If Trump wins, 20 million folks might lose medical health insurance. If Biden wins, 25 million might win.

Millions of Americans will win or lose health insurance in the 2020 presidential election.

An unfavorable Supreme Court ruling next year could mean millions of low-income and middle-class people may lose their health insurance in the middle of a pandemic. A freshly seated Judge Amy Coney Barrett and other Conservative justices could invalidate most or all of the Affordable Care Act, as Donald Trump's administration tells the court to do.

The Trump administration last week announced its plan to protect people with pre-existing conditions in this scenario, which was practically no plan at all. It was instead a plea to be trusted that Trump would find a way to restore protection, despite struggling to reset it during his first term in office.

The Supreme Court could also reject the argument in favor of repealing the ACA. And if Joe Biden wins the presidency, he could hold a mandate to expand health insurance coverage to millions more Americans and, for the first time, create a state health insurance plan available to medium-sized, working Americans as an alternative to private insurance coverage offered by their employer. Low-income people living in the states that have refused to expand Medicaid would join this new government program and expand the safety net to millions of people who have previously been denied it.

Universal health insurance would be within reach. A decade after Obamacare's death, Joe Biden was able to fulfill his mission.

Democrats accuse Senate Republicans of affirming Trump's new Supreme Court nominee as an existential threat to the ACA and its most popular regulations. It's a new twist on their most successful message in mid-2018 when the Democrats pounded Republicans for their efforts to repeal the health bill and won a house majority on that argument.

"What is at stake here is what the President wants, as he has made clear, to get rid of the Affordable Care Act." He ran on it. He agreed to it and he settled it, ”said Biden at the first presidential debate on Tuesday. "He's just before the Supreme Court trying to get rid of the Affordable Care Act that will take 20 million people out of insurance."

But if Democrats are actually given the chance to rule, they must decide how ambitious they want to be in the midst of a pandemic and economic recession. The focus in the Democratic Party and health care country has shifted significantly to the left since the Biden and Barack Obama victory in 2008. Obamacare is quite popular, the winning theme for Democrats that House Speaker Nancy Pelosi was once ridiculed for would be. A public option – once so radical that it was removed from the Affordable Care Act to win Republican votes – is seen as a moderate, single-paying alternative to Medicare-for-All.

The possible future prospects for US healthcare may never have been more diverse than it is today. In one of the most extreme scenarios, 20 million people could lose health insurance. The other could cover 25 million people.

The first domino will fall in the November elections, when American voters decide which candidate to preside over the next chapter of health care reform.

Trump has no plan if the Supreme Court ends cover for 20 million people

The Supreme Court has scheduled oral arguments in California against Texas for November 10, the week after election day. Republican-led states and the Justice Department have urged the Court to invalidate the ACA in its entirety, arguing that the repeal of the law in the 2012 National Federation of Independent Business against Sebelius (z (Chief Justice John Roberts wrote the majority opinion of the Court of Justice) no longer applies – so Obamacare must fall.

Trump would be the silent author of a verdict that will crush Obamacare if the three judges he has appointed – Neil Gorsuch, Brett Kavanaugh, and Amy Coney Barrett – work with archconservatives Clarence Thomas and Samuel, provided it is confirmed in time to resolve the issue Hearing case Alito to overthrow the law. A decision is expected to be made in spring 2021.

In this scenario, more than 12 million people who received coverage through the Medicaid upgrade could lose their coverage. This also applies to most of the 11.4 million people who purchase coverage in the law's private insurance markets because they rely on government subsidies that would also not be taken into account. Protective measures for pre-existing conditions would be deleted from the books. The provision that guarantees free prevention including contraception would be gone. The US would effectively start over as if a decade of health reform had never happened.

Urban Institute

However, if the court does what Trump tells them to do, its administration appears to have no plan to replace the ACA. The president is promising something "much cheaper and far better" – such a decision "would be a huge win for the US," as he recently tweeted – but the White House has provided no evidence that such a plan exists.

After weeks of promises of an upcoming health plan, the Trump administration convened a call with reporters last week to reveal some health policy news. But the details were astonishingly skimpy: Trump would sign an executive order that "it is the policy of the United States" to protect people with pre-existing conditions.

This arrangement actually has no legal force. With Obamacare eradicated, insurers would be free to charge people higher premiums based on their medical history or to deny coverage altogether. And it was already revealed during the failed Republican Obamacare lifting fiasco that there is currently no consensus within the party on how to protect people with pre-existing conditions. It seems to require government spending and regulations for insurers – both of which contradict the stated ideology of the GOP.

Some conservatives would probably like to restore many of Obamacare's policies – guaranteed emission, tax subsidies, and the like – with tweaks that they believe would make the premiums cheaper.

