NPR’s Domenico Montanaro talks about healthcare and the 2024 election

There’s not much mystery about the candidates in the 2024 presidential election, but there are some unanswered questions about the role of healthcare in the race for the White House.

Domenico Montanaro, NPR's senior political editor, talks about healthcare in the 2024 election cycle during the Hospital + Healthcare Association of Pennsylvania Leadership Summit.

With a rematch looming between President Biden and Donald Trump, the former president, the outcome could determine key healthcare policies for Americans.

Domenico Montanaro, NPR’s senior political editor, discussed healthcare in the presidential race during a conversation at the Hospital + Healthcare Association of Pennsylvania Leadership Summit earlier this month. The hospital association invited me to talk with Domenico about healthcare and the election.

In a question-and-answer session, we talked about prescription drug prices, abortion rights and women’s health issues, the Affordable Care Act, Medicare and Medicaid, and more.

Here are some edited excerpts from my 48-minute conversation before Pennsylvania hospital executives.

Q: We have an audience of hospital and healthcare leaders. What role is healthcare going to play in the election?

A: “Has anybody heard anything about $35 insulin? Because I don't think I've ever heard a campaign that has talked so much about that. We've never had a campaign before, we're never going to hear a campaign after. But it's in almost every one of Biden's ads. In ads where Biden is trying to woo black voters, he talks about it. And where he’s trying to woo Latino voters, he talks about it. That's a big piece of it.”

“Now, it's also true that the Affordable Care Act was this big divisive issue. You know, you could argue that in 2010, the big reason why Democrats lost as many House seats as they did was because of the ACA and the way Republicans had framed that. So it was interesting after 50 votes that Republicans have taken in the House, where they weren't able to repeal and replace the healthcare law, that Trump started to talk about it again. And I think that gave Biden an opening.

“Because the law, once you took Obama's name off of it, has suddenly become a lot more popular. People are seeing how to use it within states. More states have actually adopted it, and more states have expanded Medicaid that comes under that. So I think that that's a big piece of what you're seeing.

“Obviously, it’s not the headline of the election. I think that the Biden folks are running on democracy, and certainly on abortion rights.”

Q: Let's talk about the Affordable Care Act. President Biden has run very much on the idea of defending the Affordable Care Act, making sure it's in place and protecting it so that more Americans have access to health care. Donald Trump in his first two campaigns made a central part of his campaign getting rid of the ACA. Now, he has pivoted somewhat and said he doesn't want to get rid of it, but he wants to make it better and bigger.

A: “It kind of reminds me of when I covered the Tea Party for NBC News, and I was out on the campaign trail with them a lot and I would talk to a lot of folks who were party activists, and I would hear quite a bit people saying, ‘You know, the government's doing too much. I'm taxed too much. There's too many government programs. But keep your hands off my Medicare.’”

“And I was like, you know it's a government program, right? And it was just one of these things that once you have an entitlement that goes into place, once you have a program that people are using and it becomes part of their lives, it's much harder to take that away.”

Q: You did mention abortion a few minutes ago, so we should probably talk about that. It’s a highly charged issue where well-meaning people have differences of opinion. Since the Supreme Court’s Dobbs decision, a number of states have basically all banned abortion, with some very limited exceptions. Some say it's made doctors and hospitals have some very complicated decisions in when they can actually provide emergency care, and they aren't even weighing in on the politics on the issue. They’re just worried about delivering emergency care in this situation.

A: And what are the rules, right? And I think that people want to know what to expect. Whether it's Wall Street or whether it's healthcare, people want to know what the rules of the road are so that they can plan, so they can make a business plan, so that they can go out and actually serve patients and do what they need to do. We've seen that in Texas, obviously, where it's very confusing for a lot of doctors and a lot of folks are concerned that they are going to be penalized. Our poll was interesting, 84% said that they think criminalizing abortion would be a bad idea.”

“Obviously, the restrictions area, and how many weeks, are areas where people disagree. But there's a huge roiling effect that the Dobbs decision had in overturning Roe and not having a standard across the country. And you've had a lot of Republican-controlled states, especially across the South, that have really tried to push very restrictive laws. And you have a lot of those efforts still continuing. And I think that that has made for some real uncertainty.

