It's Decision Time: What the 2024 Election Will Mean for Healthcare

First of five parts

With the exception of abortion and reproductive rights, most experts see healthcare issues as residing in the second tier of what will influence how Americans vote in the Nov. 5 presidential election.The economy, immigration, a gaggle of topics that come under the heading of cultural issues, the character of the candidates themselves — the conventional wisdom is that they are shapers of opinion and the swayers of votes.

In her campaign speeches, Vice President Kamala Harris often references the Affordable Care Act (ACA) and its protections against denial of health insurance because of preexisting conditions and the Inflation Reduction Act and the caps it put on insulin and Part D out-of-pocket costs. Former President Donald Trump has fused illegal immigration with many issues, the solvency of Medicare among them, and also asserted that he can improve the ACA and make it less expensive.

So although healthcare may not be among the red-hottest of buttons this campaign season — again, apart from abortion and reproductive rights — it is very much in the conversation.

Here we take a look at the exception, abortion and reproductive rights.

President Joe Biden has supported abortion and reproductive rights, but when he dropped out of the presidential race in July, these issues moved swiftly to center stage.

Harris is a strong supporter of restoring the right to abortion, which was struck down federally by the Supreme Court in June 2022 in the Dobbs v. Jackson Women’s Health Organization decision, with three justices appointed by Trump voting in the 6-3 majority. Harris and the Democrats have framed abortion rights as an issue of freedom, and the polling advantage that she and her running mate, Gov. Tim Walz of Minnesota, have among women is due partly to their positions on abortion.

Trump has tried to distance himself from the most ardent abortion opponents in the Republican Party, construing the Dobbs decision as returning abortion rights to the states and keeping a federal abortion ban out of the Republican Party platform. He has also said he favors exceptions to abortion bans in cases of rape or incest or when the life of the mother is at stake. Trump eventually came out against a ballot measure in his adopted home state of Florida that would allow patients to seek an abortion up to about 24 weeks of pregnancy but also said he thought the state’s current law banning abortion after six weeks of pregnancy was too restrictive.

Meanwhile, both federal and state issues surrounding reproductive rights — not just abortion — are on the table this November, through ballot measures and elected officials.

Janene Oleaga

“If we continue to see states enact abortion restrictions and bans, and we absolutely will during a second Trump presidency, what follows is that reproductive care is restricted and access to IVF [in vitro fertilization] significantly decreases as reproductive endocrinologists cannot treat their patients in a manner that meets the standard of care,” says Janene Oleaga, a lawyer in Portland, Maine, who specializes in embryo donation and other family formation issues.

Oleaga says that many Republicans claim they are “pro-life” but refuse to support legislation, such as the Access to Family Building Act, that would protect IVF federally. Only two Republican senators, Susan Collins of Maine and Lisa Murkowski of Alaska, voted to move the bill forward.

Democrats have made IVF part of their campaign and cast Republicans as a threat to IVF by virtue of their position on abortion. Trump, in a surprise move, has come in favor of universal insurance coverage of IVF through insurance mandates and unspecified other means.

Oleaga also said that reproductive and marriage rights for LGBTQ+ individuals will be shaped by the 2024 election. The next president will likely have anywhere from one to three Supreme Court appointments, according to Oleaga. Marital rights and parental rights are separate but related issues. “If gay marriage ends, there is no marital presumption that extends to gay married parents growing their families through donor conception,” she said.

One of the most notable reproductive rights issues that could be affected by the election is claims of personhood for fetuses and zygotes, said Amanda Stevenson, Ph.D., who leads the Colorado Fertility Project and is an assistant professor at the University of Colorado Boulder. Using the 14th Amendment to claim personhood for pregnancy “really puts far more than just abortion on the line,” she said.

That everything is at stake with respect to abortion is not an understatement, says Sarah Prager, M.D., director of the Family Planning Division and a professor in the Department of Obstetrics and Gynecology at University of Washington Medicine, a health system in the Seattle area. “A Trump presidency and expansion of conservatives on the Supreme Court would make it easier to codify restrictions or completely blockaccess to abortion and contraception, IVF, and lots of different kinds of reproductive healthcare,” she said.

Prager said she believes there would most likely be a national abortion ban of some sort if Trump is elected. “I think we’d see more pregnant people dying from lack of access, both to contraception and...to abortion. That’s going to be the real consequence of all these bans that we’re already actually seeing, which is increased rates of maternal mortality.”

With a Harris presidency, regardless of her position, the battle over abortion rights will continue on a state-by-state basis because of the Dobbs decision. Voters in six states have voted for amendments to state constitutions that protect abortion rights. This fall, voters in five states will vote on abortion-related ballot measures and signatures have been submitted to put measures on the ballots in four others.

Abortion bans affect more than just those who are pregnant. They affect where doctors choose to train and practice. NPR reported that in Idaho, which now has a complete abortion ban, 58 obstetricians left Idaho or retired, while only two moved into the state during the same period. Meanwhile, three Idaho maternity wards closed since the Supreme Court decision. Patients are losing access to maternity care, as medical students are also applying less frequently to institutions in states with limited abortion access, according to the Association of American Medical Colleges.