Health Policy Issues on the Ballot

The 2024 elections will be among the most consequential in American history, as voters grapple with profound policy differences on everything from the economy to foreign policy, climate change, and, of course, health care. 

This episode of the Princeton Pulse Podcast unpacks the health policy issues at play. Host Heather Howard, a professor at Princeton University and former New Jersey Commissioner of Health, is joined by Joanne Kenen, a contributing editor to Politico Magazine, and journalist in residence at the Johns Hopkins Bloomberg School of Public Health and the Institute for Policy Studies at the Johns Hopkins School of Nursing.

Kenen is a leading health care journalist and trenchant observer at the intersection of health care policy and politics. Over the course of her career, she has covered implementation of the Affordable Care Act (ACA), the Covid-19 pandemic, and much more.  

Howard and Kenen discuss how the upcoming election could impact the health and wellbeing of millions of Americans. They address reproductive health care, the fate of the ACA, prescription drug costs, Medicare, and broader questions on the future of Medicaid and our health care safety net.  

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Read KFF Election Coverage  (KFF is an independent health policy organization.)

Read one of Kenen’s most recent articles for Politico. 

Read other articles about health policy and the upcoming election:
Health Is on the Ballot in the Presidential Election  (JAMA)
History Repeats—The Election Battle for Medicaid in 2024  (JAMA)

The Princeton Pulse Podcast is a production of Princeton University's Center for Health and Wellbeing (CHW). The show is hosted by Heather Howard, a professor at Princeton University and former New Jersey Commissioner of Health and Senior Services, produced by Aimee Bronfeld, and edited by Alex Brownstein. You can subscribe to The Princeton Pulse Podcast on Apple Podcasts, Spotify, or wherever you enjoy your favorite podcasts.

Transcript

Episode #15: Health Policy Issues on the Ballot 

SPEAKERS
Joanne Kenen, Heather Howard

Heather Howard  00:02
Hi and welcome to the Princeton Pulse Podcast. I'm Heather Howard, professor at Princeton University and former New Jersey Commissioner of Health and Senior Services. On campus and beyond, I've dedicated my career to advancing public health. That's why I'm excited to host this podcast and shine a light on the valuable connections between health research and policy.  

Our show will bring together scholars, policymakers and other leaders to discuss today's most pressing health policy issues, domestically and globally. We'll highlight novel research at Princeton, along with partnerships aimed at improving public health and reducing health disparities. I hope you'll listen in as we put our fingers on the pulse and examine the power and possibilities of evidence-informed health policy.  

Welcome. The 2024 elections will be among the most consequential in American history as voters grapple with profound policy differences on everything from the economy to foreign policy, climate change and, of course, health care.  

On today's episode, we'll unpack the health policy issues at play with Joanne Kenen, a contributing editor to Politico Magazine and journalist in residence at the Johns Hopkins Bloomberg School of Public Health and the Institute for Policy Studies at the Johns Hopkins School of Nursing. Joanne is a leading health care journalist and trenchant observer of the intersection of health care policy and politics. Over the course of her career, she has reported on implementation of the Affordable Care Act, the Covid-19 pandemic, and so much more.  

Joanne joins me today from her office in Maryland to discuss how the upcoming election could impact the health and wellbeing of millions of Americans. We'll cover everything from reproductive health care to the fate of the ACA, prescription drug costs, and broader questions on the future of our health care safety net and global health. Welcome to the show, Joanne. 

Joanne Kenen  01:57
Hello, Heather. Thank you for having me so

Heather Howard  01:59
Great to have you here. Well, as I mentioned, we know there are profound differences between the candidates on many issues, but for purposes of this discussion, should we think about this as a health care election?

Joanne Kenen 02:12
In terms of reproductive rights and abortion? Obviously, yes, it is one of the motivating forces in this election. In terms of health care as we've traditionally thought about it, in the political context of cost coverage, the role of government, how much money should we spend, the state government versus the federal government, all those issues that we've been fighting about for decade -- Medicare, Medicaid, the entitlements… these issues have usually been dominant, or often the top domestic policy issue in an election, year after year after year. This year? No. In terms of reproductive health, yes, it's a health care election. In terms of that whole big, messy, brimming over bucket of 20% of the economy and $4 trillion and all of our lives, no, it's not. It's not nonexistent, but it's not dominant.

Heather Howard  03:00
And by that, I think I'm hearing you just say that it's not the most salient issue in the discourse.  

