The COVID-19 pandemic has uprooted voters' lives and may shape the way they cast their ballots Tuesday.
Some eight months in, the novel coronavirus has so far killed more than 230,000 Americans, with cases rapidly rising as flu season begins. Earlier failures containing its spread led to a patchwork of local lockdowns spurring job losses, business closures and now a recession.
While some early polling though suggests economic issues might be a stronger driver in who shows up to vote, healthcare issues, from the pandemic to insurance coverage via Medicaid and for pre-existing conditions are also top of mind.
A Gallup poll from last month found the economy topping voters' lists of key election issues, followed by terrorism and national security, then coronavirus response. Healthcare ranked fourth, though 80% of voters still said it was important to them. Healthcare topped Democrats' lists while the economy and national security led for Republicans.
A September poll from the Kaiser Family Foundation found the economy topped voters' lists of issues most important to them in deciding their vote. Coronavirus response and criminal justice and policing followed, then race relations, healthcare and immigration.
Voters concerned about healthcare policy are likely considering the teetering fate of the Affordable Care Act, slated for U.S. Supreme Court oral arguments a week after Election Day.
President Donald Trump's newest court pick, Justice Amy Coney Barrett, will likely play a critical role during that case, where Republican governors and the Trump administration seek to dismantle the law.
On his first day in office, Trump issued an executive order saying: "It is the policy of my Administration to seek the prompt repeal of the Patient Protection and Affordable Care Act."
Republican efforts to repeal and replace the law floundered in 2017, though the administration began steadily chipping away at key tenets of the decade-old law through regulatory avenues.
One of the most popular parts of the law is protecting patients with pre-existing conditions. During a North Carolina rally in September, Trump unveiled his "America First Healthcare Plan" if re-elected, largely touting administrative efforts already in the works, like repealing the ACA, rather than new initiatives and those that require further action to move forward.
He signed two executive orders: one prompting Congress to end surprise billing and another to protect patients with pre-existing conditions. The proclamations have little power on their own, though, with congressional intervention needed to give them teeth.
Critics also note the administration has promoted short-term plans that don't require coverage for pre-existing conditions and in fact rarely do.
Beyond repealing the ACA, the other key tenet of Trump's healthcare policy so far has been a push for transparency for prices charged by hospitals and paid by insurers within the healthcare system. Despite pushback from hospitals groups and a lengthy court battle, providers will have to publish the negotiated rates they reach with insurers for services provided to patients starting Jan. 1.
It's unclear where former Vice President Joe Biden, the Democratic candidate, stands on the price transparency issue. But there is no doubt Biden will do all he can to boost the ACA, created under his former boss President Barack Obama.
Biden also supports creating a public option and lowering the Medicare eligibility age to 60. Both proposals are opposed by hospital lobbies, as they would be likely to lower overall payments to providers.
If Biden wins and Democrats manage to gain control of the Senate, they could save the ACA in the event of a Supreme Court decision striking it down, and shore it up further.
Another aspect of the law that has become more popular even in some red-leaning states is the expansion of Medicaid. Originally mandated by the law, it became optional following a Supreme Court ruling.
Voters this year in Missouri and Oklahoma passed legislation to expand Medicaid under the ACA. Thirty-nine states have expanded Medicaid while 12 have not.
An survey published last week from the Commonwealth Fund found strong support for Medicaid expansion in states most likely to determine the 2020 election outcome.
Voters in key swing states including Arizona, Florida, Georgia, Michigan, Minnesota, North Carolina, Ohio, Pennsylvania, Texas and Wisconsin "will likely have an outsized impact on the outcome of the 2020 presidential election and, ultimately, the future of the Affordable Care Act and the coverage expansions it has afforded millions of Americans," according to the survey.
Half of those states (Arizona, Minnesota, Michigan, Ohio and Pennsylvania) have expanded Medicaid under the ACA.
Among all swing states, voters said they strongly support Medicaid expansion under the ACA. In states that have not yet expanded, three-quarters of likely voters favor expansion — including two-thirds of independents and nearly half of Republicans, the survey found.
"While demographics, geography, and political ideology vary greatly among the swing states, their support for Medicaid expansion does not," according to the survey.