Health care is suddenly front and center in the final sprint to the presidential election, and the outcome will shape the Affordable Care Act and the coverage it provides for more than 40 million people.

Besides reproductive rights, health care has been a shadow issue for most of the campaign. However, recent comments by former President Donald Trump and his running mate, Ohio Sen. JD Vance, about possible changes to the ACA have opened Republicans up to greater scrutiny.

More than 1,500 doctors from all over the country recently launched a letter asked Trump to reveal details of how he would amend the ACA, saying the information was needed so voters could make an informed decision. The letter came from the Health Protection Committee, a national physician advocacy group.

“It’s remarkable that a decade and a half after the passage of the ACA, we’re still debating these fundamental issues,” said Larry Levitt, executive vice president for health policy at KFF, a nonprofit health information organization that includes KFF Health News. “Democrats want to protect people with pre-existing conditions, which requires money and regulations. Republicans have sought to reduce federal regulations, and the byproduct is fewer protections.”

The two parties’ tickets have starkly different goals for the ACA, a sweeping law passed under former President Barack Obama that set minimum benefit standards, made more people eligible for Medicaid and ensured that consumers with pre-existing conditions could not be denied coverage medical.

Vice President Kamala Harris, who previously supported a universal health care plan, wants to expand and strengthen the health law, popularly known as Obamacare. She advocates for permanent, temporary, enhanced subsidies that lower the cost of premiums. And she is expected to press Congress to expand Medicaid coverage to more people in the 10 states that so far have not expanded the program.

Trump, who has repeatedly tried and failed to repeal the ACA, said in September’s presidential debate that he had “concepts of a plan” to replace or change the legislation. While that bit got a bit of a laugh because Trump had promised an alternative health insurance plan many times during his administration and never delivered, Vance later offered more details.

He said the next Trump administration would deregulate insurance markets — a change that some health analysts say could offer more options but would erode protections for people with pre-existing conditions. He appeared to adjust his position during the vice presidential debate, saying the ACA’s protections for pre-existing conditions should be left in place.

Such health policy changes could be advanced as part of a major fiscal measure in 2025, Sen. Tom Cotton (R-Ark.) he told NBC News. This could also open the door to changes in Medicaid. Conservatives have long sought to roll back the health insurance program for low-income or disabled people from the current system, in which the federal government contributes a formula-based percentage of states’ total Medicaid costs, to one that caps federal spending through block grants or per capita funding limits. Supporters of the ACA say that would shift significant costs to states and force most or all states to opt out of expanding the program over time.

Democrats are trying to turn the comments into a political liability for Trump, with the Harris campaign running ads saying Trump doesn’t have a health plan to replace the ACA. Harris’ campaign also released a 43-page report, “The Trump-Vance Health Care ‘Concept’,” saying her opponents would “rip away coverage from people with pre-existing conditions and raise costs for millions.”

Republicans have been stymied in the past when they tried unsuccessfully to repeal the ACA. Instead, the law became more popular, and the risk Republicans posed to protect the status quo helped Democrats take back control of the House in 2018.

In a KFF poll last winter, two-thirds of the public he said it was very important to uphold the law’s ban on charging people with health problems more for health insurance or denying them coverage.

“People in this election are focused on issues that affect their family,” said Robert Blendon, professor emeritus of health policy and political analysis at Harvard. “If people think their own insurance will be affected by Trump, it could matter.”

Vance, in a Sept. 15 interview on NBC’s “Meet the Press,” tried to minimize this impact.

“You want to make sure pre-existing coverage — the conditions — are covered, you want to make sure people have access to the doctors they need, and you also want to implement a deregulatory agenda so people can choose a plan to healthcare that suits them,” he said.

Vance went on to say that the best way to make sure everyone is covered is to promote multiple options and not put everyone in the same insurance risk pool.

Risk pools are fundamental to insurance. They refer to a group of people who share the burden of health care costs.

Under the ACA, enrollees are generally in the same group regardless of their health status or pre-existing conditions. This is done to control premium costs for everyone, using the lower costs incurred by healthy participants to control the higher costs incurred by unhealthy participants. Separating sicker people into their own group can lead to higher costs for people with chronic health conditions, potentially putting coverage out of financial reach for them.

The Harris campaign seized on the threat, saying in its recent report that “health insurance will go back to discriminating based on how healthy or unhealthy you are.”

But some ACA critics believe there are ways to separate risk groups without undermining coverage.

“It was not surprising, it was blown out of proportion for political purposes,” said Theo Merkel, a former Trump adviser who is now a senior fellow at the Paragon Health Institute, a right-wing organization that produces health research and policy proposals market based. .

Adding short-term plans to the coverage options will not affect the ACA market and will give consumers more affordable options, said Merkel, who is also a senior fellow at the Manhattan Institute. The Trump administration increased the maximum duration of those plans, then Biden rolled it back to four months.

Subsidy-eligible people would likely buy full ACA plans because, with financial aid, they would be affordable. Thus, the ACA marketplace and its protections for pre-existing conditions will continue to work, Merkel said. But also offering short-term plans would provide a more affordable option for people who don’t qualify for subsidies and who would be more likely to buy the non-compliant plans.

He also said that in states that allowed people to buy non-ACA compliant plans Off-exchange, exchanges performed better than in states that banned it. Another option, Merkel said, is a reinsurance program similar to the one operating in Alaska. Under the plan, the state pays insurers back for covering very expensive health claims, which helps keep premiums affordable.

But ACA supporters say that separating sick and healthy people into different insurance risk groups will make health coverage unaffordable for people with chronic conditions, and that allowing people to buy short-term health plans for longer terms will backfire.

“It’s underinsuring people when they get sick,” said Leslie Dach, executive president of Protect Our Care, which advocates for the health law. “There’s no reason to do that. It is unthinkable and makes no economic sense. They’ll hide behind saying ‘we’re making it better’ but it’s all untrue.”

Meanwhile, Harris wants to preserve the temporary expanded subsidies that helped more people get health coverage at lower prices under the ACA. Those expanded grants, which help about 20 million people, will expire at the end of 2025, setting the stage for a pitched battle in Congress between Republicans who want to let them run out and Democrats who say they should be made permanent.

Democrats introduced a bill in September to make them permanent. A challenge: Congressional Budget Office it is estimated that this would increase the federal deficit by more than $330 billion over 10 years.

Ultimately, each candidate’s ability to significantly increase or change the ACA rests with Congress. Polls suggest Republicans are in a good position to take control of the Senatewith the result in the house higher in the air. However, margins are likely to be tight. However, many initiatives, such as expanding or restricting short-term health plans, can also be pushed through executive orders and regulations, as both Trump and Biden have done.