Joanne Kenen 03:05
For voters. It's baked into your political identity, right? If you're a Democrat, you think certain things. If you're a Republican, you think other things. But this is not the motivating "am I voting for Trump, or am I voting for Kamala Harris, or am I voting?" It is not dominant. It is already baked into our political identities, but it is not what's getting people to the polls. It is not what is getting people all riled up compared to pretty much every other election I've ever covered, going back to the 90s.

Heather Howard  03:37
But you're not saying that there won't be significant consequences for health care. It's just not what we're talking about as much.

Joanne Kenen 03:44
It is not a top tier issue in the election, but it will be a top tier issue in the coming year. No matter who was elected, there are several huge... am I allowed to say humongous... issues involving health care. One of the big ones is the future of the ACA subsidies. President Biden extended the subsidies, made them go up the income ladder. More middle class people are getting subsidized if they're in Obamacare, or the Affordable Care Coverage exchanges, if they're getting insurance through the ACA. Those expire next, about a year from now, and Congress has to decide if they are going to extend them or not. The Republicans tend to think that it's too generous, that too many people are getting them, that it's too high into the middle class. Democrats are going to want to extend them. I will say that once you've given a benefit, it is really, really hard to take it away. It's not unprecedented, but it is extremely rare. Once people get used to some kind of health benefit or other social benefit, it's very hard for Congress to say, "Whoops, we're taking that one away."  

Heather Howard  05:02
I have some estimates here. So you're talking about the premium tax credits. In the Biden administration, in the American Rescue Plan and the Inflation Reduction Act, they were basically expanded, right? They were made more generous to make health care more affordable.  

Joanne Kenen 05:15
More people became eligible, because you could have a higher income and still get subsidized.  

Heather Howard  05:21
I've seen estimates that 4 million people could lose health insurance, could become uninsured, and premiums could go up by 25 to 100% if these aren't extended. So if that's the case, if that's a looming threat to the ACA, why didn't we hear about that from Vice President Harris in the debate? 

Joanne Kenen  05:41
Good question. I mean, we didn't hear about everything in an hour and a half. We didn't hear about education. We didn't hear about a bunch of other things. We didn't hear that much about the tax fight, either. I would be surprised if we don't see more campaign ads, if we don't see her talking about it. It is a pocketbook issue. And you know, as President Obama said when he was speaking at the Democratic National Convention a couple weeks ago, they don't call it Obamacare anymore, now that it's popular. And it is popular, even Republicans say. They're talking about tweaking things. All health care programs, all federal health care programs, go through changes. Some of them go through changes every single year, and some of them are sort of more of a technical nature. They don't want to end up on the front pages. People don't always understand it all. They're constantly changing. Something that was created in 1965 looks really, really different in 2024, and it should, right? So you'll see the ACA go through changes, and you'll see Republicans trying to shrink it a bit, or sort of flip it in certain ways. I would be really surprised if we see another huge attempt at repeal, because that didn't go very well for the Republicans. 

Heather Howard  07:02
In fact, you know, President Trump's response to a question about the ACA was pretty jumbled in the debate, right? He first claimed that he saved it. Then, when asked if he had a plan to replace it, he said he had concepts of a plan. So what did you make of it? I mean, is this just evidence that he's scrambling, because it's really hard to figure out how to move on from the ACA? 

Joanne Kenen  07:29
It's now part of American health care. It is part of not just how people get covered. We have coverage at very, very historically low insurance rates. It's something like seven and a half percent. It's low. It's very low. Remember, before the ACA, it was like 18 or 19%. It was very high. It's baked in now. I'm not saying it's immune to change. If there's a Republican Senate and a Republican House and a Republican White House, some of those changes, even though Democrats would still have power to block things in the Senate, some changes would probably happen. But I would be stunned if there was a whole dismembering of it, because too many people get their insurance that way. And providers get a lot of income this way. Providers would rather treat insured people than uninsured people because they are much more likely to get paid. So, there are a lot of things in the ACA that sort of don't register for the general public, but agencies and programs in terms of sort of changing health care and making it more quality rather than quantity driven. Value-based care. A lot of this stuff is driven by programs within the ACA. The big, humongous part of it that we all think about is coverage. It actually did a lot of other things to try to steer health care toward an overhaul, in terms of how chronic diseases are treated and managed, etc. It's not a done deal. We haven't succeeded in cracking how to improve every aspect of American health care, by any means. But there are tools within the ACA that the general public isn't that cognizant of, that the health care world is.

Heather Howard  09:13
Yeah, I was struck recently when Senator Lankford of Oklahoma, a conservative, said, "We have health care now." It's not just Obamacare, it's health care. This has been in place now for a decade. You're not going to be able to just pull out everything that was there. So it sounds like that is consistent with what you're saying. It's fairly baked into the social policy fabric. You may have a Harris administration leaning in to strengthen it, and a Trump administration leaning out, but you don't see it going away. 

