Health care is suddenly front and center in the final run of the presidential election, and the outcome will shape the Affordable Care Act and the coverage it provides to more than one person. 40 million people.

Along with reproductive rights, healthcare has also been an overshadowed issue for much of the campaign. But recent comments by former President Donald Trump and his vice president, Ohio Sen. J.D. Vance, about possible changes to the ACA have opened Republicans up to tighter scrutiny.

Recently, more than 1,500 doctors nationwide published a letter He called on Trump to release details on how he would change the ACA, saying the information was needed so voters could make an informed decision. The letter came from the Committee to Protect Healthcare, a national advocacy group of doctors.

“It is remarkable that fifteen years after the ACA was passed, we are still discussing these fundamental issues,” said Larry Levitt, vice president of health policy for KFF, a nonprofit health information organization that includes KFF Health News. “Democrats want to protect people with pre-existing conditions, which requires money and regulation. Republicans have sought to reduce federal regulation, and the byproduct has been fewer protections.”

The two party tickets have starkly different goals for the ACA, a sweeping law passed under former President Barack Obama that sets minimum benefit standards, makes more people eligible for Medicaid and ensures that consumers with pre-existing conditions cannot be denied health insurance.

Vice President Kamala Harris, who has previously supported a universal healthcare plan, wants to expand and strengthen the healthcare law popularly known as Obamacare. He supports permanent, temporary and increased subsidies that reduce the cost of premiums. He is also expected to pressure Congress to expand Medicaid coverage to more people in the 10 states that have not expanded the program so far.

Trump, who has repeatedly tried and failed to repeal the ACA, said during the presidential debate in September that he had “a concept of a plan” to replace or change the law. Although that brief statement drew some laughs, as he had promised an alternative health insurance plan multiple times during the Trump administration and never delivered, Vance later provided more details.

He said the next Trump administration would deregulate insurance markets; Some health analysts said the change could provide more options but could erode protections for people with pre-existing conditions. The vice president appeared to change his position during the debate, saying the ACA’s protections for preexisting conditions should be left in place.

Sen. Tom Cotton (R-Ark.) says such health policy changes could be advanced as part of a major tax measure in 2025. he told NBC News. This could also open the door to changes in Medicaid. Conservatives have long sought to transform the health insurance program for low-income or disabled people from the current system in which the federal government contributes a formulaic percentage of states’ total Medicaid costs to a program that limits federal spending through block grants or block grants. Financing limits per person. ACA advocates say it would transfer significant costs to the states and force most or all states to abandon expansions of the program over time.

Democrats are trying to turn the comments into a political liability for Trump by running ads from Harris’ campaign saying Trump does not have a healthcare plan to replace the ACA. Harris’ campaign also released a 43-page report: “Trump-Vance ‘Concept’ in Healthcare” claims its rivals will “rip out coverage for people with pre-existing conditions and increase costs for millions.”

When Republicans tried to repeal the ACA in the past, they failed. Instead, the law became more popular, and the risk Republicans posed to preexisting condition protections helped Democrats regain control In Parliament in 2018.

In a KFF survey last winter, two-thirds of the public He said it was very important. Maintaining the law’s prohibition on charging people with health conditions more for health insurance or denying coverage.

“People in this election are focusing on issues that affect their families,” said Robert Blendon, professor emeritus of health policy and political analysis at Harvard. “This could be important if people believe their insurance will be affected by Trump.”

Vance in an interview on NBC’s “Meet the Press” on Sept. 15 I tried to minimize this effect.

“You want to make sure that pre-existing health insurance — the conditions — are covered, you want to make sure that people have access to the doctors they need, and you also want to implement some deregulatory agenda so that people can choose a health care plan that suits them,” he said.

Vance said the best way to ensure everyone has coverage is to encourage more options and not put everyone in the same insurance risk pool.

Risk pools are the basis of insurance. They refer to a group of people who share the burden of healthcare costs.

Enrollees under the ACA are generally in the same pool, regardless of their health status or pre-existing health conditions. This is done to control premium costs for everyone by using the lower costs incurred by healthy participants to control the higher costs incurred by unhealthy participants. Separating sicker people into their own pool could lead to higher costs for people with chronic health conditions, potentially denying them financial access to insurance coverage.

The Harris campaign seized on the threat in its latest report, saying “health insurers will go back to discriminating based on how healthy or unhealthy you are.”

But some ACA critics think there are ways to separate risk pools without weakening coverage.

“Unsurprisingly, it has been blown out of proportion for political purposes,” said Theo Merkel, a former Trump aide who is now a senior research fellow at the Paragon Health Institute, a right-leaning organization that produces health research and market-based policy recommendations. .

Merkel, who is also a senior fellow at the Manhattan Institute, said adding short-term plans to coverage options would not hurt the ACA market and would provide consumers with more affordable options. The Trump administration increased the maximum duration of these plans, then Biden pushed it back to four months.

People who qualify for subsidies will likely purchase comprehensive ACA plans because, with financial assistance, these plans will be affordable. Thus, the ACA market and its protections for pre-existing conditions will continue to operate, Merkel said. But offering short-term plans as well would provide a more affordable option for people who don’t qualify for subsidies and are more likely to purchase incompatible plans.

Also in states where people are allowed to buy Non-ACA-compliant plans Outside of the stock market, exchanges have performed better than states that have banned it. Another option is a reinsurance program similar to the one operating in Alaska, Merkel said. Under the plan, the government reimburses insurance companies for covering very expensive medical claims, which helps keep premiums affordable.

But proponents of the ACA say separating sick and healthy people into separate insurance risk pools would make health insurance unaffordable for people with chronic conditions, and allowing people to buy short-term health plans for longer periods would backfire.

“This leaves people uninsured when they get sick,” said Leslie Dach, executive director of Our Protection, which advocates for the health law. “There’s no reason to do this. It’s irrational and makes no economic sense. They’ll hide behind saying ‘We’re making it better,’ but all of that isn’t true.”

Harris, meanwhile, wants to preserve the temporarily expanded subsidies that helped more people get lower-priced health insurance under the ACA. These expanded subsidies, which have helped nearly 20 million people, will expire at the end of 2025, setting the stage for a tough fight in Congress between Republicans who want to let the subsidies expire and Democrats who say they should be made permanent.

Democrats introduced a bill in September that would make them permanent. One challenge: Congressional Budget Office Doing so is estimated to increase the federal deficit by more than $330 billion over 10 years.

Ultimately, the ability for either candidate to significantly expand or amend the ACA rests with Congress. Polls show Republicans in good position control of the senateThe outcome in Parliament is even more uncertain. But margins will likely be tight. In any case, many initiatives, such as expanding or restricting short-term health plans, could also be advanced through executive orders and regulations, as both Trump and Biden have done.