There was always an expectation that health care would be one of the biggest issues in this year’s presidential campaign, as was the case in the 2018 mid-term elections.
That is definitely the case, but not in the way anyone saw coming. In a surprise plot twist, a pandemic has eclipsed other issues like the Affordable Care Act (ACA), though do not expect those other issues to fade entirely.
The notion of “issues” in this campaign is, to be sure, something of a misnomer. The election is likely to be largely a referendum on President Trump. And Trump has never been a conventional candidate with conventional policy proposals. He governs and campaigns more through 280 character tweets than 10-point plans.
Voters will no doubt judge Trump based on the tone of his public statements and his conduct in office, but also on his policy actions and inactions and how they contrast with what former Vice President Biden is proposing. Much of that policy making has revolved around health care, especially as the coronavirus disease 2019 (COVID-19) pandemic continues to hit the US much harder than the rest of the world. Polling shows the public has an increasingly negative view of Trump’s response to the public health crisis, which could prove to be an important barometer for the campaign.
Below is an overview of how Trump’s record compares with Biden’s proposals on a range of major health care issues.
Trump: As of mid-August, the US accounted for 4% of the world’s population but 25% of all COVID-19 cases and 22% of deaths. He has on many occasions downplayed the severity of the pandemic, sent mixed signals on masks, and suggested wrongly that US cases were increasing because more tests were being done. He has delegated primary responsibility for responding to the pandemic to the states, pulled out of the World Health Organization (WHO), and pushed to reopen schools for in-person learning. He has signed several major pieces of legislation on pandemic response and economic relief.
Biden: He pledges to put “scientists and public health leaders front and center” in communication with the US public and to give the federal government primary responsibility for pandemic response. He also supports expanded testing, eliminating out-of-pocket costs for COVID-19 treatment, additional pay and protective equipment for essential workers, reopening schools in-person only after sufficient reductions in community transmission, and reversing the decision to withdraw from the WHO.
ACA and Medicaid
Trump: He has supported failed Congressional proposals to repeal and replace the ACA with weakened protections for preexisting conditions, reduced premium assistance, elimination of the Medicaid expansion, and a cap on all federal funding for Medicaid. He supports a lawsuit currently before the Supreme Court to overturn the ACA in its entirety, and expanded the availability of short-term insurance plans that have lower premiums but can exclude coverage of preexisting conditions and ACA-required benefits. In addition, he ended cost-sharing subsidy payments to insurers, suggesting they would cause the ACA to be “dead” and “gone.” Insurers, however, largely offset the terminated federal payments by increasing premiums, which in turn increased federal premium subsidies. He also signed legislation to repeal the individual mandate penalty.
Biden: He proposes to build on the ACA by increasing premium assistance and creating a Medicare-like public option plan, which would be available to anyone and automatically cover people with low incomes in states that have not expanded Medicaid. He would also lower the age of eligibility for Medicare to 60 years, and supports increased federal funding to states for Medicaid during the economic crisis.
Prescription Drug Prices
Trump: He has emphasized the need to address high drug prices, but put in place few policies to do so. Insulin costs for some Medicare enrollees have been capped. Ideas that have been proposed but not implemented include: limiting prices for certain physician-administered drugs to those charged in other countries, allowing patients to import drugs, banning rebates paid to pharmacy benefit managers in Medicare, and requiring drug companies to disclose list prices in television advertisements (a proposal blocked by a federal court).
Biden: The centerpiece of his plan is to give the federal government authority to negotiate drug prices for Medicare and other public and private purchasers, with prices capped at the level paid by other high-income countries. He also proposes to cap out-of-pocket drug costs in Medicare, allow consumers to import drugs, and eliminate tax breaks for drug advertising expenses.
Trump: He has prohibited federal family planning funds for clinics that provide or refer for abortion, and permitted employers to exclude ACA contraceptive coverage for religious or moral reasons. He has also repealed antidiscrimination provisions for LGBTQ patients and those who have terminated a pregnancy, and reinstated and expanded the “Mexico City Policy” that blocks federal international assistance for organizations that perform or promote abortions. Trump supports overturning Roe v Wade.
Biden: He supports Roe v Wade and promises to nominate judges who will uphold abortion rights. He also proposes to reverse Trump administration actions on family planning funding, contraceptive coverage, antidiscrimination rules for LGBTQ patients, and the “Mexico City Policy.”
Immigration and Health Care
Trump: He took a variety of steps to restrict immigration, including phasing out the Deferred Action for Childhood Arrivals (DACA) program, building a wall on the US–Mexico border, ending chain migration, and eliminating the visa lottery program. In addition, he expanded public charge rules restricting lawful entry of people likely to receive certain noncash public benefits, including Medicaid. He also issued a proclamation allowing new immigrants to be denied entry without proof of health insurance or ability to pay for medical costs.
Biden: He proposes to reverse Trump administration actions on DACA, the border wall, public charge rules, and separation of parents and children at the border. He supports a roadmap to citizenship for certain unauthorized immigrants. In addition, he would remove the 5-year waiting period for Medicaid and the Children’s Health Insurance Program for lawfully present immigrants. He would also permit unauthorized immigrants to buy coverage in the ACA marketplace, but would not make them eligible for subsidies.
Open Access: This is an open access article distributed under the terms of the CC-BY License.
Corresponding Author: Larry Levitt, MPP, Henry J. Kaiser Family Foundation, 185 Berry St, Ste 2000, San Francisco, CA 94107 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
Levitt L. Trump vs Biden on Health Care. JAMA Health Forum. 2020;1(9):e201110. doi:10.1001/jamahealthforum.2020.1110
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