Joanne Kenen  09:38
I don't see it going away. I do think there will be a fight about the subsidies in Congress this year. It'll probably get wrapped into larger spending issues. There are not too many things in Congress that are freestanding bills, because they're not very good at getting things done. And therefore, they hit these deadlines, and they throw all these unfinished things into this big, ugly legislative package, and there's lots of horse trade. You know, I get this, and you get that. That's when it works. I get this, and you get that. When it doesn't work, nothing happens. And, you know, we're, yet again, facing the possibility of a government shutdown. There'll be some kind of a patch. I don't think it'll shut down in two weeks, but it's not really a great way to govern. But that's the way we've been doing it for years because Congress is so divided. Last year, there were two big spending bills. Despite all the partisanship, we have had bipartisan deals, which are the old-fashioned "you get this, I get that, I don't get everything, you don't get everything." But we function. So even though we're in this era of intense partisanship -- many people have argued it's the most intense since the Civil War reconstruction, some things have been done. We're not in a very copacetic place as a country, but some old-fashioned, bipartisan budget and appropriations work has been done in the last year.

Heather Howard  10:58
Let's pivot to if it's not a health care election, though reproductive rights are the salient health care issue. Let's situate our listeners. Since the Dobbs decision in 2022, when the Supreme Court overturned Roe v. Wade and ended the right to abortion, we've seen 14 states enact total bans, and 27 states have partial bans. By many estimates, one in three women now live in states where abortion is banned or mostly banned. Do you think we're looking at a national ban if Trump is elected?

Joanne Kenen  11:33
The Republicans would need 60 votes in the Senate to get that through. I have trouble seeing that. There's one obscure thing called reconciliation, where you get a budget bill, and people put all sorts of stuff that isn't budget in there. I think it's hard to get something as controversial and not really a budget issue through. I mean, you can argue [that a national ban] is a budget issue by really stretching it. But under normal rules, you need 60 votes to get something through the Senate, because everything is filibustered. Even if the Republicans win the Senate, which is widely anticipated at this point, that the Senate will flip, the anticipations is that it's 51/52 -- nowhere near a 60 vote Senate. Something extraordinary would have to happen in the next six or seven weeks for us to be talking about a 60 vote Senate. Plus there are a couple of Republicans, such as Susan Collins and Lisa Murkowski, who are not going to agree. The Republicans probably won't have 50 votes, let alone 60. So the idea is, would Trump sign a ban? And we've gotten really mixed signals about that. He's saying lately that he wouldn't. He's saying that it should be up to the states. He's saying everybody wanted Roe to go away because everybody wanted it to go to the states, which was sort of a stretch. It's not what people wanted. I mean, some people wanted it, but it certainly wasn't what most of the country wanted, on either side. The anti-abortion people want a national ban, and the pro-abortion people want national access. Nobody wanted this. I mean, I'm sure some individuals did, but it was not the choice of either side. 

Heather Howard  13:09
But couldn't a national ban on abortion be imposed without Congress, through enforcement of the Compstock Act?

Joanne Kenen 13:25
It would be hard. It would end up in court. This court is obviously, clearly anti-abortion, but they also chose to turn it to the states when they ruled two years ago. There are people who want to get the Compstock Act repealed in the next six months before a Republican Senate might take over. That's tough, too. It's approximately a 100-year-old law.

Heather Howard  13:57
It's a 19th century act that bans the mailing or shipping of obscene materials, including instruments used in terminating pregnancies. So arguably, it could be used to ban abortion by banning the mailing of abortion medication, even materials and surgical materials being used and shipped across state lines, right? 

Joanne Kenen
The obstetricians use those [materials] in situations that have nothing to do with abortion. So it would be hard. It would be an extreme move to try to do. There are people in the anti-abortion movement who want to do it. I don't think it is seen as the most likely scenario because it could also affect non-abortion [interventions]. There are interpretations that say they would also affect contraception, access to birth control. It's quite a can of worms. Could it happen? Yeah. It's impossible to know what Trump wants on abortion, because he's not consistent on his policy statements, to say it in a fairly gentle way. Sometimes in the course of the same rally he says more than one thing. He has currently been saying he wouldn't sign an abortion ban, that he wants it to be up to the states. We don't really know. There's also Republicans who want something less than a total ban, people who want it restricted, people who are basically in the anti-abortion camp but want fewer restrictions, who do want it available in the case of rape, incest, health of the mother. There's a big fight over health of the mother versus life of the mother. Where do you draw that line? What starts out as a health problem could become a life problem that's not treated, as we're seeing. And you know how Kamala Harris talked about that in the debate... bleeding out in the parking lot.  

