America decides
The vitriolic and personal 2016 US presidential campaign, in which the individuals rather than the issues have too oft en been the subject of debates and media coverage, draws to a close on Nov 8 when Americans go to the polls to select their new leader. In such a toxic atmosphere, it has been diffi cult at times to compare the candidates' policies on health care and public and global health. What is clear is that Republican candidate Donald Trump and Democratic candidate Hillary Clinton off er strikingly diff erent visions and philosophies for the future of health in America, ones in which Barack Obama's progressive ideology will either be continued or be abandoned. Under this agenda, Obama's health legacy includes the passing of the landmark Aff ordable Care Act (ACA) which has led to 20 million more Americans gaining health insurance, the curbing of coal emissions under the Clean Power Plan, and strong support for biomedical research. But substantial problems exist, including spiralling healthcare costs, almost 30 million Americans uninsured, a fl at medical research budget, and entrenched health inequalities. What are the presidential candidates proposing to improve health and health care in the USA? Trump promises to repeal the ACA if he is elected. His proposed reforms to replace the law include allowing individuals to deduct the full amount of premiums for individual health plans from their federal tax returns, providing block grants to fi nance state Medicaid programmes for low income families, and allowing insurers to sell insurance across state lines. According to a report released on Sept 23 by the Commonwealth Fund and the RAND Corporation that models the anticipated eff ects of the candidates' health care reforms, these policies would increase the number of uninsured individuals by between 16 million to 25 million people in 2018 relative to the ACA, with low income individuals and those in poor health disproportionately aff ected. Americans with individual market insurance would also face higher out of pocket spending than under current law. Clinton promises to improve and expand the ACA. The report by the Commonwealth Fund and RAND analysed four of her health care reforms: refundable tax credits to off set costs of more than 5% of income; reduced premium contributions for marketplace enrollees; a fi x to a glitch in the ACA that leaves some families with expensive employer coverage; and the introduction of a public option, a government run insurance plan, in all state marketplaces. These policies would increase the number of insured individuals by between 400 000 and 9*6 million people in 2018 and decrease consumers' health spending relative to the current law. Refundable tax credits are predicted to have the biggest eff ect increasing coverage by 9*6 million and decreasing average spending by up to 33% for those with moderately low incomes. The health and wellbeing of Americans is not dependent only on medical care and insurance. The USA has had a long history of protecting public and global health; whether this continues will very much depend on the candidate elected. The nominees' diametrically opposed positions are numerous. Trump has said that he will appoint Supreme Court justices that will reverse the landmark Roe v Wade ruling stating that a pregnant woman has a constitutional right to choose to terminate her pregnancy; Clinton will protect the legislation and defend access to aff ordable contraception as well as safe and legal abortion. Trump promises to protect the constitutional right of Americans to bear arms; Clinton would expand background checks for gun sales and support laws preventing ownership by high risk groups, such as those with a history of violent crime. Trump would exit the Paris climate change agreement; Clinton promises to deliver on the pact, including reduction of US green house gas emissions by up to 30% in 2025 relative to 2005. Clinton's global health policies also include creating a dedicated rapid response fund for disease outbreaks; Trump focuses on a national agenda. Whichever way the election goes, one issue is certain: the next president of the USA will inherit a country in which deep health and health care inequalities exist along multiple lines, including income, race, and gender. The Lancet's second Series on health in the USA will be published early next year and hopes to inform the next administration about diff erent dimensions of these inequalities, with solutions for addressing them. It is clear that one candidate over the other has several policies that support the ideals behind the Series, those of health equity and social justice for the creation of a fairer society. The world will be watching closely as America decides what kind of future it wants. The Lancet See World Report pages 2223 and 2224 Ch ip S om od ev ill a/ St aff
The Lancet