Midterm elections in the USA: a pivotal moment for health

The economy and high inflation will be the main priorities on the minds of voters across the USA when they cast their ballots in the midterm elections this November 8. But the stakes could not be higher for health in this election, especially in the context of a conservative-leaning Supreme Court that has rolled back rights on abortion, gun control, prescription reimbursements, and climate change regulations. Dobbs v Jackson overturned the constitutional right to abortion, and has already led to 13 states enacting abortion ban laws. Depending on the election outcome, further federal and state restrictions that are antithetical to health justice will likely be legislated, risking people's health for decades to come.

Historically, the political party that controls the White House usually loses seats in the House of Representatives during midterm elections. Redistricting following the results of the US 2020 Census has also created opportunities for both Republican and Democrat incumbents. It is possible but not inevitable that the Democratic party will lose control of both houses of Congress.

Such a result would jeopardise chances to mitigate and reverse some of the damage to the health of Americans caused by the Supreme Court's recent decisions. Democrats need to have a majority in both houses of Congress to pass Biden's pledge to codify abortion rights at the federal level and sign a bill into law. On gun control, New York State Rifle and Pistol Association v Bruen ruled that the state law requiring a license to carry concealed weapons in public places was unconstitutional, but Biden says he wants to expand the Bipartisan Safer Communities Act and will urge Congress to take further legislative action on gun safety, including a ban on assault weapons and high-capacity magazines, to strengthen background checks, and to enact safe storage laws. Currently, only eight states have a ban on assault weapons. These plans will be thrown out by a Republican-led Senate, and could see further loosening of restrictions on guns.
And what of universal health coverage? Basic health-care needs, including for reproductive health, mental health, addiction treatment, and catastrophic medical coverage, could all be covered in a universal health-care package under an expanded Affordable Care Act (Obamacare). The Democratic National Committee's platform articulates a vision of universal health coverage with a public option, but they do not have the majority needed to pass such legislation and certainly will not if the Republicans win both houses of Congress. The Democrats are also calling for legislation that will rein in health-care spending, an issue that 40% of people in a recent poll said was their primary concern.

Over 350 Americans are still dying each day from COVID-19, and the USA's fragmented public health infrastructure is not remotely ready for the next pandemic. In The Lancet, Nancy Krieger discusses how fixing the US public health infrastructure would cost less than 1% of the annual US military budget. Whoever controls the Senate following the election needs to make pandemic preparedness a priority and that requires robust, well funded public health institutions. The results will be good for health and for the economy.

Globally, a Republican win in Congress would put US health commitments at risk, because they must be approved every fiscal year. Although it is likely that PEPFAR would continue to enjoy strong bipartisan support, funding for WHO and UNFPA—which were both cut by the former Trump Administration—and the US$6·1 billion pledge Biden made to the Global Fund's Seventh Replenishment could be at risk. Support for Ukraine might also be under threat given the House Republican Leader Kevin McCarthy's recent statement that getting Ukraine aid through Congress “would be difficult”. What does that mean for Ukrainians this winter and for a stable world order?

Health matters to American voters. Polling shows that issues such as reproductive rights, health-care spending, and prescription costs are key motivators in this election. It is little wonder. Life expectancy has dropped in the USA for the second year in a row, from 77 years to 76·1 years. This drop was largely driven by the pandemic—to date, COVID-19 has killed more than 1 million Americans. But COVID-19 does not operate in a vacuum. It does disproportionate harm where public health infrastructure is disparate and weakened, where millions of people are unable to access good quality health care, and where inequalities are entrenched. What do American voters want to do about it? They will have their say on November 8.