Heather Howard  15:53
That struck me. Is this the first time we've seen a candidate for national office so passionately defend abortion rights as health care? Did that strike you as different?

Joanne Kenen 16:07
It's really different because Hillary Clinton is very pro-abortion rights, but remember her signature phrase was "safe, legal and rare." And Kamala Harris is just saying "safe and legal"." It doesn't mean she wouldn't personally want it to be rare. She's not coming out and saying, "let's all have abortions instead of contraception." She's not saying that. She's just saying that this is health care, that women's lives are threatened. 

There's a piece that came out about half an hour ago. I didn't read it all, I just read the first few paragraphs, but there do seem to be a few documented deaths now of women who really didn't get the care they need, women with other children. I haven't read it all the way through yet, so I don't really want to say more than that about it. But there are situations where wanted, planned pregnancies can go bad, and they can go bad in all sorts of ways. Miscarriages are way more common than people realize, until they're having one. And they can be life-threatening, horrible situations that can kill a pregnant person or can hurt her future fertility. So there's that issue, and that's what Kamala Harris is highlighting, that these extreme bans have actually endangered some women's lives and their future fertility. And we've heard them speak. We've heard some of these women come forward. We heard them at the DNC, at the Democratic convention. We heard three really striking stories. Most abortions are not because of life-threatening situations. Most abortions are, in fact, first trimester elective abortions. The description of these ninth month abortions, or Trump talking about abortion after birth [are not accurate]. By definition, that's not abortion, that's infanticide. That is illegal, and it doesn't happen. They're very, very rare. There was one horrendous situation in Philadelphia, 10 or 12 years ago -- I might be getting the number of years wrong -- where that had happened and the guy was prosecuted for murder. Under our Criminal Code, abortion is a different thing than infanticide. Infanticide is illegal. There are people whose religious beliefs say that an embryo or a fetus is child; you're killing a child in their view. But in terms of our legal system, they're separate. 

Heather Howard  18:34
We talked about returning this issue to the states. Another interesting trend in this area we've seen is that every state, thus far, in which the decision has gone to the voters, has affirmed a right to abortion, including states like Ohio, Kansas and Kentucky, really conservative states. By my count, there are 10 ballot initiatives this fall to enshrine abortion rights in state constitutions. What are you looking for in those state votes?

Joanne Kenen  19:05
There's been a lot of litigation around the language and the way they're presented. The courts have ruled, and these are conservative states, their state courts have tended to rule with some of the caveats in language that the conservative, anti-abortion groups have wanted, but not 100%. I think, was it Missouri, in which it was knocked off the ballot then put back on. It's hard to remember all 10 states, but I'm pretty sure that was it. Most or all of them will get over 50% of the vote. In some cases, that's not enough. Florida requires 60%. They've all won, including the states you mentioned, like Kansas. I don't think any of them have gotten over 60%. That's steep. It's not really anticipated that Florida will get over 60%. It is possible, because knowing that the threshold is so high may be a turnout issue, and they may get there. It's not widely seen as what's expected. What's expected in Florida is over 50, less than 60, meaning it "wins," but it doesn't go into law. 

Heather Howard  20:18
Then Florida's six-week abortion ban stays on the books.  

Joanne Kenen 20:21
Yeah, but there's going to be litigation. I mean, we're not going to stop this. The post Roe era is an era that we're going to have ongoing litigation, ongoing politics. The intensity is on the other side. During the years between Roe in' 73 and falling in '22, the intensity was on the opponent, the political organizing intensity was on the anti-abortion group, because they were the outs. Something was the law that they didn't like, and they were trying to change it. Now you see the intensity factors changed, right? One could argue that the pro-abortion rights people were way too sanguine about the threat, because we saw abortion rights chipped away. We saw access chipped away, beaten. Chipped is too mild a word. We saw access restricted in many states. A lot of abortion clinics closed. Women had to travel miles. In some of the conservative states, there was only one part-time abortion provider in some areas. So access had already been already been limited through the political process, but it still was the law of the land. Now it is not the law of the land everywhere, and the intensity is obviously on the pro-choice, pro-abortion rights, Democratic side. And that's why you had a lot of races. You had Kamala Harris talking about it. It's going to bring voters. It's a turnout issue. If you think something that you value is on the ballot, you're more likely to turn out than if you think it's safe. And Democrats had not turned abortion voters to the extent that they are now, because they thought it was safe. The Supreme Court had ruled 50 years ago. And they didn't think it was going to go away. And they were wrong. 

