Things We Can Learn from the First 2020 U.S. Presidential Debate: A Health Equity Perspective10/3/2020 Perhaps it is appropriate that the anarchic U.S. presidency term which witnessed spectacles including a government shutdown, a presidential impeachment, a global viral pandemic, the spur of global anti-racism protests, and a recession as the final flourish, should end (or renew?) with a bang. Although there were many valuable lessons to be learned from last week’s debate between President Donald Trump and former Vice President Joe Biden, namely not interrupting others while they speak and refraining from name-calling, there were also some important health equity takeaways that can be discerned from the affair that left most in a daze. The Question of Affordable and Inclusive Health Care Insurance Availability First up in the debate was the topic of health care, commonly the topic of choice to start off many U.S. presidential debates. In the first few minutes of the debate, the discussion turned to the possibility of overturning the Affordable Care Act (ACA) (aka Obamacare) by the Trump administration to be replaced by a long-awaited mysterious plan not yet known even to Trump. In it's goal to provide affordable and un-restricted health insurance coverage; the ACA gave a wider range of coverage options and expanded Medicaid (medical cost aid for people with limited income and resources), provided coverage options for pre-existing health conditions previously denied under the pretext of the illness or injury occurring before coverage, denied insurance companies the ability to hold a preset monetary limit on health coverage, and promised to make prescription drugs more affordable. The ACA had a monumental impact on the quality of care and health care costs in the United States. It led to more than 16 million Americans obtaining health insurance coverage within the first five years, an increase in health insurance coverage among low-income individuals and people of color, the prevention of an estimated 50,000 preventable patient deaths from 2010 to 2013, savings of over $26.8 billion on prescription drugs by Medicare beneficiaries from 2010 until 2017, and showed how some states decisions' not to expand Medicaid resulted in approximately 15,600 excess deaths from 2014 through 2017. Using the ACA as an example, affordable and equitable health care insurance availability makes great strides in overall population health status and in decreasing the load on medical systems and providers. The possibility of overturning the ACA by the Trump administration is highly uncertain and may be a scare tactic used by Biden to garner votes more than a certain outcome, but the debate has done more to confuse the public than assure them about the future of health care coverage. Drugs are Cheap as Water The candidates’ discussion on the drug prices was inconclusive to say the least. President Trump highlighted that the prices of insulin are so inexpensive; "it's like water." In reality, insulin continues to retail for about $300 per vial in the U.S.A. On the other hand, the Centers for Medicare & Medicaid Services (CMS) recently declared that it is expanding the number of Medicare Advantage plans that provide insulin for a $35 or less monthly copay. This disorientation has a significant impact on health security and health equity. Although the prices of medicines vary widely across countries and among regions, as well as between the public and private sector; medicines remain are largely unaffordable for poorer patients. For example, insulin remains unaffordable to millions of Americans with private or no health coverage due to costs that add up to hundreds or thousands of dollars monthly. These patients require health insurance with comprehensive medicinal coverage and a functioning public health care delivery system that is absent in most low- and middle- income countries to attain medicines. More than half (55%) of uninsured Americans under the age of 65 are people of color. Patients who don’t achieve those means often pay high out-of-pocket costs for medicines, which can be financially devastating as medicines account for the largest category of out-of-pocket health expenses in low- and middle-income families. The effect of the costs of drug prices on patients with commonly manageable diseases can be confounding on the health prospects of those patients. COVID-19: Masks and The Highly-Anticipated Vaccine The debate also failed to give any closure on the COVID-19 matter and could be said to have added to the general confusion on vaccines. While the President assured the public that a vaccine was arriving soon, the Centers for Disease Control and Prevention (CDC) proposed otherwise. In relation to health equity, national and international pandemic preparedness plans should incorporate the goal of reducing social inequality in health care. As discussed in more detail in the previous blog post Health Equity Considerations in a Pandemic, pandemic mortality rates were historically (including the 1918 and 2009 pandemics) highest among those with the lowest socioeconomic status (SES). Yet thus far, no country includes low SES groups in their prioritized list of groups for pandemic vaccination. Vaccination should therefore be viewed not only from a practical vantagepoint, but also as an opportunity to feature equal health care. Mask wearing also succeeded in garnering differing views from the candidates, with Biden stating that mask-wearing and social distancing would save 100,000 lives between now and January, and President Trump directly refuting that. For individuals who lack access to communication resources and trusted media outlets that provide regular updates on the pandemic, and for those who deficient in health literacy or navigation abilities of these services, enlisting trusted voices has been shown to make public health messages more effective in changing behaviour during epidemics (1). If the two candidates agreed on the efficacy of mask-wearing during the debate, it could have resulted in much more compliance with the protective measure by the public, and consequently reduced transmission levels as proposed by the CDC (2). You may ponder why it is important to look back at the key takeaways from an hour and a half chaotic squabble unfolding between two adults seeking to reign over the world’s only democratic superpower. As a matter of fact, it serves as a great opportunity to examine other countries’ experiences of health care and learn from the imparted successes and missteps. This outsider perspective can allow for better detection of some of the aspects of health care that can fall between the cracks; such as inequities in the delivery of health care and possible disparities in the access to information and public health campaigns. Finally, it illustrates the importance of consistent government messaging in ensuring fair access to health care awareness for all. Written: Saja Abid Al Hadi |
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