The Health Care Policy Debate That Did Not Happen: A Practical Guide to Improving US Health Care Post 2024 Presidential Election

Am J Manag Care. 2024;30(Spec. No. 13):SP970-SP977. https://doi.org/10.37765/ajmc.2024.89646

The 2024 US presidential election cycle was unique in many ways, including an incumbent president dropping out of the race just months before the election and a former president seeking office after a prior unsuccessful reelection campaign. Throughout American history, election cycles and the corresponding candidates are often remembered not just for the personalities involved but also for the issues debated and the stance taken on these issues. Although the economy generally is at the forefront every 4 years, other key issues such as health care only seem to emerge prominently in particular election cycles. Health care garners significant attention and debate and has proven to be influential in contrasting differences among candidates and ultimately influencing election outcomes. For example, in 1964 President Lyndon B. Johnson defeated Sen Barry Goldwater in a landslide election that focused on a Great Society platform, which included a number of health-related policy priorities such as the eventual establishment of Medicare and Medicaid in addition to investments in health research and capital investments in hospitals and health care treatment facilities.1 In the 1994 presidential election, candidate Bill Clinton made access to affordable health care a major component of his campaign, noting that inflation in health care spending, occurring at multiples of general economic inflation, was “terrorizing American families and businesses and depriving millions of the care they need.”2 Although the Clinton health plan, as it became known, faced formidable postelection challenges to implementation, many credit health care reform as a significant piece of Clinton’s domestic policy platform that aided his victory over incumbent President George H.W. Bush.

The 2008 presidential election between nominees Sen John McCain and Sen Barack Obama set in motion what would be an intense debate through 4 election cycles about health care in the US. Both candidates in 2008 campaigned prominently on the need to fix American health care, with Obama ultimately winning the election and working to pass the Affordable Care Act (ACA) in 2010, widely acknowledged as one of the most broad and sweeping packages of health system reforms in American history. The ACA focused on reducing the number of uninsured individuals by using mandates, government subsidies, and Medicaid expansions, and it included other features such as requiring coverage of preexisting conditions and the creation of new value-based payment models.3 In the 2012, 2016, and 2020 presidential elections that followed, distinct lines were drawn between candidates on the basis of support for the ACA, with Democrats wishing to maintain the ACA and Republican candidates seeking to repeal it, arguing it was too costly and a bastion of big government.

Significant Health Policy Debate Missing in the 2024 Presidential Election Cycle

After many years of significant and intense debate on health care policy, political analysts and journalists alike were struck by the absence of health care as a prominent issue in the 2024 election campaigns of both nominees. Illustrative of this sentiment was an article published by reporter Margot Sanger-Katz on September 13, 2024, in the Upshot section of The New York Times titled “The Campaign Issue That Isn’t: Health Care Reform,” with a subtitle that read, “The topic has been a major concern in presidential elections for decades. Its absence as a top issue now is notable.”4

As editor in chief of Population Health, Equity & Outcomes, I too saw what Sanger-Katz observed, namely that health care policy was going to take a back seat in the 2024 presidential election. Although this puzzled and even bothered me, given the myriad problems and challenges that remain in US health care—high costs for individuals, employers, and taxpayers; significant numbers of uninsured Americans; and lack of timely and equitable access to needed medical care, pharmaceuticals, and behavioral and mental health care—I sought to use the journal as a vehicle for eliciting informed nonpartisan opinion and analysis about practical solutions for addressing these many problems with health care in the US. Even if this well-informed and apolitical analysis might not have catalyzed preelection debate on the issues, I thought these ideas could be useful post election, regardless of the outcome.

So I queried my editorial board, asking each to identify a single or small set of practical solutions that could be feasibly implemented and that, if done, could improve American health care. I asked that these not be focused on specific pieces of legislation currently in consideration in Congress or tied to a particular political party. I also asked my editorial board to not only discuss the merits but also the potential challenges these ideas might face and what practical actions might be needed to implement the ideas. I was pleased by the outcome—original ideas and commentary provided by 11 experts—written in commentary format and in a way that could be understood by those without an MD or a PhD. The authors of these pieces, who are heavily involved in professional careers in some aspect of health care, have varied backgrounds and significant experience, including as trained clinicians, health policy analysts, and those who contract for and manage health insurance benefits or run health care companies such as managed care organizations or accountable care organizations (ACOs). Some board members represent the particular interests of specific groups of patients. The ideas generated from this exercise were both unique and varied, and, as discussed below, they can be further reduced into some common themes. Although not a panacea or an agenda for something as comprehensive as the ACA, collectively these ideas shed light on where health policy and health care spending are falling short and where some concrete ideas—what one might call basic blocking and tackling—could go a long way to making a difference for many Americans in terms of physical and mental health and well-being, including economic well-being.