Heather Howard  22:12
And you note the irony that some of the Supreme Court justices wrote that in returning this issue to the states, they hoped it would stay out of the courts. In fact, it's been the opposite. There's been more litigation, right? But also, when you look back at the Dobbs decision, one strand I want to get your take on is that some of the more conservative justices hinted at questioning broader rights. In overturning Roe v. Wade, they weren't just overturning the right to abortion, perhaps they were planning in the future to go after other rights that have similar bases, including the right to contraception. Do you see that now being the political discourse, too? 

Joanne Kenen  23:03
There was a lot of talk about how states and the federal government would try to ban contraception. We have not seen that to date. I would be surprised if there was a push to ban all contraception. There are some methods of birth control that anti-abortion groups call de facto abortion methods, certain IUDs, the "morning after pill," which the FDA has actually changed the label to say this is not causing abortion. I think you could see efforts to ban certain contraceptives. Most Republicans, even in Congress, don't have 12 kids. People practice birth control. I would be surprised to see an effort to ban all contraception. I think you could see targeted attacks on specific drugs. I've been surprised that we haven't seen more about the so called "morning after pill." I thought we'd see more of that. The fact that we haven't seen more of that doesn't mean we wouldn't in two more years. But it wasn't most of the Supreme Court justices. In fact, some of them wrote the opposite. This is only about abortion. This is not about contraception. I think it was Clarence Thomas on birth control, and I can't remember whether Alito joined him on that. 

Heather Howard  24:18
And marriage equality, right? 

Joanne Kenen  24:20
Right. It was marriage equality. But I can't remember whether Alito joined both of those. 

Heather Howard  24:25
Is it possible that Democrats going on offense on IVF has blunted some of that? That's taken up a lot of oxygen, right?  

Joanne Kenen 24:34
Trump said he's very "for fertility." On that debate, he was the fertility guy. Many, many babies have been born through IVF. Many people, including Mike Pence, have had children because of IVF. There are many conservative Christians, Pence being the sublime example, who use IVF, who believe it's a gift if you want kids and can't have them any other way. We all know people who had kids that way, and we all know kids who were born that way. There's a movement, which just a few years ago was seen as fringe, the fringe of the fringe, that is now part of mainstream Republican politics, which is the personhood movement. [It embraces the notion] that as soon as there's fertilization, when there's two little cells, that is a person. There's a human being with all the same rights as anybody who's outside the womb, what we all would agree is a full human. The movement to grant personhood to an embryo from the earliest stages of its development puts IVF in the crosshairs. The Republicans are trying to find their way on this because they sort of want to be pro-IVF, but also pro-person. You can't be both. 

Heather Howard  26:04
So I want to switch gears and talk about health care costs. You said that this is not a health care election, it's an economy and inflation election, right?  

Joanne Kenen  26:13
Health care costs are part of that. Not as much talk about that as there is about groceries, though. What are you hearing about? You're hearing about groceries. I don't know quite why that is. It might be that we've just been talking about health care costs and we've given up on bringing them down. It might be that the grocery costs over the last two years have been really acute, and you're hit with them all the time. You're hit with grocery costs every time you walk into a supermarket, whereas you're only hit with health care costs when you get sick. So that might be part of it. Also, the Biden administration has made gains, a little. They haven't solved the problem. But they have made some gains on drug costs, including protecting seniors. Medicare recipients are going to have an out-of-pocket cap of $2,000. Two thousand dollars is a lot of money, but lower income people get extra assistance. So the people who really can't afford it will get [assistance] through the Medicare Drug Act, and the people who are on both Medicare and Medicaid get extra assistance. Two thousand dollars is manageable, maybe not liked, but manageable. Many American families are now paying more than that. So even if seniors complain about the $2,000, if they were paying $4,000 or $6,000 or $10,000 or $15,000 or $20,000, it is going to bring them relief.

Heather Howard  27:35
So you expect Vice President Harris to lean into the progress they've made on prescription drugs, and talk about expanding that? 

