A myriad of issues are in the forefront of the 2024 Presidential election. The economy, immigration, national security, and reproductive rights have been put forth as the key concerns in the upcoming election. Where is health care on this list? We hear that insulin is $35 per month for retirees and prescription drugs are too expensive. Anything else? Not that I’m hearing.

The Affordable Care Act (ACA) aka Obamacare will be ten years old in 2024. According to a 2023 study done by the Kaiser Family Foundation, 90% of self-identified Democrats approve of the ACA, while 70% of self-identified Republicans disapprove of it. Originally, the ACA was designed to regulate insurers so that they provide better coverage for more Americans including those with preexisting conditions, require all Americans, especially healthy ones, to purchase health insurance to spread out the risk, and help low-income people to afford health insurance through subsidies and Medicaid expansion. In 2017, however, the Tax Cuts and Jobs Act eliminated tax penalties for people who didn’t buy health insurance. The Act became effective in 2019, so it is too early to really gauge the impact of it on the provisions of the ACA, i.e. fewer healthy people to offset the cost of covering people with preexisting conditions.

Some aspects of the ACA are working as expected. More young adults have coverage; they can remain on their parents’ health insurance until age 26. More preventative costs are covered, or the cost may be significantly reduced. Anyone can get some form of health insurance through a health insurance marketplace. The ACA is working in the way it would be expected to work.

While in broad brush strokes the ACA has been a success, getting into the weeds of health insurance coverage may expose some frailties in the actual system. The cost of covering everyone regardless of a preexisting condition with fewer healthy individuals enrolling becomes a burden on the insurance companies and results in smaller networks of providers and higher premiums for participants. Depending on where you live, finding doctors within a network can be a challenge.  With respect to prescriptions, It is difficult to put a label on what constitutes better drug coverage; it really depends on what medications are needed for a particular illness or condition.

Evaluating the impact of the 900-page Affordable Care Act would be a considerable endeavor. To say no work needs to be done on our health care system would be comical. But so far, there have been no concrete health care plans proposed by any Presidential candidates, whether Democrat, Republican or any other party. It is the 800 pound elephant in the room that no one wants to tackle.