On November 3, American voters will choose the next leader of the USA, and with it the future health prospects of its citizens. The US election comes at a precarious time; the COVID-19 pandemic has claimed over 200 000 American lives, disproportionately affecting minorities and the socioeconomically disadvantaged, and deepening the country's already yawning healthcare and economic divide. The Affordable Care Act (ACA)—Barack Obama's signature healthcare legislation—hangs in the balance, with the constitutionality of the law's individual coverage mandate in the hands of a Supreme Court now devoid of the staunch social justice advocate Ruth Bader Ginsberg. For all US citizens—but particularly for the most vulnerable—the stakes could hardly be higher.
The USA has many dubious distinctions when it comes to healthcare. Among other high-income countries in the Organisation for Economic Co-operation and Development (OECD), it spends the most on healthcare (around 17% of GDP), yet has the worst healthcare outcomes; it also has fewest practicing physicians on a per-population basis. For the roughly 91 million US adults living with chronic rheumatic conditions, for example, the burden of disease substantially exceeds specialist capacity, with only 5600 board-certified rheumatologists in active practice. Many of these are clustered in metropolitan areas, meaning that access for patients in more rural areas is particularly challenging. What's more, the ongoing COVID-19 pandemic is threatening the viability of private rheumatology practices across the USA; in a recent survey, 75% of rheumatologists said their practices could survive 4 months or less in the current financial climate.
The incoming president will preside over legislation that could help to relieve such workforce shortfalls, including the recent Healthcare Workforce Resilience Act, a bipartisan bill introduced in response to COVID-19 that calls for the reallocation of 40 000 unused green cards to foreign-born doctors and nurses. Whether this bill will be supported by President Trump, who has taken a notoriously anti-immigration stance and whose policies will have reduced legal immigration by half between 2017 and 2021, is unclear.
Cost of care is an ongoing concern to patients with rheumatic diseases—life-long diseases characterised by long-term pain and substantial disability. Patients in the US already have higher out-of-pocket healthcare expenses than those in most other countries, and targeted drugs for rheumatic and musculoskeletal diseases are among the most expensive on the market. Indeed, in a US survey of patients with rheumatoid arthritis, the most commonly reported barrier to achieving treatment success was the cost of treatment.
Looking for relief from high drug costs, patients with rheumatic diseases might be buoyed by Trump's repeated promises to stand up to pharmaceutical companies and reduce drug costs by up to 70%. Unfortunately, however, the reality has fallen far short of the rhetoric; consumer prices for prescription drugs increased by 3% in 2019, after a modest 0·6% decline in 2018. In fact, list prices for targeted rheumatoid arthritis drugs increased by 160% between 2010 and 2019, outpacing savings to consumers achieved by the ACA's closure of a Medicare coverage gap.
But perhaps the most prominent health-related concern around the US elections is the fate of the ACA, which Trump has vowed to dismantle since he took office in 2017, and which former Vice President Joe Biden vows to preserve and expand if elected. Should the Supreme Court rule the individual mandate unconstitutional—a strong possibility if Trump succeeds in a pre-election Supreme Court appointment to fill Ginsberg's seat—many fear that the ACA as a whole will become untenable. If this occurs, an estimated 20 million Americans will lose their insurance coverage, and the benefits gained as a result of the ACA—including increased access to care, reduced medical debt, improved health outcomes, and a narrowing of health inequities—will be reversed. Once again, the impact would be disproportionately felt by minorities, with the most dramatic loss of coverage among Black and Hispanic people. On the backdrop of the ongoing COVID-19 crisis, which itself has rendered 40 million Americans jobless, the results would be devastating.
Amid the chaos of the first Presidential debate, Biden at least managed to communicate a genuine concern for the welfare of the American people and promised a measured, science-driven approach to the continued fight against COVID-19—a clear contrast to Trump's political abandonment of the country's most vulnerable populations and frequent attacks on science.
When US voters head to the polls next month, we hope they make a choice for better, more equitable health.
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