Joanne Kenen 27:42
Insulin is sort the poster child of affordable drugs, the $35 insulin for Medicare. They're talking about looking at ways of making it $35 for everybody else. Trump was also for $35 insulin. It's a little harder for them. I mean, they can fight about who reaches more people. But remember Trump at the very beginning of his presidency, the first couple of days, he started talking about bringing down drug prices, and he actually put out a like 45-point plan of ways that you could possibly bring down drug prices. I was the editor overseeing all the health care coverage of Politico and I do remember one time that reporters were going through this list of 40-odd suggestions and counting the number of question marks. And maybe it was more. Maybe it was 44 question marks in 60-something ideas; it was three or four pages of potential ideas. So Trump had claimed lower drug costs as a priority. It didn't happen under him. Under Biden, there's been some gains. Drug costs are still high, but everything is high. I mean, more people are insured, right? The ACA... we've already talked about how more people are insured. More people are getting help. Insurance is more affordable for many people, not for everybody, but insurance is more affordable for people who couldn't have it before. It's still expensive, but health care itself is expensive. Remember that most people are not on the ACA. There are more people on Medicare, more people on Medicaid, more people are getting covered through their job or a family member's job, and it's expensive, and there are high deductibles, and there's things that are out of out-of-network, and there's a lot of problems with American health care that we have not fixed. Cost is the driver right now. We've made huge gains in coverage. Seven and a half percent is a low insurance rate for our country. It's not low enough, but it is low. But health care inflation, you know, a $25,000 cost, even if it's split between your employer and you, that's money that you're not getting in wages. If your employer is paying $18,000 for your health care, it's not coming into your pocket in the form of wages and other benefits.

Heather Howard  29:55
You're smart to remind us that we've made tremendous progress on reducing the rates of uninsured, but even as more people have health insurance, people still struggle with costs. We have people who are underinsured. 

Joanne Kenen  30:07
Less than we used to do, but we still do. 

Heather Howard  30:10
And medical debt is a problem. And that's one thing Vice President Harris has talked about, medical debt. That's a topic we've covered on an earlier episode of the Princeton Pulse Podcast. Do you think we'll hear her talking more about medical debt? Is that an area of policy innovation? We talked about Medicare in a couple ways. Is there anything else we should be on the lookout for in terms of Medicare from either Trump or Harris? Or do you think it's off the table? You know, in terms of, it's not going to be subject to cuts. 

Joanne Kenen  30:25
I think that we will hear her talking about how specific she's going to get about medical debt. Some of it [has been addressed]. It's not showing up in your credit reports. You still have the debt, but it's not running your economic credit report. I think that she's going to talk about health care costs. It does not look like there's going to be another debate. I mean, who knows? It could change 20 times in the half an hour you and I are talking. At this point, it looks like there's not another presidential debate. There is a vice presidential debate. I do think that you will hear her talking about the need to continue to bring down health care costs. But also, you know, the Democrats are a little vulnerable because they haven't. Health care costs are still a problem, despite the ACA. I think she'll talk about wanting to do more. I don't know if she's doing any town halls. We haven't seen a lot of that yet in this campaign, and we might not see it. If you did have a town hall, I'd be surprised if you didn't hear health care costs because it's such a huge pocketbook issue. But I think, like right now, partly because of what I said before, you see the cost of groceries every time you go into a supermarket. You see the cost of gas, which has actually come down, every time you go to a gas station. And you see the health care costs when you get sick.  

Even before Paul Ryan became house speaker, what sort of drove him to prominence in the Republican Party, on the House side, was his efforts to, or his advocacy for really significant changes to Medicare. They didn't like the word voucher system. The Republicans got mad if you used that, but it was basically a voucher system. Republicans have stopped talking for now about huge structural changes to Medicare or Social Security. We're not hearing that. Trump has said in both of his campaigns, all three of his campaigns, that he's not going to go after Medicare or Social Security. It doesn't mean there won't be some changes or things around the edges, which always happens. What he has not said is that he has not vowed to protect Medicaid. He has not said that he won't touch Medicaid. So Medicaid is really big. It's hundreds of millions of dollars, and that's if you're paying for tax cuts, or you're doing other social programs, or you do, like Republicans have stopped talking about, deficit reduction. But if they wake up in the middle of the night and say, "We just had a deficit nightmare. We need to do something," then Medicaid is a pot of money. The other thing you've seen in Medicaid is that the program has changed tremendously since it's since its creation in 1965, arguably even more than Medicare has changed. The public perception, and there's data on this from the Kaiser Family, now called KFF. They do a lot of polling on health care, and they have found that the public perception of Medicaid has changed. The country used to think of it as a welfare program, and therefore it had less support. Now they think of it as a health care program, which means it has more support, even close to half of Republicans describe it as a health care program. That shift from welfare to health gives it a lot more political sustainability. It gives it a lot more political support. It becomes harder for Trump or any the House Republicans or the Senate, whoever. It becomes harder to do a big raid on Medicaid. 

