At 5:30 a.m. on Saturday, Oct. 19, with the sky still pitch black, the parking lot of the Executive Education Academy in Allentown, Pennsylvania, was unusually active. The charter school, tucked between a minor-league baseball stadium and the Lehigh River, was about to open its doors for a free pop-up medical clinic providing essential medical, dental, and vision care for people who otherwise would go without. Folks seeking treatment had begun filling the lot the night before, with many sleeping in their cars.
Angel — a thirtysomething Allentown local dressed in sweatpants and Crocs adorned with little plastic charms reading Dior and Gucci — arrived at midnight, right as workers opened the lot. “I actually was dropped off by my husband,” she said, “so I was sitting outside in a chair. I had two really awesome people on both sides of me. One gave me a robe to borrow, and one gave me a blanket. So thank God for them. Amen. It got cooold.” But she had to make sure she got access to care, she explained: “I desperately need dental work done.”
Angel works in a grocery store full-time and overtime “whenever I can get it,” she said, and pays the premiums for her employer-provided medical and dental insurance. But that insurance is inadequate to cover the treatment she needs. She’s far from alone: According to a survey by the Association of Health Care Journalists, roughly half of working-age adults have health insurance that provides insufficient coverage and leads to delayed or skipped care.
In the final days before the presidential election, Pennsylvania, a crucial swing state, is being inundated with ads. Kamala Harris, Donald Trump, and their allies have collectively spent over half a billion dollars in Pennsylvania, more than in any other state. Since August, Pennsylvania households on average have been seeing 16 ads a day. But the ads being blasted all over the state have focused on matters like the economy and culture wars — and have barely mentioned health care. As The New York Times noted last month, the topic of health care reform has been virtually absent from the presidential contest.
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The contrast between the campaign messages bombarding Pennsylvanians and the pressing health care needs of people like Angel lays bare this glaring omission in the 2024 election: In contrast to years past, neither candidate is offering a sweeping vision of health care reform, despite polling consistently showing voters are deeply concerned about medical care and its costs, and the fact that major health care matters, from skyrocketing drug costs to the fate of Medicare, could be decided by the next president.
The same day the medical clinic was running in Allentown, Trump booster Elon Musk, the world’s richest man, was in Pittsburgh, Pennsylvania, unveiling his potentially illegal $1 million daily lottery for registered voters in swing states. Trump himself was in Latrobe, Pennsylvania, spending far more time gushing over legendary golfer Arnold Palmer’s anatomy than he did discussing health care.
The Allentown clinic was run by a nonprofit group called Remote Area Medical, or RAM, which has been running free clinics domestically and internationally since 1985. Patients were led first to a “triage” area, where they filled out minimal paperwork and had their vitals checked. In front of the triage were three primary zones: medical, vision, and dental. As is common with RAM clinics, dental services were in the highest demand, and volunteer dentists treated patients’ teeth on the school’s expansive, squeaky-clean sports courts, flanked by massive banners cheerily shouting “AROUND HERE WE WIN.”
Brad Sands, a RAM clinic coordinator, was overseeing the operation. While his tufting beard and wallet chain suggested “off-duty heavy metal drummer,” he exuded calm. He didn’t talk politics, but as he shared his own experience in the medical field, he struck at a central issue at the heart of the American health care system: It’s based around private health insurance, and maximizing corporate profits. This is why the United States spends more on health care than other wealthy countries, and Americans experience worse health outcomes.
Before joining RAM a few years back, Sands explained, he’d bounced around the medical field, working at trauma centers and firehouses, and had gotten “fed up” with “all the barriers to care.” He had even been thinking of quitting and going to welding school. Then the opportunity to work for RAM came up.
Now, he gets “to do the one thing I want to do: bring care to people. I don’t have to make an insurance company happy. I just need the patient present in front of me.”
What Happened To Health Care Reform?
The last few presidential election cycles have been dominated by debates over massive health care changes, most recently the progressive push for Medicare for All, a long-pledged public health insurance option, and Trump’s promise to repeal the Affordable Care Act.
Americans are still very much frustrated with their health care experiences: According to polling from Gallup, for the first time in two decades, more than half of Americans consider the country’s health care “subpar.” And yet in this cycle, conversations on health care policies have barely figured in the candidates’ stump speeches, on their campaign websites, or at their party’s conventions.
The conversations that have occurred have been stop-start. Soon after becoming the Democratic nominee, Harris walked back her previous support of Medicare for All, or a universal, single-payer health care system. Trump, who previously expressed support for single-payer, attacked Harris as if she still supported the idea, too. “You’re going to be thrown into a system where everybody gets health care,” he warned. When asked about his health care strategy during the September presidential debate, Trump replied he had “concepts of a plan.”