“But it's also politically given Democrats a huge advantage because they've won special election, after special election. With it now being on Florida's ballot, Democrats had essentially written off Florida as a state that had been moving a little bit more Republican, even though it was only less than four points that it got decided in the last election. Obama won it twice. There’s a lot of electoral votes out there.

“So a lot of these groups that Democrats need to turn out at the polls that I think they're going to try to see at least, if there can be enough activism, to make Florida, a state that they can compete in again.”

Q: You mentioned some special elections where abortion rights supporters led Democrats to some pretty big and, in some cases, unexpected victories. How does this play out in a presidential election?

A: “I mean, I think that it's obviously going to be even more compounded, because this is the first presidential election since Dobbs. And I think that is not something people have quite wrapped their brains around.”

“I think that they'd be like, well, yeah, Dobbs happened. There's been these elections, but not a presidential (election). There's going to be billions of dollars spent in trying to motivate voters to go out to the polls who care about this as an issue now.”

Q: Let's talk about Medicare and Medicaid, which is a lifeline for so many Americans and obviously important for hospitals. It provides critical funding for hospitals to keep their doors open. Do you see any difference in Medicare and Medicaid funding depending on who wins the election?A: “You know, it's interesting, I think it's more in the states and who decides to kind of expand Medicaid, which we saw a lot under the Affordable Care Act. 

“I think it's really more of a state's issue on whether or not places expand out but there are ways that the government can add more money to that. They're going to need to figure out … $32 trillion is the federal debt, and a lot of that is driven by entitlements: Medicare, Medicaid, Social Security.

“I think it's going to be a huge fight on how much funding the government is going to have, and I think that's been the key issue. A lot of Republicans have just said that they think that the government is spending too much money and have wanted to stand in the way of the government, even spending at the current levels of spending.”

Q: With Medicare, the last of the baby boomers hit retirement age in 2030. So you’re going to have a lot more people hitting 65 in the coming years. So figuring out Medicare funding is going to be imperative for the next president.

A: “It's a huge driver of the federal debt. I mean, it's hard because, as you know, in this room, the big piece of expanding the healthcare law was the fact that Obama was trying to get these cool young Invincibles to sign up. And they were trying to force people to buy that care so that they could supplement older folks who use the care more, so if the government is paying for Medicare, which is people 65 and older, they're the ones using the care more, and you wind up with what we have.”

Q: You mentioned the $35 Insulin before. We should talk a little bit more about prescription drug prices. It's something that everyday Americans can relate to. Is this something that can be a factor in driving some folks to the polls?

A: “Certainly, the Biden campaign hopes so. I think Biden is very proud of having moved on some of that without a lot of help on the other side of the aisle. So I do think that certainly, insulin is a thing that we're going to hear repeatedly in this election. We'll see if they move to a different message but I mean, it's just in all the ads everywhere that I've seen.”

Q: The Centers for Disease Control is obviously so important in public health and in preparation for public health emergencies, including pandemics. The National Institutes of Health is the government's leading source of biomedical research funding. Are these agencies that could see a loss of funding depending on how the election shakes out?

A: “I think that's definitely possible. We've seen Republicans hold funding to the NIH far more, and I think part of that is the politics of what we've seen. I live fairly close to NIH and during the pandemic, when I would drive by, there were huge protests that were happening outside of NIH. And I just thought, ‘This is weird.’ You know, the NIH, I just never thought that this would be a place where you'd be seeing those kinds of protests.

“I think the key line, if you look at what do people feel, and which side do they agree with … the role of government is the biggest dividing line. Should government do more to help people? Research, funding all that stuff, usually that's people who are now center-left. And if you're saying government's doing too much, and spending too much, that's usually more center-to-right.

“I think it's difficult. Things like education, health care … they're not traditionally supposed to be things that are partisan. Those are places where, after campaigns, and we've seen in the past, the parties are able to run things together. But it doesn't seem that way anymore.”