The US presidential campaign has been spectacularly re-energised by Kamala Harris’s candidature but voters’ election priorities haven’t changed. Economic worries are their overriding concern; protecting democracy comes in at second place. Despite warnings about how a second Trump presidency would reshape America, it’s feared that voters might prioritise the health of their finances over the health of their democracy.
One of the factors compounding household economic stresses — and an area of strength for the Democrats — is the cost of healthcare. A tracking poll conducted for the health policy organisation KFF earlier this year showed healthcare topping the list of basic expenses Americans worry about, ahead of petrol, food and rent. Despite more than 90 per cent of the population having some form of health insurance, medical debt remains a persistent problem.
The United States spends more on healthcare than any other developed nation, yet it has lower life expectancy than in comparable countries and the highest maternal and infant mortality rates. Racial and ethnic disparities continue to influence the quality of care and access to services. With 90 per cent of the nation’s $4.5 trillion in annual healthcare spending going to people with chronic and mental health conditions, coordinated interventions to prevent and manage these diseases could have significant health and economic benefits and improve worker productivity.
And that’s not to mention the health, social and economic costs of gun violence, the opioid crisis and the conservative right’s success in reducing abortion access and women’s reproductive freedoms.
How would Democratic candidate Kamala Harris and Republican candidate Donald Trump tackle these issues? And what is driving their approaches, policies and commitments? So far, the information from both sides has focused on ideology and slogans rather than policy specifics. The KFF has pulled together a detailed comparative analysis of what is known to date about the two presidential candidates’ positions on healthcare, but more revealing is the record of both presidential tickets and what has so far been promised on the campaign trail.
Although Harris hasn’t yet laid out her policy agenda, she has said that she plans to deliver a policy platform focusing on the economy in this coming week. Specific issues seen as key to her campaign’s success are also likely be discussed during the Democratic National Convention later this month.
Harris inherits and is likely to build on Joe Biden’s healthcare agenda. Biden’s presidency was shaped by huge health-related decisions, including mass vaccinations against Covid-19 and scaled up testing; a revival of the “cancer moonshot” he spearheaded as vice president; steps to close the gender gap in medical research; executive orders to protect abortion access after the Supreme Court overturned Roe v Wade; Medicaid demonstration waivers to allow the states to expand health insurance coverage; allowing Medicare to negotiate drug prices; and limiting the cost of insulin.
Despite Republican opposition, Biden has come closer than any American president to the elusive goal of universal health coverage, building on the provisions of the Affordable Care Act — better known as Obamacare — which is now more popular and more used than ever. In 2024, 92.3 per cent of the US population, or 316 million people, have some form of insurance coverage.
Harris says her views on healthcare were shaped by her mother, cancer researcher Shyamala Gopalan, who died of colon cancer in 2009. As attorney-general of California she focused on the impact of large-scale of healthcare company mergers and clashed with major insurers, hospitals and drug companies. She isn’t afraid to aggressively use anti-trust laws to resist companies’ anti-competitive behaviour. More recently she has cemented herself as the Democrats’ foremost advocate of abortion rights.
If he’s elected vice-president, Tim Walz will undoubtedly be an active player on health, healthcare and the social determinants of health, including school food programs, schoolgirls’ access to period products, gun control, access to IVF services and gay rights. His stand on these issues is influenced by his father’s death of cancer when Walz was nineteen, leaving his mother drowning in medical debt. As governor, he signed legislation banning medical providers from withholding medically necessary care because of unpaid debt and banned the transfer of medical debt to a patient’s spouse.
Walz was a strong supporter of veterans’ benefits legislation while he was in the House of Representatives, where he also backed legislation to regulate tobacco products. He has spoken out in favour of protecting access to fertility treatments, citing his family’s struggle with infertility.
For some health policy experts, Walz is seen as a pragmatic healthcare champion; for others — those who focus on the state laws he signed making abortion a fundamental right in Minnesota, ensuring medical care for transgender people and legalising marijuana — his record is anything but moderate. On healthcare, his policies align with Harris’s. From abortion rights to healthcare affordability to medical debt, he has sought to do at the state level what Harris aims to accomplish federally.