Each of the commentaries can be found online at ajmc.com/pheo-policy, and so my goal is not to repeat their content but instead to attempt to summarize succinctly in a way that might be useful for the Trump administration, for those elected and serving in Congress, for leaders in state government, and for the many Americans who work in and on health care on a daily basis. All of them have the ability to effectuate change, including much-needed innovative thinking and action to attain the elusive value for health care dollars spent. The remainder of this article summarizes some key themes emerging from these independent commentaries while pointing readers to the details provided in the specific articles when more nuance and a more in-depth understanding might be valuable.

It’s the Economy, Stupid—But Health Care Is Nearly 20% of the US Economy!

Not surprisingly, what seems to have mattered a lot to voters in the 2024 election was the economy, driven largely by significant inflationary pressures in consumer prices, as well as other key areas such as interest rates, housing stock shortages, and tax policy and government spending. Less discussed was the relationship of the health care sector to the overall economy. This is complicated because although every dollar spent in health care represents an expense to someone, it also represents income to someone else, and, as Segel writes, organizations and individuals don’t give up income easily.5 Yet in many sectors of the economy, high prices, inefficient production, subpar quality, and waste are generally not allowed to perpetuate because these things get competed away by more efficient producers in an economy where there are limited barriers to entry. And although the US health care system brings many positives for many patients, few would argue that it is a sector of the economy that is a beacon of efficient production. Here is where the opportunity lies and where, in some cases, simple solutions could make a big difference. For example, Jain suggests moving physician and nonphysician licensure away from states to a national licensure system.6 Doing so would allow patients to maintain relationships with their preferred providers across state lines and take advantage of technological platforms that allow for such care delivery when appropriate. It can also smooth the significant labor shortages and surpluses that occur across geographies. Authors Jain,6 Broome,7 Muhlestein,8 and Balkrishnan9 each argue that annual insurance enrollment (rather than multiyear enrollment) not only drives up wasteful administrative costs but also prevents useful and productive longer-term investments that insurance companies and providers could make if they were assured of longer-term member or patient relationships. Young and Isaacs talk about the potential for artificial intelligence (AI) to serve as a complement to the health labor workforce, both to assist with the significant shortage of qualified and trained health professionals in the US (eg, doctors, nurses, physician assistants, behavioral health therapists) and to solve care access delays by thinking about how to incorporate the power of AI into workflows and throughput so as to manage workload burdens while also reducing wait times.10

And if the goal of the health care sector is to produce health, Staloff and Marcotte point out that the US significantly underinvests in primary care, which offers one of the biggest returns on investment, if not to individuals, at least to society.11 Finally, Scanlon and Sciegaj note that health is not just produced by doctors, drugs, devices, and procedures but is also related to social determinants of health (SDOH).12 We know this, but we lack sound evidence for how investments in SDOH can lead to more efficient health production, and our public and private accounting systems often don’t factor such investments and spending into the equation to paint a comprehensive economic picture. In sum, because the health sector is such a large component of the overall economy, logic would suggest that economic improvement requires a significant focus on the health care sector. As outlined above, a number of authors provide suggestions for where the health focus should be.

Get the Government Out of My Health Care

The outcomes of the 2024 election seem to suggest that many voters wanted to send a message about “getting the government out of my everything”—any objective thinker would infer from the results that a large part of the electorate was delivering an indictment on big government. The challenge in health care is that the government is—and has been—involved in health care to a significant extent, and although certain rhetoric might suggest otherwise, removing government from certain types of health care programming (and spending), such as Medicare, is often described as the political third rail. This is the challenge because many Americans seem to like and value government health programs such as Medicare and specific aspects of the ACA, including the removal of preexisting condition limits. In addition, 19% of insured Americans have coverage through Medicaid, a federal-state program funded with tax dollars, which pays for 41% of annual childbirths.13 Health care professionals must meet state licensure requirements, and federal and state antitrust agencies are supposed to protect consumers from anticompetitive practices that jack up prices for consumers. The popularity of many government-run health programs does not always match the rhetoric of removing government from health care. This might suggest that a more productive discussion would be the goal of right-sizing government involvement in health care and making it the most efficient it can be.

