care and are considered underinsured.
Patients in the U.S. are also more likely to lack a regular doctor or place of care compared to people in other countries. The Netherlands, the United Kingdom, and Germany insure everyone and prioritize primary care at affordable costs, though the U.K. faces challenges with wait times and austerity measures that have compromised care. The U.S. and New Zealand rank lowest in health equity; many people with lower incomes are unable to afford care and experience discrimination.
Poverty, homelessness, hunger, discrimination, gun violence, and substance use further strain the U.S. health system. Other countries address these social needs more effectively, investing more in housing, reducing childhood poverty, and preventing hunger and food scarcity. This reduces the burden on their health systems and budgets and contributes to health and well-being.
This news is bleak, but there is good news for Americans. First, policy matters. Policies that expand access to health care and improve affordability and equity have been shown to make a significant impact on people’s health, financial security, and longevity. Second, other countries have achieved these goals; the U.S. can too. Other countries prove it is possible to have a health care system that works — one that insures everyone and supports chronic disease prevention, early diagnosis and treatment, affordable access, and cost containment. Finally, it is an election year. Voters have an opportunity to make their voices heard.
The candidates for president in 2024 represent two different directions for health care. We can look to the records of both candidates and imagine the direction health policy is likely to move under a Harris or Trump administration.
When he was in office, former President Trump’s approach focused on reducing federal involvement and costs in health care through deregulation and funding cuts, while Vice President Harris and the Biden administration have emphasized expanding health care coverage and protections with a focus on equity and affordability. Trump aimed to repeal and replace the Affordable Care Act (ACA), which would have left more than 24 million Americans without health insurance. The Biden–Harris administration expanded ACA subsidies and fixed the “family glitch” to improve access to health insurance. The administration also encouraged states to expand Medicaid to cover more people and increased funding for housing and nutrition supports, while the Trump administration limited federal spending and eligibility for Medicaid, proposing block grants and work requirements. Regarding women’s health, Trump restricted access to maternal care and family planning services, appointing three Supreme Court Justices who overturned Roe v. Wade, while Harris and Biden have advocated for protecting and expanding access to women’s health services, including abortion.
Mirror, Mirror and other research shows that policies that expand access, improve affordability, and reduce health inequities will likely improve the performance of the U.S. health system. Policies designed to diminish or repeal health insurance access could widen the access and affordability gap, weakening the health system and undermining the health of millions. Policies to restrict a woman’s ability to access the full continuum of health services would likely worsen our already poor maternal health outcomes, further exacerbating inequities faced by low-income, Black, Latino, and Indigenous people, women, and those who live in rural areas.
The outcome of the 2024 election is uncertain, but some things are sure: the United States is failing to protect the health and welfare of its residents, it is possible to do better, and policies can and do have a real impact on the lives of everyday Americans. In November, voters have an opportunity to consider these certainties — and the health and health care of their families and communities — and it has never been more essential that they do so.
