The candidates focused more on bumper sticker sloganeering on costs and access until recently. Harris — and Biden, before he withdrew from the race in July — emphasizes reproductive care and drug prices, while Trump and Sen. JD Vance (Ohio), the GOP vice presidential nominee, mostly deliver generic attacks against the ACA.
The stakes are high for health insurance companies, providers and patients. A Harris victory would mostly maintain the status quo, including a low uninsured rate, billions in tax credit subsidies that drive enrollment and stronger oversight of healthcare companies, while a Trump win could lead to rollbacks in Medicaid and the health insurance exchanges and to laxer federal regulation.
Harris plans
Of the two candidates, Harris has been more transparent about her intentions for the healthcare system, whereas Trump conceded during a debate last month that he has only "concepts of a plan" nearly a decade after entering electoral politics, including four years as the president. That created an opening for Harris and brought the issues to the fore.
"Vice President Harris will continue to support the current administration's policies," Susan Feigin Harris, co-head of healthcare at Norton Rose Fulbright, said during a roundtable discussion her law firm hosted Sept. 22.
As president, Harris would make a major push to renew the enhanced subsidies for low- and middle-income health insurance exchange enrollees that are due to expire at the end of 2025 and likely attempt a fresh effort to reduce the uninsured, especially in the 10 states that did not expand Medicaid eligibility under the ACA.
The Harris campaign has also touted her support for expanding the Medicare prescription drug price negotiations program that debuted under Biden, capping insulin costs at $35 a month and out-of-pocket spending on prescription medicines at $2,000 a year for everyone, as Biden did for Medicare beneficiaries, and relieving medical debt.
Generally, Republicans oppose such policies on ideological grounds and note that they carry large price tags taxpayers would have to cover.
Trump plans
Since the Harris-Trump debate, the former president has provided little in the way of clarification on his intentions. But Vance has elaborated somewhat on what Trump's concepts may be during rally speeches, interviews and his debate on Tuesday against Minnesota Gov. Tim Walz, the Democratic vice presidential nominee.
For example, Vance appeared on NBC News' "Meet the Press" on Sept. 15, and suggested Trump would revive policies from his first term such as lower-quality, short-term health insurance policies and association health plans, as well as shift people with preexisting conditions into high-risk insurance pools.
Health policy analysts and Democrats quickly pointed out that such initiatives haven't worked in the past and tend to disadvantage people with preexisting conditions. The Harris campaign released a 43-page document harshly criticizing high-risk pools and other healthcare proposals from the controversial Project 2025 plan created by Trump allies including former officials from his administration.
During the debate Tuesday, Vance demurred on the broader question of Trump's health agenda, saying a detailed plan "wouldn't actually mean anything" because Congress would assert its priorities.
Vance said his points about insurance pools were more about a flexibility from the ACA itself that allows states to create alternative coverage programs, so long as they achieve the same outcomes as the exchanges and expanded Medicaid. During the Trump administration, several states employed these so-called section 1332 waivers to create reinsurance plans that reduced the impact of high-cost patients on insurance pools.
"The reinsurance regulations is what I was talking about," Vance said Tuesday.
With Trump mostly mum and Vance downplaying some of his own comments, Trump's record as president offers a guide to what he might do if he takes office again. Biden undid most of Trump's healthcare policies but Trump could restore them from the White House.
In addition to efforts to repeal the ACA, which would have led to more than 20 million people losing coverage, Trump took numerous steps to weaken the law. His administration set up parallel markets for cheaper, less comprehensive insurance such as short-term, limited-duration plans, slashed financial support for enrollment counselors, withheld billions of dollars owed to insurance companies covering the lowest-income exchange customers, allowed states to create work requirements for Medicaid beneficiaries and proposed capping Medicaid budgets via block grants.
Trump wouldn't even pursue ACA repeal if he wins, and congressional Republicans have no interest in reopening debates on matters such as high-risk pools, predicted Jennifer Young, a partner at the lobbying firm Tarplin, Downs & Young.
"I think we will continue to have the operation of the status quo, with his focus being instead on things like what happens next with the ACA," Young said during a briefing hosted by the health policy research institution KFF on Tuesday.
"Republicans have been quietly content for the last couple years to see the conversation move elsewhere," said Young, who was an assistant secretary at the Health and Human Services Department under President George W. Bush. "If JD Vance had not said what he had said, would we have been having this conversation as Republicans? No."
Congressional complications
Any policy pushes, however, are complicated by Congress, and who controls it, and by other demands facing the legislature.
In 2025, Congress will confront not just the enhanced exchange subsidies that Democrats want to extend, but the expiration of the tax cuts Trump enacted in 2017, which Republicans want to renew. Another federal debt ceiling fight also looms.
For the most part, Democrats and Republicans are on opposite sides of those issues, making the outcomes easier to predict if one party takes both the House and Senate. Under a divided Congress, the prospects are murkier.
If Republicans sweep, extending the exchange subsidies is not likely and the GOP may even seek to limit eligibility for financial assistance and reestablish Medicaid work requirements, which federal courts and Biden ended. If Democrats win both chambers and Harris is in the White House, renewing the exchange tax credits and possibly expanding coverage will be top priorities.
There are scenarios under a split Congress where Harris would at least get to retain the enhanced exchange tax credit subsidies in exchange for Democratic support of some Trump-era tax cuts, said Chris Jennings, founder of the lobbying firm Jennings Policy Strategies and a former White House adviser under President Bill Clinton.
"There's no situation or dynamic that I know of that a Democratic administration would leave that negotiation table without significantly extending those tax credits," Jennings said during the KFF briefing.
Although Republicans may oppose the ACA and continuing the bigger subsidies, voters feel more warmly about the law than when Trump took office in 2017 — and the GOP is eager to advance the tax policy they support, Jennings said.
"The Republicans have a great desire to extend tax cuts for significant numbers of people, and I have a feeling that this would get more thrown into the tax debate," Jennings said.