There are ideological divides, of course, and opinions at the extremes, but if we acknowledge that removing government entirely from health care is likely a nonstarter, there are a number of concrete suggestions that could be considered. For example, Broome7 and Jain6 each discuss how the government reimburses for care in Medicare Advantage, traditional Medicare, and ACO programs, including related issues such as methods for risk-adjusting payments based on the health needs of beneficiaries. Each describes concrete and practical suggestions for improvements. Similarly, Bright discusses the burgeoning industry of quality measurement, which on the one hand is necessary for understanding what health benefits are produced from dollars spent, but on the other hand has seemed to grow exponentially while failing to take appropriate account of what matters most to patients.14

With respect to regulation, Berger points out that the formulary, originally developed as a tool to make sure patients had appropriate access to health-enhancing drug therapies, has become a weapon used against patients by those looking to perpetuate opaque accounting systems used to extract additional margins from patients and source-payers, creating layers of questionable administrative bureaucracy that in the worst case delay access to important pharmacological therapies for patients who need them.15 Many point to the federal government and its antitrust authorities needing to more strongly enforce antitrust protections, and there is also significant discussion of allowing the federal government to more aggressively negotiate drug prices and discounts. There are other options for government action as well, but the take-home message might be that the will of the population may be more about right-sizing government involvement in health care and seeking efficiencies that could make a positive difference for many Americans, rather than eliminating government involvement altogether.

Short-Term Thinking—and Incentives—Don’t Solve Complex Long-Term Problems

Complex problems can’t be solved with simple solutions, and simple solutions generally don’t have a lasting long-term impact. Many authors discussed the need for both long-term thinking and incentives that will promote solutions that last. For example, Jain,6 Broome,7 Balkrishnan,9 and Staloff and Marcotte,11 among other authors, discuss how status quo health system operational decisions, such as payment methods, annual insurance enrollment, or even research investments, often serve to promote short- vs long-term thinking, and by doing so often miss opportunities for prioritizing population health needs.

For example, Broome describes challenges with ACO attribution and payment models that don’t promote long-term population health management approaches.7 In his article, he discusses how payment incentives promote short-term thinking and short-term relationships rather than longer-term investments, which would be more likely to yield measurable changes in population health outcomes. Bright makes a similar argument regarding quality measures, suggesting the focus on process measures rather than patient outcomes creates more of a short-term than a long-term focus.14 Sherman and Tobb discuss the importance of trust in health care, including the trend of declining trust in health providers, and note that this is a dynamic concept that improves as parties have more experience with each other.16 Scanlon and Sciegaj emphasize that long-term thinking is also necessary when considering investments in SDOH, with a recognition that such investments, while having the potential to yield a return on investment for society, often take time to materialize.12

Maybe We Should Consider Designing a Health Care System “by the Patient and for the Patient”

Are you likely to hire or do business again with a contractor or firm that lost your trust during a prior transaction? Not if you can help it! As Sherman and Tobb describe, trust in health care organizations and health care providers has reached an all-time low.16 These trust issues span multiple professional and transactional levels. Providers don’t trust the health systems that have acquired them and for whom they now work; patients don’t always trust providers because they don’t have enough time to get to know them more deeply other than for the purpose of rendering a diagnosis or making a referral; and there is no love lost between health care providers and insurers that pay for care and government programs that set reimbursement rates. We created this system of increasing distrust, and as a result, we are seeing provider burnout and more early retirements, resulting in less joy in the practice of medicine and more challenging workforce shortage issues.

Whereas other industries have advanced in terms of adopting user-friendly and efficient solutions, health care has done so at a glacially slow pace, far behind the pace seen in other industries. Many would say this system is not at all designed for the end user, which is both the patient and the customer. With full awareness of the complexities health care professionals face in their careers, even positive incremental change can be effectuated by stepping back and considering the goals and concerns of the end user in health care. Bright mentions this in her commentary, where she describes the need to prioritize the concern of the end user—patient-centered health outcomes—over process and layers of associated regulation, limited transparency, and bureaucracy that often simply exist to maintain the status quo.14 Balkrishnan supports this point of view, emphasizing that health care in the US is too complex, too costly, and fraught with waste and inefficiency, and ultimately it does not meet the needs or the expectations of the end user. 9