Not long after the debate, GOP vice presidential candidate J.D. Vance suggested that a second Trump administration would push for placing people in insurance “risk pools” depending on their medical histories. This proposal, which defies the entire concept of health insurance, would mean people with preexisting conditions facing massive premiums, or struggling to pay for care at all. The Harris campaign responded by accusing Trump and Vance of “ripping away protections for preexisting conditions.” In early October, the Harris campaign ineffectually attempted to re-center health care via an ad blitz warning that Trump’s plan would mean Americans losing coverage.
Earlier this year, Pennsylvania Gov. Josh Shapiro (D), a top contender for Harris’ V.P. pick, announced his plan to spend $4 million to wipe away $400 million worth of Pennsylvanians’ medical debt. (That’s possible to do because medical debt is often sold by hospitals to collectors for “pennies on the dollar.”) The governor’s office estimated the state’s total amount of medical debt — which is associated with a decline in overall population health and an increase in mortality rates — to be $1.8 billion, a figure that could be canceled many times over by the hundreds of millions of dollars spent on ads for the presidential contest in Pennsylvania alone.
This is a national problem, with over 100 million Americans carrying more than $195 billion in medical debt. Harris has floated her own plans to tackle medical debt.
Amid the relative lack of communication on health care from both Harris and Trump, there’s the looming specter of Project 2025, the Heritage Foundation’s right-wing blueprint for a second Trump administration, which aspires to impose a private version of Medicare (the federal insurance program that covers Americans 65 and over) called Medicare Advantage as the default option for all Medicare enrollees.
While Medicare Advantage is generally popular, the privatized plans often wrongly deny patients’ care and cost the government far more than traditional Medicare. A massive expansion of Medicare Advantage would mean that the Medicare Hospital Insurance Trust Fund — which covers all inpatient costs for Medicare enrollees — could be bankrupt within five years.
As the executive director of the advocacy organization Social Security Works, Alex Lawson works to expand Social Security and push Medicare for All. He said that what feels like a deprioritization of the health care debate may be in fact a symptom of the way that mass media works today. He argued that the Harris campaign has been effectively “narrowcasting” their positions on health care. For example, he noted the Harris team has been pushing their proposed expansion of Medicare to cover in-home care specifically to the “Gen X sandwich generation,” who are fretting about getting “crushed putting their kids through college and their parents in a nursing home.”
“If I had my druthers,” Lawson added, “they would push even harder on health care because it’s such a winner. People hate delays and denials by corporate insurers, and Donald Trump would turn health care over to the corporate insurers. Motherfucking concepts of a plan? He has a plan. It’s ‘turn all health care over to the giant insurance corporations.’ UnitedHealth would be in charge of health care. That’s Donald Trump’s plan.”
Ten days after the RAM clinic, Trump would be in Allentown itself, where he promised to “make America healthy again” and magically cut “the rising rates of childhood depression, suicide, and cancer… by 50 percent within four years.” He pledged to do so by consulting “top experts” such as his ally Robert F. Kennedy Jr., known for his opposition to vaccines.
On the same day, Harris was in Washington, D.C., delivering her sweeping campaign wrap-up speech, in which she pledged to cap insulin costs and cover home care. For Harris, it was a continuation of what has been the Democratic campaign strategy throughout the election cycle: a promise of marginal improvements rather than the kind of wholesale change that would come with universal health care
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As I wandered around the RAM clinic, a tall man in a natty straw fedora grabbed me and asked, “You wanna speak to a volunteer from Scotland?” His name was John Deffenbaugh, and he was an American expat living in Glasgow. While traveling the U.S. this election season, he said the only political figure he heard really focus on the health care issue was Sen. Bernie Sanders (I-Vt.), who campaigned in 2016 and 2020 on Medicare for All.
“Bernie stood up for an hour in Baraboo, Wisconsin, without notes, without a teleprompter, and talked passionately about everything we have in Scotland,” Deffenbaugh said. Scotland, like the rest of the United Kingdom, offers universal health care through the National Health Service, meaning it’s free at the point of service. That’s why Deffenbaugh said he liked RAM: “It’s like a mini-Scotland.”
“This Is Medicine At Its Best”
Eugene Lechmanick, a retired family practice doctor with a bushy white mustache, stood behind a table in the medical zone, waiting for patients. After I identified myself as a reporter, Lechmanik joked he was happy to be interviewed so he could use the attendant media attention “to start my OnlyFans.”
A veteran of free medical clinics, Lechmanick said that the people coming into a RAM clinic “have the same diabetes, depression, osteoporosis as everybody else. The problem is they don’t have access to get basic medications. They don’t have access to funds. Doctors tend to shy away from people who don’t have money. It’s just the milieu.”
At one free clinic where he worked, he said, a patient came in with recurring acid reflux, and the clinic helped her get a procedure known as an upper endoscopy. “Turned out she had esophageal cancer,” Lechmanik said. “Holy shit, you know, nice that we figured that out!”