Pinning down the Trump–Vance healthcare goals is much harder. Of the twenty core promises on Trump’s website, the only one that directly refers to health is a pledge to “fight for and protect social security and Medicare with no cuts, including no changes to the retirement age.” Other than that, what Trump and Vance say varies from day to day, depending on whether they are talking to campaign audiences or television interviewers.
Trump seems aware that the traditional Republican opposition to surgical and medical abortion, fertility treatments, medical services for transgender people, the Affordable Care Act, and adequate spending on Medicare and Medicaid programs is seen as threatening by many voters, even his own supporters. On these, he has endlessly prevaricated, and even unilaterally changed the Republican Party platform. So far, nothing he’s said or done is likely to convince undecided voters, despite leaving him at odds with his party’s very conservative, mostly evangelical, right wing.
Trump has predicted (wrongly, most political analysts would say) that abortion is “going to be a very small issue” in this election. “I think the abortion issue has been taken down many notches,” he said during a news conference at Mar-a-Lago. “I don’t think it’s a big factor anymore.” He has refused to answer when asked if he would direct the Food and Drug Administration to revoke access to mifepristone, a medication used for abortions. And he won’t say how he will vote on a proposed Florida state constitutional amendment that would overturn the state’s six-week abortion ban, although he has predicted the vote on it would wind up in a more “liberal way.”
This is not an issue Vance has dared to bring up during his speeches in five battleground states. When asked in a TV interview about women in red states who are unable to abort non-viable pregnancies, he simply responded: “What President Trump has said is we are gonna let voters make these decisions.”
Trump has said he will not support cuts to Medicare and Medicaid, although he has said he would cut waste and fraud in those programs — a popular euphemism for funding cuts. He made a similar promise eight years ago yet his administration’s 2020 budget proposal cut Medicaid by $1.5 trillion and Medicare by $845 billion.
Rather than repealing the Affordable Care Act, Trump is now promising to make it “much better, stronger and far less expensive” if he wins in November. That’s a promise he was unable to deliver on in his previous term. The popularity of the Obama-era healthcare law makes this a fraught issue for Republicans, especially as most of the big increases in enrolments have been in red states including West Virginia, Louisiana, Ohio, Indiana and Texas.
A frequent feature of Trump’s campaign speeches is his commitment to “not to give one penny to any school that has a vaccine mandate.” This statement ignores the fact that every state in the nation has vaccination requirements for children to attend school. It also ignores a recent report from the US Centers for Disease Control and Prevention showing that routine childhood vaccinations have prevented approximately 508 million cases of illness, thirty-two million hospitalisations and more than a million deaths since 1994.
Both Trump and Vance have engaged in vicious attacks on the lesbian, gay, bisexual, transgender and queer community and those who would provide their healthcare. Human rights organisations widely criticised the Trump administration as one of the least friendly to these communities; more recently they have called out Vance for his “cruel record.” This level of discrimination and rolling back of rights would continue under a second Trump presidency.
Much has been made of the Heritage Foundation’s Project 2025 program, which includes chilling plans for the Department of Health and Human Services and its associated agencies. With this blueprint having become an effective focus of attack for Democrats, Trump has sought to distance himself from the document and its authors. His claim that he has no idea who is behind Project 2025 has been thoroughly debunked, and his efforts were further undermined when news came that Vance has written the introduction to a book by Heritage Foundation president Kevin Roberts, chief author of Project 2025.
Just over eighty days remain until the election. In that time Harris and Walz must build on their honeymoon start and define themselves and their policy priorities. The signs so far are encouraging — one poll, for the Financial Times, even has Trump trailing on the economy for the first time — but more effort will be needed to consolidate gains and win over critics, sceptics and those not currently paying attention.
Harris and Walz must overcome President Biden’s difficulty in communicating the economic and health benefits delivered by the current administration. In particular, they must deal with the economic and healthcare disparities and insecurities experienced by many communities, especially people of colour. They must explain how healthcare funding (properly targeted) is an investment in the nation’s future and the economy. Above all, they must build trust with voters that they can deliver on these commitments in a timely and equitable fashion. •