"It's an alternative form of single market with important technical differences," said Avik Roy, president of the Foundation for Equal Opportunities Research in the Free Market and a proponent of such a plan, recently. "We'd end up in a pretty similar place, but with a reformed retail market."

However, others on the right, including the Trump administration in their proposed federal budgets, continue to support a framework similar to the 2017 Graham Cassidy Act, which effectively converts Obamacare's money into block grants to states that it sees fit fit (and which would cause millions of Americans to lose cover, according to Congressional Budget Office estimates). In any case, cuts to Medicaid seem likely as Republicans reform the health system. Both camps propose them.

The pressure to act and prevent millions of people from losing cover would be enormous. But the White House still lacks an official plan, a month before the election and the Supreme Court oral argument, and Trump has not shown himself to be adept at getting key legislation passed through Congress. It must therefore be taken as a plausible result that if the Court of Justice knocks Obamacare down, no agreement will be reached and the law will be allowed to expire without replacing anything.

The US uninsured interest rate already rose under Trump after regulatory action undermined the ACA's private markets, and Covid-19 has resulted in millions of people losing more insurance coverage. In this worst-case scenario, the losses could be even greater: Up to 20 million people are suddenly no longer insured without a repair being guaranteed.

Joe Biden's plan would cover more than 20 million people – if it were ever to become a reality

Regardless of how the Supreme Court rules the Texas case, Joe Biden could have the opportunity to reshape the American healthcare system. If the court were to knock down the ACA, the Biden government would obviously be forced to act.

But even if the judges obey the law, Biden could still proactively decide to enforce another health reform law. Some senior Democrats envision what they termed "never again" when they control the White House and Congress, a response to Covid-19 that addresses many of the vulnerabilities exposed by the pandemic. Covering the roughly 30 million Americans who are not yet insured would be a natural addition to such a legislative agenda.

Even for Biden, the consummate operator in Washington, it would be a challenge to get a massive health bill passed. Democrats will have to make big decisions, starting with the Senate passing a law. Should they use budget reconciliation with the associated constraints on spending? Should they eliminate the filibuster and pass every bill they submit by a bare majority? These will be delicate discussions.

Then comes politics. Some Democratic advisors I've spoken to believe that the smart move, assuming the party enjoys a full campaign, is to keep up the pressure on the Republicans. Democrats could pass laws they believe will be overwhelmingly popular with the public and Republicans dare to oppose it. That would be an argument that health care is a little more reluctant. Instead of trying to establish a public option that the health industry strongly opposes and that will spend millions rejecting public opinion, the Democrats could instead expand the existing Obamacare subsidies to private insurance.

But progressives, especially those with an enlarged House majority, will push for more – at least a public option, if Biden specifically supports it. And considering how much health policy has changed in the years since Obamacare's death, Democrats could actually create a public option without risking voter backlash by going that route.

More Americans are in favor of the ACA (49 percent in the Kaiser Family Foundation's September tracking poll) than disapproving of it (42 percent). Earlier this year, nearly 70 percent of Americans said they supported the creation of a public health insurance option to compete with private plans.

Even the center-left candidates whom the Democrats trust to win competitive Senate races and a new majority now say they are on board with the public option 10 years after what was then Sen. Joe Lieberman threatened to block Obama's health care reform bill if the public option was not removed.

"I think we should let Americans stay on their private insurance if they want," said Barbara Bollier, a Democratic Senate candidate in Kansas, on a questionnaire Vox had sent out to campaigns. "But they should also have an affordable public option to shop into if they are either not happy with their plans or have no coverage."

Biden could use this dynamic to urge Democrats to pass a public option next year. He suggests that the 2 million people currently uninsured because their state hasn't expanded Medicaid through Obamacare be automatically enrolled in the new public plan for free. Up to 12 million people who are currently insured through their work could find the public option as a cheaper alternative, according to estimates by the Kaiser Family Foundation. Biden also wants to widen the premium tax subsidies so that they pay for a more generous plan and more people qualify for them. Individuals who are not currently eligible for this government support could cut their monthly premium by half or more.

The Kaiser Family Foundation table below compares what percentage of their income a person who earns too much money to qualify for Obamacare's grants pays for status quo health insurance versus what they get under Biden's Plan would pay.

Kaiser Family Foundation

The Biden campaign estimates that 97 percent of Americans would have health insurance under their plan. Modeling a program very similar to that proposed by Biden, the Urban Institute determined that all U.S. citizens legally present would have coverage. About 6.6 unauthorized immigrants would remain uninsured.

The CBO estimates that about 20 percent of the 30 million uninsured Americans are illegally present, which means Biden's plan would cover up to 24 million currently uninsured people if Urban’s projections are correct.

In the most pessimistic post-election scenario, 20 million people could lose their insurance. In another more optimistic reality, it could benefit more than 20 million people. The difference would be who sits in the White House on January 20, 2021.

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