Unpacking the Absence of Strong ACA Talk in the 2024 Presidential Election

As mentioned above, the 2024 presidential election was unique in that repeal of the ACA was not the dominant point of health policy discussion. Although the topics of women’s health and abortion did receive significant attention, many other health policy matters, such as the ones discussed by authors of these editorials, received little attention. That was a surprise to many, so the question is, what to make of it? This is conjecture, of course, but here are some thoughts. First, health care is expensive. There is perhaps no better statistic to demonstrate this than KFF’s recent reporting that the cost of a family health insurance policy now exceeds, on average, $25,000 per year. This prompted Drew Altman, PhD, president and CEO of KFF, to say in an October 2024 news release, “Employers are shelling out the equivalent of buying an economy car for every worker every year to pay for family coverage.”17 The cost of and inflation in health care may have been implicit in the broader discussion of inflation and the economy, so one should not infer that a lack of discussion of the high cost of care reflects a lack of concern for the issue. Similarly, the lack of serious discussion about repealing the ACA should not be viewed as a ringing endorsement that it has addressed all of health care’s problems. Evidence of this is that we still have more than 25 million uninsured Americans (down from approximately 45 million in 2010),18 high rates of medical debt,19 and an increasing portion of household income going toward health care costs.20 At the end of the day, the relatively little air time health reform received in the pre-election stage may simply reflect the lack of a clear turnkey solution, including no “free lunches” as Segel suggests,5 which should further motivate creative and innovative thinking about potential solutions. This may also signal that there is neither a ringing endorsement nor a complete rejection of government involvement in health care, but rather a desire to seek efficiencies in the areas where government is involved, such as within Medicare.

Don’t Blind Ourselves With Science

Several authors make important suggestions about the roles of research and science in helping to improve and inform the creation of a more efficient and better health care system. For example, Staloff and Marcotte discuss the extremely small proportion of overall research funding allocated annually by the National Institutes of Health that goes toward primary care, despite the widespread belief that some of the most impactful changes that could be made to improve health in the US and avoid some long-term costs would fall in this area.11 They call for a primary care moonshot, similar in magnitude to the cancer moonshot effort, with the argument that more experimentation bearing more data will yield significant dividends in terms of both population health and likely also budgets.

Similarly, Young and Isaacs discuss the need to develop research and knowledge about AI so that this technology can be harnessed for purposes of improving health and generating production efficiencies while avoiding the significant concerns society has about data privacy, ethics, the potential for discrimination among population subsegments, and other challenges, often too simplistically labeled as hallucinations in the AI space.10 For those who have not been paying attention, science and research are under attack right now by many in the US, with questions ranging from topics studied, value of funds used for studies, and the practical utility of the research products. Certainly, many in the scientific community feel this is a problem because, in theory at least, decisions can be more optimally made when informed by sound evidence. Perhaps the narrative and nomenclature should be flipped in favor of the phrase research and development, which is not only accepted and used in business but also is well supported as a way to advance innovation and entrepreneurship. That is exactly what authors such as Young and Isaacs,10 Staloff and Marcotte,11 and Scanlon and Sciegaj12 are talking about—namely how to promote productive innovation and efficiencies and improve processes and outcomes for patients, providers, and taxpayers by using the scientific principles of research and development to improve health care. So perhaps we don’t get blinded by the term science to the point where it prevents improvements and advances in an industry that consumes 20% of each dollar spent in the US economy.

Just Like Letterman, Sometimes We Need a Top 10 List

Former late-night host David Letterman was known for his top 10 lists—a pithy way to interject comedic relief while highlighting the key points about the topic at hand. Without suggesting that improvements in American health care are a laughing matter, Jain provided his own top 10 list of things that could be done, somewhat practically, to address the major flaws in our current system, which include high costs, access problems, inequitable care on many dimensions, and avoidable as well as premature mortality.6 Some of the items on Jain’s list overlap issues raised by other authors, such as the administrative complexity and inefficiencies that come from annual insurance enrollment. Other items on Jain’s list reflect a consensus regarding where America has clearly fallen behind other industrialized countries despite outspending those countries by multiples. For example, Jain discusses the US’ dismal performance in maternal mortality rates, which rose by 40% between 2021 and 2020 and disproportionately impacts some minority groups. Other ideas include employing and deploying community health workers to provide assistance, which can potentially supplement shortages of higher-trained providers. There are multiple options that could be prioritized and implemented in reasonably timely fashion, and that don’t have to be as divisive as major policy reforms seem to be. The key is to put together a list of top priorities—perhaps 10—and then develop an action and implementation plan.

Parting Thoughts

As many of our contributors note, none of these ideas is likely to solve the American health care conundrum alone. Instead, the diverse perspectives represented here offer starting points for the incoming administration and, likely, future administrations. Just as importantly, they highlight focus areas for experts, policy makers, and advocates alike to continue exploring with the end goal of creating a better system for all.

AcknowledgmentS

The author would like to thank Matthew Crager for excellent research and editorial assistance and Tess Wilson for editorial assistance.

Author Information

Dr Scanlon is Distinguished Professor of Health Policy and Administration at The Pennsylvania State University in University Park and the editor in chief of Population Health, Equity & Outcomes.

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