Ever since the Reagan years, we've also been hearing about block granting Medicaid or turning it into a per capita cap, which is sort of a variant of a block grant. It was the Reagan years. So, do the math. In 40 or 40-something years, it hasn't ever happened. And I think there's a "careful for what you wish for." The Republican governors get a lot of -- not just Republican governors -- states get a lot of federal money from Medicaid. The federal government pays for most of Medicaid. Do they really want less money? It's not clear to me that they really want what they say they want. And we also haven't been hearing about that as much in the last couple of years.

Heather Howard  34:57
Well, you transitioned so nicely and smoothly between Medicare and Medicaid. We should remind people, Medicaid is the largest public health program. Eighty-one million people are covered by it now, so more than Medicare and more than the ACA marketplaces. It's the largest, accounting for $600 billion in federal spending. So what I hear you saying, Joanne, is that it's at risk, in part, because it's not being talked about and because there is so much money there. It's the largest public health care program that covers low-income people.  

Joanne Kenen 35:32
That covers a lot of births. It covers a lot of newborn babies. It covers a lot of pregnant women. Supposedly, one of our priorities right now as a country is reducing maternal mortality and reducing the racial disparities in maternal mortality, and Medicaid is a key player in that. The other thing about Medicaid is that it's a huge source of coverage for mental health and for addiction treatment, and long-term care. It is the single biggest payer, I believe. The last time I looked at the numbers -- I haven't looked recently -- but it has historically been the biggest source of long-term care, both in a nursing home and home setting, what they call home- and community-based care. Most people who are older or disabled, who have needs, do prefer to stay home if they can, rather than being institutionalized. These services are all paid by Medicaid. If you go back to the ACA, and the final that dramatic vote in the Senate, when John McCain put thumbs down, one of his reasons [for voting no] was that he thought it would hurt Arizona Medicaid. The other thing... and our listeners don't know this, but I recently guest taught in one of Heather's class, and I showed a picture. Do your listeners remember the "littlest lobbyists"? They were the families of disabled kids who were lobbying to preserve the ACA, and they were very effective. I mean, how could they not be? How can you look at these adorable children, smiling, asking for their health care to be preserved? These were disabled kids, all races, all income brackets. If you have a disabled kid, your bills are amazing. So Medicaid is less vulnerable. I was trying to find a story the other night, and I couldn't find it.  

Heather Howard  37:23
If you look at Project 2025, there's some pretty ambitious proposals in there that would dramatically cut Medicaid.  

Joanne Kenen 
Yes, but it doesn't mean they get through Congress, and it doesn't mean the governors really want them. And there's dramatic proposals in there for pretty much anything, including the FDA and the CDC and the ACA. Yes, the Heritage Foundation does not like Medicaid. They never liked it. There wasn't a project 2020, per se, but they would issue briefs and position papers. They wanted to block grant and shrink Medicaid. That's a given. If Trump wins with a Republican House, with a Republican Senate -- and the House is still up in the air -- we don't know. At this point the prognosticators are predicting a narrow Republican Senate. Are there people going to try to cut Medicaid? Yes, I would anticipate attempts to cut Medicaid. Would there be attempts to restructure Medicaid? Quite possibly, there are a few influential senators who want to do that. Would it happen? That's a lot less certain. You're not going to have a 60 vote Senate. 

Heather Howard 
Yeah, thank you. You're reminding us that Medicaid is in a lot stronger position than it was.

Joanne Kenen  38:39
Shockingly. It was really the weak sister, to have the least constituency. It was considered a welfare program. And our country does not love welfare programs or people who benefit from them, and because it is the funder of last resort for long-term care. I mean, if your grandma ran out of her money paying for her Alzheimer's care in her nursing home, which is very expensive, and she didn't have any more money... or your grandpa, or whatever relative who needs long-term care. The private insurance market for long-term care is ridiculously expensive and dysfunctional. Most of us do not get it at work, so Medicaid ends up paying. And everybody who has a grandma or a grandpa or anybody else who needs long-term care, is thankful for Medicaid. It's not that people don't spend down their assets to get it. They do. I mean, if you want to talk about health care costs and broken things that are still in our system, long-term care is definitely one of them. But that's what we've got, and people don't want to see that chipped away. There are people who are on Medicaid briefly, right after they lose their job, because Medicaid expansion under the ACA made that possible. Before, if you were an able-bodied person who lost their job, chances are, depending on your family circumstances, you'd just be uninsured. Medicaid has become a backup for the unemployed kid getting out of college, or the [young adult] who is still under 26 but can't get under their parents plan for whatever reason. There are kids who are getting out of college who are on Medicaid, or getting out of graduate school on Medicaid, or even probably some out of high school who don't have their first job yet. Most kids under 26 can be on their parents' plan, but there are exceptions, depending on how your parent get their insurance. So Medicaid isn't just for poor, lazy people. It's for any American who needs it, with the exception of the 10 states that haven't yet expanded it, and they still have a coverage gap. 

