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One might think, in 2020, the year in which a pandemic has drastically altered the daily lives of all Americans—and taken the lives of more than 200,000 of them—that this year’s election would be all about health care. Even before the onset of COVID-19, there was broad, bipartisan agreement that the bloated, inefficient, and costly U.S. approach needs fixing.

But a discussion about the shape and future of the country’s health care system has been largely absent in the presidential campaign in recent weeks. That changed in last night’s debate between President Trump and former Vice President Joe Biden, his Democratic rival.

Health care was the subject of one of the night’s first and most bitter exchanges—a signal that the subject is back on the candidates’ agenda. And none too soon.

This story is part of a special report examining what’s at stake for a wide range of industries—and for many workers—in this year’s election.

The Supreme Court is set to hear arguments over the constitutionality of the Affordable Care Act (ACA) in early November. That case recently took on new urgency with the death of Supreme Court Justice Ruth Bader Ginsberg. The shifting makeup of the court has added uncertainty to the ACA’s fate. At stake is the insurance of millions of Americans currently provided by the law.

While the two political parties are clearly divided over the law, however, the debate largely stalls out there. The nation is just not engaging on the subject in a substantive way right now. “Aside from COVID, we’re not really focused on policy,” says Gerard Anderson, a professor at the Johns Hopkins Bloomberg School of Public Health. Along with other experts, Anderson notes that the lack of policy debate is due in part to the fact that the Republican Party effectively doesn’t have a health care platform (other than the one it created in 2016) and hasn’t offered clear views on many issues.

While that makes the situation harder to parse, the 2020 election certainly represents a critical juncture for the U.S. health care system and the millions of Americans who use it. And for those who work in the health care industry, there are some clear priorities that need to be addressed. Here’s what is at stake.

Clarity on the Affordable Care Act

The first big issue relates to insurance coverage. President Trump excited many of his supporters in 2016 with his pledge to repeal and replace President Obama’s signature law, the Affordable Care Act, which protected Americans with preexisting conditions from being denied or excessively charged for coverage and that—in part, through the individual mandate—expanded health coverage to millions of Americans. According to the Commonwealth Fund, the percentage of uninsured Americans fell from 20% in 2010 to 12% in 2018; the number of people who were underinsured during that time increased, according to the study. While Congress repealed the individual mandate, weakening the ACA, the Trump administration has not articulated an alternative (though it has repeatedly said one is coming).

“The Republicans keep talking about a fix, and they’ve not come up with a fix,” says Bill Hoagland, a senior vice president and self-described “moderate Republican” with the Bipartisan Policy Center. He called President Trump’s executive order last week protecting Americans with preexisting conditions “silly.” Why? Because it didn’t actually change policy. “That’s what the law says now,” says Hoagland.

The Democrats, meanwhile, did have a robust debate about the future of health care during the primaries. Biden’s position involves building on the Affordable Care Act by creating a public health insurance option.

Get serious about controlling costs

A second pressing issue for the health care industry is America’s ever-growing medical bill, which at last count totaled $3.6 trillion in 2018, or roughly 18% of GDP. In other advanced economies, the rate is 8% to 10%.

That discrepancy is not justified by results, says David Blumenthal, president of the Commonwealth Fund, a nonpartisan foundation that researches health and social policy issues. “We do not do more stuff,” says Blumenthal, comparing the U.S.’s health system with that of other industrialized countries. “What we have are prices that are astronomically higher on a per-service basis. We pay a much higher rate per hospitalization, for drugs, for physician visits, for surgical procedures—multiples of what other countries pay.”

That costs are too high is not controversial. Both parties believe health care spending is out of whack. But they’re divided over the best way to address the issue. While the Republicans are generally in favor of more competition to control costs—price transparency has been an elusive goal of the Trump administration—the Democrats argue for a combination of competition and regulation, says Hopkins’ Anderson, who notes the debate hasn’t really changed or progressed in 40 years. “I honestly do not know what will change the trajectory,” he says, adding that one of the problems is that “there isn’t a strong champion for cost containment.”

While President Trump has been vocal about drug prices being too high—and there’s a growing consensus about the role of hospitals and increasing consolidation in the sector in driving up prices—experts like Anderson speculate the pandemic has given “some cover” in the near term to pharmaceutical companies and health systems because of their high-profile roles in responding to the pandemic.

Blumenthal suspects there is support across the ideological spectrum for reducing monopolies and oligopolies in health care but is less certain how it would work out politically in the current environment. “The health care industry is very powerful, just as the pharmaceutical industry is very powerful,” says Blumenthal.

He thinks U.S. companies may offer the best hope at effecting change. “Employers in the United States have never been effective purchasers of health care,” says Blumenthal. “One way for markets to resolve some of these issues would be for the purchasers to be more aggressive and effective in buying insurance.”

As for the ongoing pandemic that provides the backdrop for this election, Blumenthal believes that it raises questions about what sort of public health care system America should have going forward. Says Blumenthal: “For those who are sympathetic to government, the pandemic has provided another argument for its critical role in health care, and society in general.”