Nearby, Aaron Jaworek, a young ear, nose, and throat specialist, chose his words carefully.
“It can get a little political, but this is a microcosm of a bigger issue,” he said. “This highlights the need for preventative care, for everyone having access to care. The irony is that half of U.S. citizens have some form of health care supplemented by government funds anyway, through Medicare, Medicaid, or the VA system. That’s what always resonates for me. We’re already halfway there. What does it take to get to the other half? But I’m a physician taking care of patients, not a politician running for office.”
One patient, Scott Davis from Bennington, Vermont, used a cane and wore a flat cap; on one arm he was wearing a wrist guard plastered with patches reading things like “Fuck Around and Find Out” and “Living The Dream.” He arrived from Vermont, a four-plus hour drive through grinding rush-hour traffic, the day before; he explained that he regularly travels long distances in order to get care from RAM clinics. “It’s, like, the best health care I’ve ever had,” he said. “I’m not joking. I mean, they’re good. They pulled a wisdom tooth; the next day, I was in no pain.”
Davis later got flustered at the long wait times for his dental care. But his disappointment was a rare sour note. Mostly, people were beaming. As one person put it, “You don’t have to pay! And you don’t even have to prove you’re poor!” Alex Massengale, a cinematically wizened doctor in a white lab coat, told me, “I can talk to patients, I can take care of them, and I don’t have to fill out a bunch of paperwork. In a way, this is medicine at its best.”
Later in the day, I caught up with Angel again. She’d begun her dental treatment and was now awaiting an oral surgeon; her face was numb from the anesthetic, so she could barely talk. In an email, Angel later explained she was dealing with “broken teeth at the gumline — I still have four left to be extracted. And was informed I need two root canals but might end up getting them extracted due to money. That would leave me with very little teeth. I am in need of replacing teeth, hopefully with implants but financially seems impossible. So praying for some type of replacement teeth that are in my reach financially.”
While the debate on the issue has been minimized, the potential health care ramifications of either a Trump or a Harris administration are huge. If Trump wins, the subsidies that have helped make individual health insurance premium costs more affordable for 20 million people could disappear. Days before the election, House Speaker Mike Johnson (R-La.) said Republicans could once again move to repeal the Affordable Care Act if Trump wins, adding: “We want to take a blowtorch to the regulatory state.” Perhaps aware of how objectionable repeal would be, a Trump spokesperson quickly responded that this is “not President Trump’s policy position.”
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Dr. Ed Weisbart, the national board secretary of the advocacy group Physicians For A National Health Plan, said the evident unpopularity of Trump’s health care plans might explain why the candidate isn’t talking about health care: “It’s not hard to understand why the Republicans aren’t campaigning on, ‘We’re going to raise your premiums!’”
Weisbart added that some of the Harris campaign’s policy proposals, if enacted correctly, would be “foundational” to his organization’s goal of enacting universal health care. He ticks them off: lowering the eligibility age for Medicare from 65 to 60; increasing Medicare’s ability to negotiate drug prices; expanding Medicare to cover dental and vision. For seniors who rely on free medical clinics like RAM, the last item would have an obvious benefit.
Still, the profound need for RAM suggested how far the American health care system has to go.
A Conversation With An Actual Undecided Voter
RAM was originally founded in 1985 with “the intention to serve in remote areas of developing countries,” according to a spokesperson. But since 2019, with “the need for free health care in the U.S.” being “so vast,” it has only operated in this country. By the end of the Allentown clinic, RAM would provide nearly 250 patients with over 400 services — ranging from dental and vision care to mammograms and flu shots — with an estimated total value of $118,000.
In other wealthy countries, Weisbart said, pop-up medical clinics like RAM just “don’t happen.”
Right before I left, I got lost in a meandering conversation with Betsy, a sixtysomething Pennsylvanian. She told me about volunteering for 1972 Democratic presidential candidate George McGovern in high school, meditating with Buddhists, and hanging out with her two close friends, one a Christian and the other an Anarchist.
It turned out Betsy was the exact kind of Pennsylvanian that half a billion dollars had been spent on persuading: an undecided voter. Weeks before the election, she said she really didn’t know who she was going to vote for. She said she felt Harris’s policies were like “band-aids.” She said she didn’t know much of anything about Trump’s plans at all. But we didn’t end up talking about politics all that much.
She asked, “Do they provide glasses here as well?” She hasn’t had a new pair in ten years. The last time she considered getting new glasses, she spent the money fixing the air-conditioning in her car. She divulged her medical issues, elliptically: “I have a thyroid condition and I got cancer recently and whatever…”
She said she has a friend currently undergoing cancer treatment. Based on what she’d heard about the costs involved — they often drive Americans to bankruptcy — she was worried.
If she owed that kind of money, she joked, “I would hope I wouldn’t live that long, because I would run out of my life savings.”
