Health care persists as one of the top concerns for voters as they consider candidates this fall — not just for the presidency but up and down the ballot.

A lot got said at the political conventions in the last two weeks on the topic, and, to their credit, media organizations have engaged in fact-checking and myth-busting  about health-related topics.

But beyond the crafted speeches over four nights for each party and looming past the repeated talking points of the candidates and their hand-picked supporters, voters will confront issues of huge gravity — some well known and others maybe less so.

This blog has covered extensively the Covid-19 pandemic response, and this issue is inescapable with more than 180,000 Americans dead and more than 5.9 million infected — and the toll rising, all but unchecked. The coronavirus has combined with other big challenges to the U.S. health system, including:

Health care needs and the ACA

Which candidate(s) will be prepared to deal best with the resurgence of Americans problems in accessing and affording health insurance, especially as the nation experiences pandemic-related, sky-high, and persistent joblessness that cuts people’s major reliance on workplace coverage?

Because of the Affordable Care Act, millions of Americans have secured in their sudden, new unemployment health policies provided with subsidies and available on Obamacare exchanges. Or they have found shelter for themselves, their families, and especially their children under ACA-expanded Medicaid, the program that provides coverage for the working poor and the poor.

As the economy keeps sputtering and with the pandemic surging and slowing and surging, what will be the sustained plan for Americans’ health coverage?

The Justices and the ACA

The U.S. Supreme Court, a week after the presidential election, will hear arguments from GOP state attorneys general and the Trump Administration as to why Obamacare legally should be ended. Democratic attorneys general will argue against this.

But voters may wish to focus in the campaign season on what politicians say about the preparations that are under way or need to be made for U.S. health care after the high court rules and no matter what the justices decide, likely sometime in 2021.

Glib answers or blithe assurances are unacceptable: 20 million Americans, in a worst-case scenario, might see their health insurance evaporate, while 54 million of us may be exposed anew to insurers’ denials of coverage based on pre-existing conditions or lifetime limits. Parents may not be able to keep young people on their policies until age 26 — which could be a nightmare for a generation seeking to launch itself in a coronavirus-crushed economy.

Republicans in Congress and the White House have campaigned without end for a decade to kill Obamacare. But will they be like the big dogs that chase the trash trucks down the street forever — and suddenly find they have captured their obsession? What next? The GOP has never said, and it has been one of Trump’s giant unfulfilled promises to provide a comprehensive, specific plan to replace the ACA. This matters not just for individuals’ coverage …

Medicaid, Medicare and Financial Gloom

If a saving grace of the ACA’s existence has been its expansion and support of Medicaid, a glum collateral effect of the pandemic may be how it is wreaking havoc on the program’s finances.

Lawmakers and the White House have rushed to rely on Medicaid and Medicare, the social protection program for seniors, as fast, existing ways to address a growing array of Americans health care needs during the pandemic. At the same time, politicians have not grappled for the most part with the tough issue of determining how added demands will be paid for.

Politicians have started to “rob Peter to pay Paul” and to advocate financial sleights-of-hand that do not bode well for the stability and even the sustained existence of these crucial programs. Medicare insolvency has become a giant policy maker worry. The coronavirus’s harms also extend to one more critical program: Social Security.

Seniors at huge risk?

President Trump and his aides have obsessed about delaying or eliminating the payroll tax, arguing — including as part of the re-election campaign — that ordinary, working Americans would benefit by keeping a few more dollars each week in their paychecks.

The downside of this plan? The Social Security Administration itself has said the elimination of the payroll tax would result in disability payments for millions of Americans ending in 2021. The rest of Social Security would halt in 2022 or 2023. The programs, once stopped, would be in such a state that they could not be restarted.

The Republican plan would kill a leading way in which tens of millions of Americans live and stay out of hunger and poverty in their old age. GOP opponents call Social Security, Medicare, and Medicaid “entitlement” programs. But workers contribute to their funding during their lifetime with taxes, notably the payroll levy. While the president and the treasury secretary have slammed the payroll tax, they have not specified how Social Security would be supported without it.

Would Congress, notably Republicans on the Hill, support Trump’s payroll tax attack? Could it survive ferocious opposition from Democrats and advocates for the aged?

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 was an ordeal before the pandemic, driven by the skyrocketing cost, complexity, and uncertainty of treatments and prescription medications, too many of which turn out to be dangerous drugs. Covid-19 has added a significant level of challenge and complexity to U.S. health care, including, yes, causing experts to worry whether our problematic system will stand up to the overwhelming tests tied to this disease.

Americans have gone through a decade of bruising politics over health insurance alone, and it is not the alpha and omega of health care. It is an important way for us to share the risks and costs of the reality that all of us are a blink away from unanticipated illness or injury — including a sudden and desperate need for medical services bankrupting for ourselves or our loved ones. In the wealthiest nation in the world, health care cannot be a privilege and it must be a right. This nation, before the pandemic, spent $3.6 trillion annually on health care, while lagging other western industrialized nations in our health outcomes.

Covid-19 has pounded home for Americans even more the importance of our health care, political leadership, shared commitments and responsibilities for each other, and being informed and wise about facts and evidence in medicine and science. As President Obama emphasized, elections have consequences. Please research carefully and well the competing health policies, and, in a few weeks, cast those votes as if our lives depended on it. Because they will.