Starting this week in Miami, 20 Democrats over the course of two nights will try to make the case that they deserve to be elected President. Now what will they and Republicans have to say about health care, which voters have declared a troubling issue that’s on the top of their minds?

In recent weeks, the current administration and members of the GOP could not have made clearer that Medicaid, Medicare, and, of course, the Affordable Care Act will be major matters to tussle over, still. Is health care a fundamental right or a privilege? Should the government assist the poor, working poor, and middle class with more affordable health care? Plenty of recent developments with federal social safety net programs will give politicians much to talk with voters about, including:

• In Arkansas, a GOP-embraced notion — that the elderly, disabled, chronically ill, and children, as well as others who get health care help through the federal Medicaid program also should  work for their benefits or prove they cannot work — has flopped, as opponents warned it would. Instead, Harvard researchers found that Draconian measures requiring Medicaid recipients to repeatedly prove they could not work, were seeking employment, or had some kind of jobs “caused thousands of poor adults to lose coverage without any evidence the target population gained jobs,” the Kaiser Health News service reported. KHN’s article said, “the Harvard study is the first to provide evidence that the [Medicaid policy] change left [program participants] uninsured and did not promote employment. The results, based on a telephone survey of about 3,000 low-income adults in Arkansas, concluded that the law befuddled enrollees and that its mandatory reporting requirements led many to unnecessarily lose coverage.”
• In Florida, an insurer has been sued by customers who accuse the firm of selling them health coverages that fail to comply with the Affordable Care Act, instead, deceiving them with “skimpy” plans that “left them vulnerable to tens of thousands of dollars in unpaid medical bills,” the New York Times reported. The plaintiffs hope to persuade a federal court to expand this case into a class-action that might include 50,000 policyholders of Health Insurance Innovations, based in Tampa, Fla. As the newspaper noted: “[These] complaints underscore problems with some types of cheaper health insurance alternatives that the Trump administration has expanded. Critics of the government’s decision, including the Association for Community Affiliated Plans and the National Alliance on Mental Illness, are also suing the Trump administration over relaxation of rules for these plans.” As part of its effort to undercut the ACA, Trump and his officials have pushed alternative health plans with lower premiums and far fewer benefits, often skipping over protections for preexisting conditions and preventive services. These policies existed before the ACA, and consumers howled about them because they found when they were sick or injured that they effectively had paid for zero coverage.
• In Nebraska, Washington, Texas, and Ohio, insurance officials are taking complaints about religious organizations where members help pay each other’s medical bills, the Wall Street Journal reported. Participants in these programs say their bills have not gotten paid or they were paid late. These “ministries” aren’t regulated by state insurance commissioners and many have been exempted as religious organizations from insurer oversight. They also, the newspaper reported, “don’t cover pre-existing conditions or preventive services such as checkups and mammograms. They don’t cover abortion and most birth control, and typically don’t share bills for mental-health services or addiction treatment. They may have limits on the total amount that will be paid for any treatment. Millions of dollars are at stake.” Health ministries existed before the ACA but have been encouraged, again, by the Trump administration as an Obamacare alternative. Though patient advocates have warned about the ministries’ slim coverage, the groups deny that members are taking risks by participating and they say the complaints are few compared with the million Americans now covered in them.
• In the name of flexibility and choice, the Trump administration has added to workers’ decision-making complexities with their health insurance by creating for “an estimated 800,000 large and small employers” yet another alphabet-soup saver account “to fund individual coverage through health reimbursement accounts, or HRAs, for more than 11 million workers,” the trade publication Modern Healthcare reported. As the online Vox news site explained: “In short, employers can pay money into their employees’ health reimbursement accounts, and then the workers can take that money and use it to buy insurance on the individual market. Companies can alternatively pay into a different kind of HRA that their workers can then use to pay directly for health care or for a ‘short-term limited duration’ insurance plan that does not have to comply with Obamacare’s rules about preexisting conditions. The regulations do put some important standards in place. For example, employers can’t pick and choose individual workers to provide HRA money to, and they cannot offer the same employees both a traditional employer-sponsored insurance plan and an HRA. But health care policy experts still expect a negative effect on the individual markets set up by the Affordable Care Act. That’s because employers in states where individual coverage is currently available relatively cheaply will have a stronger incentive, particularly if they have a sicker workforce, to offer HRAs. They can spend less on an HRA than they would on offering insurance plans. But if those companies funnel their sicker workers into the ACA markets, then premiums for the Obamacare coverage are going to increase.”

Confused by all this?  You’re not alone.

The Trump administration’s relentless attacks on Obamacare has reversed the positive trend of increased health coverage for more Americans.

As the Commonwealth Fund reported:

“Following three years of steady growth, enrollment on the Affordable Care Act’s marketplaces began to dip in 2017. Recently reported numbers show that trend continued into this year, thanks to a number of headwinds. Along with steep cuts to federal funding for advertising and enrollment assistance, the federal penalty for not complying with the ACA’s individual mandate to purchase health insurance was zeroed out as of January 1. Both policy actions were predicted to reduce the number of people who enroll in marketplace plans. Moreover, the Trump administration adopted rules that increased the availability of products sold outside the regulated individual market. It also proposed a policy that would make it more difficult for immigrants to obtain citizenship if they applied for public benefits, which may have deterred some immigrants from applying for marketplace subsidies. Further, an ongoing court case challenging the constitutionality of the ACA added another layer of confusion onto an already complex health insurance landscape.”

In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent medical care. This has become a daunting challenge due to the soaring cost, complexity, and uncertainty of treatments and prescription medications, too many of which prove to be dangerous drugs.

The nation has been riven for a decade now by partisans who insist that individual Americans, all of us who are a blink away from a catastrophic injury or illness, must buck up and deal with health care concerns mostly on our own. The GOP has ferociously resisted any moves to get the government to help Americans share the risk of staggering costs of health care. Instead, a major accomplishment of the current administration has been a protracted effort to undercut the ACA, even while giving a $1 trillion-plus tax cut to wealthy corporations and the richest few among us. That tax cut has failed to trickle down, and, meantime, Trump and the GOP haven’t delivered on the president’s promise that his would be “the party of health care.”

The ACA is imperfect still and millions could benefit by improvements to it. So what do Democrats have to offer? The 2020 presidential elections will be of keen importance to us all, and here’s hoping we can buckle down, hear the policy proposals, weigh the candidates’ characters, and make a great choice for our uncertain future.