Are you better off now than you were four years ago? Opinion pieces in this series try to answer this question by examining critical parts of our day-to-day lives. There is nothing more integral to feeling better off than having timely access to medical care when your family needs it. Small wonder that health care is a prominent “kitchen table” issue in political campaigns.

Health care has been a center of national debate since President Truman’s era. Starting with President Nixon, various models of public/private insurance were repeatedly proposed but none successfully, until President Obama’s Affordable Care Act (ACA).

Obamacare expanded health insurance coverage to an additional 20 million individuals but attracted the ire of conservatives with its mandates, Medicaid expansions, and regulatory requirements. When President Trump was elected, he vowed to repeal Obamacare (with no alternative) but the repeal fell short in Congress, by one Republican vote. He nevertheless dismantled parts of Obamacare that many of you rely on, such as open enrollment, premium subsidies, and the individual mandate, while creating policies to cut benefits in state Medicaid programs.  Instead, he promoted Associated Health Plans for small businesses and attempted pharmaceutical cost controls.

However, we are now witnessing a remarkable Obamacare revival. Even as the repeal effort went down in flames, the favorable parts of the ACA began to gain traction. It turns out, the public really likes increased access to care as well as coverage of young adults and protections for pre-existing conditions.

President Biden campaigned hard on the successes of Obamacare and, when elected, succeeded in expanding it significantly. He also promoted important expansions in Medicaid and the Children’s Health Insurance Program, which were adopted by many states, including Maine. In 2024, roughly 40 million people are enrolled through the ACA or Medicaid expansions. You might just be one of the nearly 170,000 Mainers who benefitted from these expansions.

The outrageously spiraling cost of medications also captured the attention of consumers and politicians. Trump tried capping the cost of insulin, but it was limited coverage and voluntary — only 38% of Medicare drug plans participated. Biden followed with a much more sweeping policy: a mandatory $35/month cap covering all insulin types and dosages, saving patients hundreds of dollars per year. Since Maine has the third highest rate of Type 1 diabetes (requiring insulin treatment) in the country, this will greatly benefit Mainers.

Additionally, Biden signed a law requiring Medicare to negotiate drug prices for its 50 million covered lives, something the Veterans Administration has been doing since 1993. Negotiations with drug companies are likely to produce huge cost savings.

So how have these back-and-forths in health care affected the average Mainer? Certainly, as the state with the oldest population, Maine will benefit greatly from reduced medication prices in the Medicare plan. And there is more good news for Maine in health care coverage: a record number of Mainers now have insurance, aided by ACA enrollments, Medicaid expansions, and premium tax credits. Over one million Mainers will have private, ACA, or public health insurance by 2025.

But it is important to note that increasing insurance coverage — private insurance, Obamacare, Medicaid, Medicare — does not always increase access to health care, such as access to primary care clinicians, ER visits, mental health counseling, hospital care, and medications. Health insurance is necessary but not always sufficient to increase access to care.

We see that in Maine: while coverage has increased, access has declined. The COVID-19 pandemic reduced the numbers of health care providers in Maine and the US., due to burnout and early retirements. Patients delayed care during COVID and are now pressing the health care system to address their neglected health issues. Meanwhile, the COVID pandemic actually contributed to an increase in the Maine population, through in-migration. We now have more people, with better insurance coverage, trying to seek more care from fewer clinicians — a perfect storm.

Clearly, we need to expand the health care workforce at every level. The good news is that the Biden administration has proposed some remedies that are known to work in rural states like Maine: increased funding for primary care residencies in rural areas (increasing the number of training slots) and increasing loan repayment amounts by 50% to primary care providers practicing in high need areas, of which Maine has many. Additionally, there is more good news in recent Maine workforce figures: since May 2023, 6,400 positions have been filled in the health care and social service sector.

How will the next election define health care going forward? Trump still calls Obamacare a catastrophe and wants to eliminate it. Biden rightfully touts the successes of health insurance expansions under his watch—and he’s got the numbers to prove it. Both will attack Big Pharma and medication costs.

Are you better off than four years ago? Since then, more Mainers have insurance coverage, have saved on insulin, and anticipate significant cost savings in other medications come fall. And one candidate has a plan to tackle the very real crisis of declining numbers of health care professionals.

So far, Biden’s got the edge. The beneficiary? You.