by Craig Klugman, Ph.D.

It is hard to know what to write in the middle of another drawn out ballot counting election in the U.S. I was hoping to write today about what we can expect in terms of health policy and the role of bioethics in our national debates for the next four years. But right now we are potentially still days away from knowing who will be President (despite Trumps’ self-declared, and unsupported win) and who will control the Senate (though leaning toward Republicans). 

Obviously the most pressing issue of our time is responding to the COVID-19 pandemic. With nearly 9.5 million cases in the US and over 233,000 deaths, this virus is not going anywhere soon. As Europe battens down the hatches for another round of lockdowns to control spread, what will be the U.S. approach? If Mr. Trump wins, we will stay the course—saying that we have “rounded the bend”, mocking people for wearing masks, potentially firing Dr. Fauci, and ignoring the words of scientists? Actually, the situation is worse than even ignoring scientists, it is not allowing scientists to even meet or to make recommendations. I have had the honor of being appointed to a DHHS science board (perhaps a position that this post will cost me). But, I have not yet been sworn in (5 months later) and we cannot officially do much work. See, a science board must do its work (voting, swearing in members) in a public meeting. A public meeting must be posted in the Federal Register and without any reasons given, the Register is refusing to post meeting notices for at least my board and perhaps several others. 

If Mr. Biden wins, then he talked about a national mask mandate (there’s not necessarily a legal mechanism for doing this), he would let science drive the response, and he would have a national response (things like contact tracing, testing programs, collecting and disseminating accurate data). He might also have us join international efforts such as COVAX, a coalition of 172 countries working to find a vaccine and make sure that it is fairly distributed around the world (Mr. Trump has been trying to secure U.S. doses even at the expensive of middle and lower income countries). 

The second most pressing issue is health insurance. On November 10, the U.S. Supreme Court will hear a case against the Affordable Care Act. Although the judgement won’t be released until 2021, the case could wipe out a law that Republicans have been after for a decade. For five years, Mr. Trump has talked about his newer and better plan that no one has ever seen. Without any new plan, defeat of the ACA would throw tens of millions off of marketplace insurance plans, disallow children from being on their parent’s insurance after age 18, and allow discrimination based on pre-existing conditions. In addition, Trump plans to eliminate the social security and medicare tax, meaning that by 2023, people covered by those plans would find themselves without insurance and without a significant chunk of retirement income. While a Biden win would not change the USSC case, he could ask that the government withdraw the case, he could work with Congress to create a new law, and he has stated that he wants to create a public option as a choice in the insurance marketplace. 

Again, with the ideological leanings of the current U.S. Supreme Court, a change of president is unlikely to affect future rulings on abortion. Though Mr. Trump supports anti-abortion candidates (though his own personal belief on the matter is unknown), Mr. Biden supports pro-choice candidates (though his personal belief as a Catholic is known). If the USSC finds there is no right to privacy under the Constitution, then a whole bunch of health care related laws would be in trouble—not just rights to abortion (legality would move to a question of state law), but also medical privacy and confidentiality that is based on law and even electronic privacy. Instead of national laws like HIPAA, each and every state might have to create its own. This has been the approach for digital privacy so far. 

This election found four more states (total of 15 + DC now) choosing to make recreational marijuana legal. Technically, marijuana is a schedule 1 drug meaning that it cannot be used. Under the Obama administration, the Department of Justice said they would not go after anyone in a state with a legalization law. Trump’s DoJ reversed that position but has not taken action, yet. What might a Biden DoJ do? Oregon also became the first state to vote to decriminalize shrooms, heroin, cocaine, and LSD. Instead of a criminal zero-tolerance approach, Oregon will now treat drug use and possession as a public health issue. Again, these drugs are federally illegal: Will the federal government allow Oregon home rule on the issue or will the DoJ go after anyone using these new freedoms? Trump and Biden will likely have different approaches. 

Under the Trump administration, there have been efforts to push “religious freedom” in areas of health. The idea is that people with a religious objection to certain medical procedures or populations (vaccines, abortion, treating LGBQT people) could not be forced to give such procedures or treat all patients. Under a second Trump administration, the effort to raise religion as an uber-freedom would likely to continue, in large part, this effort is a cover for bigotry, racism, homophobia, and transphobia. Under a Biden administration, religion would still be honored, but would not be used as a way to justify discrimination and hatred. 

The social determinants of health tell us that health is more than medicine, and includes education, the lived (built and natural) environment, climate, finances, recreational opportunities, exposure to toxins, safe spaces, and opportunity. Under a second Trump presidency, we would like see a further rollback of environmental protection regulations meaning companies can pollute the air and water more, mining and drilling in public and environmentally sensitive lands, further bans on diversity and inclusion training, less support for schools (in exchange for for-profit and charter schools), more support for fracking and coal extraction, more tax cuts for people with high wealth, and increased hate crimes against people of color, women, and members of the LGBQTI community. A Biden administration would rejoin the Paris Climate Accord, encourage better car fuel standards, invest in alternative energy, reinstate climate and land protections, publicly fund community college and perhaps erase some student loan debt, raising taxes (focused on high income and high net works individuals), and reinstating human rights and civil protections. 

As I sit here, along with the rest of the nation, facing what is likely to be an unclear outcome for days, if not weeks, I wonder what these results will mean for the future of medicine, health policy, and human rights. There are two clear paths represented by the two candidates. And there is a nationwide anxiety and angst as we wait to know what happened. And then wait for the court challenges and the recounts. A few lessons are clear though: We are a deeply divided nation whether on rural/urban lines, on masks/no masks lines, and totalitarianism/republic lines, and over freedom to choose your life/imposition of a singular moral vision. I am disturbed that this election is as close as it is. We did not repudiate authoritarian rule, white supremacy, hatred, divisiveness, and corruption. Nearly half of us embrace it and want more of it. The other half sit in shock and awe that we are not the enlightened, progressive nation we had though.