Heather Howard  40:41
So it's a vital and vibrant program, and that's providing political security for it. It's reaching more people, right?  

Joanne Kenen  40:47
In some cases, you're on it temporarily. It's the same for the ACA. For a lot of people, the ACA is a stopgap. You're on it between jobs. You're on it while you try to start your business and can't quite afford coverage yet. If some people are going to be on it for years, the individual market has traditionally been a stopgap. It's for the person who needs it until they get a job that offers coverage, or for people in their 60s who get laid off and it's hard to get another job, but they're not old enough for Medicare yet. Before the ACA, a lot of the uninsured were people who were 62 or 63 and had pre-existing conditions. Insurance was exorbitantly expensive. They couldn't get it, and they were uninsured in their 60s, a very vulnerable time, just counting the days until they turned 65 and could get Medicare. Again, it's not that most people are going to be in the ACA. People who are self-employed, like a solo practitioner, an architect or whatever, or a two-person firm, they may be on the ACA long-term. But for a lot of people, the ACA is used between jobs or while they're in school or starting up a new business, until they start making more money. It's not the one they’re going to be on for their whole life.  

Heather Howard  41:58
So before I let you go, I have one more question. I wanted to make sure we touched on global health. People may be familiar with PEPFAR, the President's Emergency Plan for AIDS Relief, which was the U.S. government's global HIV response, enacted in 2003 by President George W. Bush. It's been this amazing example of bipartisan support and commitment to global health. By some estimates, it saved 25 million lives. Yet this year, when it came up for reauthorization in Congress, it was the subject of immense partisan fights. It was only extended for one year. What is this? What's its fate? And what does this say, more broadly, about global health and political support for it?

Joanne Kenen  42:42
Well, I think it's the strain within Republicanism today that is isolationist, and that is not the entire party, but there's clearly a large isolationist chunk of the Republican Party. I think that anti-PEPFAR is part of that. You know, we're going to take care of Iran. We don't care about that. I think some people probably don't really understand its history. It actually had the support of American evangelicals working in Africa. It had support of the Bush administration. George Bush did this. Bill Frist was part of explaining it to Bush. He was a physician who was also a senator, and then Senate Majority Leader, Senate Republican leader. It was a Republican initiative. The Democrats embraced it and cheered, and it's been phenomenally effective. As you said, it affected an estimated 25 million lives, and it's not even that expensive. These drugs are no longer that expensive. Twenty-five million lives sounds like a lot, but actually people are still dying of AIDS, still getting infected, and we still don't have a vaccine, as we all know. It is still a scourge. It's been quite shocking for people to see the turn against PEPFAR, because it's cost-effective, and it saves lives. It saves lives of children. It saves lives of babies. It saves lives of adults. It saves lives of poor people. It was a boon. Diplomatically, it made America look good. Here we are helping these poor African countries fight AIDS and HIV, yet it became this toxic hot potato, became something that almost didn't get through for a year. It almost didn't even survive for a year. So I would expect to see another fight there. 

Remember that global health became politicized like everything else during the pandemic. There's a difference between criticizing aspects of the WHO's bureaucracy, decision-making, and communication -- whether the WHO could be better or do its job better, or needs some changes -- versus turning it into a villain, into something that is our enemy. So our international collaboration, cooperation on global health in general, has deteriorated during and since the pandemic. The isolationism is spilling into global health, with PEPFAR being the poster child for that. So I think that these two things, this politicization of public health, the politicization of global health, and this turning away from the world, including HIV-infected people in Africa, are all related as part of an ideological retreat. 

Heather Howard  45:35
Well, Joanne, you've given us so much to think about as we approach this momentous election. Thank you for guiding us. This has been a terrific discussion. Thank you for joining us. 

Joanne Kenen  45:44
Thank you for having me. 

Heather Howard  45:47
Thank you for listening to the Princeton Pulse Podcast, a production of Princeton University's Center for Health and Wellbeing. The show was hosted by me, Professor Heather Howard, produced by Aimee Bronfeld, and edited by Alex Brownstein. We invite you to subscribe to the Princeton Pulse Podcast on Apple Podcasts, Spotify, or wherever you enjoy your podcasts.