Update: On Saturday, November 7, Joe Biden was elected as the 46th president of the United States of America. The following information was published before Election Day.
The 2020 election is just days away, and health and health care issues are still at the forefront of voter concerns, as they have been all year.
The biggest health topic isn't a surprise: the coronavirus pandemic, which is "both a health and economic issue,” Tricia Neuman, senior vice president of the Henry J. Kaiser Family Foundation and director of their Program on Medicare Policy, tells Health. “As the number of cases and deaths continue to rise, and with so much uncertainty about when a vaccine will be approved and widely available, this issue will be with us well into 2021.”
President Donald Trump and former Vice President Joe Biden have very different positions on how to handle COVID-19, and their plans for other pressing issues—like the future of the Affordable Care Act, reproductive rights, skyrocketing drug prices, and reforming Medicare—take different approaches as well.
On the heels of the final presidential debate and with early voting already started in some states, here's Health's guide to where each candidates stands when it comes to health and health care.
The coronavirus has been ranked the second-most important issue in the November election, behind the economy.
President Trump has mostly delegated responsibility for the COVID-19 response to individual states, with the federal government as backup. In the spring, he signed emergency relief legislation that eliminated out-of-pocket costs for coronavirus testing and eventually for the vaccine; expanded unemployment insurance; boosted the Medicaid Federal Medical Assistance Percentage (also known as FMAP, this is the federal government's share of Medicaid expenditures) by 6.2%; and provided paid sick and extended family and medical leave during COVID-19.
Trump also extended the election period for COBRA—which allows laid-off workers to continue their group health insurance coverage by paying full price for the benefits—but his administration provided no subsidies to help pay the premiums, which can be pricey.
The Trump administration declined to reopen enrollment in Affordable Care Act Marketplace plans for the uninsured, and Trump reduced the country’s role in the global response to the coronavirus, ending US funding for the World Health Organization and announcing withdrawal from WHO membership.
Former Vice President Biden believes the Federal government has primary responsibility for a response to COVID-19. Biden proposes expanding federal COVID-19 relief to eliminate out of pocket costs for COVID-19 treatment (not just testing and the vaccine); boosting Medicaid FMAP by at least 10%; providing additional pay and personal protective equipment (PPE) to essential workers; further expanding unemployment insurance and sick and family leave; reimbursing employers for sick leave; and providing an employer tax credit for COVID-19 health care costs.
Biden would also cover COBRA with 100% premium subsidies during the COVID crisis. He would reopen ACA enrollment for the uninsured, re-embrace international engagement, and reverse the decision to defund and withdraw from the WHO.
The Affordable Care Act is also a center-stage issue this election, with the Supreme Court slated to hear arguments on its constitutionality in November. If the ACA is repealed, it would strip insurance coverage from more than 23 million Americans, according to an analysis by the Center for American Progress. And there is no alternative plan on the table.
In late September, President Trump unveiled an executive order touting the America First Healthcare Plan. But although the order promised “more choices, better care, and lower costs for all Americans,” there are currently no details about how that would be accomplished.
“We’ve been promised a replacement plan,” says Gerald Kominski, a professor of health policy and management at the UCLA Center for Health Policy Research. “It’s ‘right around the corner’ for the last four years, and yet there’s still not a replacement plan. So I don’t know what the President proposes to do if the ACA is declared unconstitutional.”
Trump supports repealing the ACA. He has cut funding for consumer enrollment assistance and outreach, shortened open enrollment periods, and limited mid-year special enrollments. He does not support a public health care option, which would allow middle-income, working-age adults to enroll in a public insurance plan like Medicare or Medicaid. Nor does he support doesn’t support Medicare for all.
Both Trump and Biden support protecting people who have pre-existing conditions. But although Trump has signed an executive order aiming to lock in insurance coverage for people with pre-existing conditions, experts point out that an executive order is unenforceable unless other laws are passed.
“The president…has not offered specifics on how he would do it,” Neuman says. “An executive order is more like a statement than an enforceable rule or regulation.”
In 2019, Trump also signed an executive order pushing for price transparency from hospitals and health plans. That’s scheduled to take effect in 2021, but the hospital transparency rule has been challenged in court by the American Hospital Association, and the rule on insurer transparency has yet to be finalized.
Biden supports keeping the ACA and wants to expand eligibility for financial assistance with marketplace plans. He wants to make premium tax credits more generous, reduce out-of-pocket cost sharing for marketplace enrollees, and restore funding for consumer outreach and assistance.
Biden also wants to create a new public health care option—like Medicare—for those who don’t like their current insurance or who don’t have coverage. The public option would be available to all people eligible for marketplace coverage, those with work coverage, and people who would otherwise be eligible for Medicaid in non-expansion states. The new public option would cover ACA essential health benefits.
Trump and Biden share more common ground when it comes to drug prices than on other issues. Both candidates support the idea that Americans shouldn’t pay more for their prescription drugs than typical prices on the international market.
President Trump capped monthly insulin costs for some Medicare Part D enrollees and has signed legislation that accelerated the phaseout of the Medicare Part D “donut hole,” or the gap in drug coverage some users have if they've already spent a certain amount on drugs. (Medicare Part D helps cover the cost of prescription drugs.) He banned “gag clauses” that prohibited pharmacists from telling customers if they could pay less for their prescriptions, and he finalized two pathways to allow prescription medications imported from abroad.
Biden wants to authorize the federal government to negotiate drug prices for Medicare and other purchasers, and to prohibit prices for all brand and some generic meds from rising faster than inflation under Medicare and the public option. He wants to limit launch prices for new specialty drugs for Medicare and the public option, and to cap out-of-pocket drug costs in Medicare Part D.
“The big difference in their strategy is that candidate Biden wants to provide Medicare and Medicaid the ability to negotiate drug prices, and Trump has not told them that,” says Mark Carl Rom, associate professor of government and public policy at Georgetown University.
Medicare is the federal health insurance program for people who are 65 and over, as well as some younger people with disabilities.
President Trump has broadened Medicare coverage of telehealth during the COVID-19 pandemic and offered funds for health care providers. He also expanded Medicare Advantage supplemental benefits. (Medicare Advantage is health insurance offered by a private company approved by Medicare.) He's also proposed changes that would reduce Medicare spending by about $450 billion over 10 years.
Trump has said he wants to eliminate payroll taxes—that part of your paycheck that’s deducted to pay for social programs like Social Security and Medicare. “He would like to defer them now, and if he’s re-elected, to permanently waive those taxes,” Rom says. “That is the source of funding for Medicare.”
Biden, on the other hand, wants to make more people eligible for Medicare, lowering the age of eligibility to 60—with an option for people ages 60 to 64 to keep their current coverage. He wants to expand coverage by adding hearing, vision, and dental benefits to Medicare. And he wants to lower drug prices by giving the government authority to negotiate drug prices with pharmaceutical companies.
Each candidate has very clear policy differences on this issue, and it’s on voters' minds as the Senate moves forward with confirming Supreme Court Justice pick Amy Coney Barrett.
President Trump hopes to make it possible to overturn Roe v. Wade, and to do so by appointing Supreme Court justices willing to overturn the court decision. He has banned the use of Title X family planning funds for clinics that provide abortion services or offer referrals to facilities that do. (Title X is a federal grant program for low-income people for family planning and reproductive health services.) Trump has also exempted more employers from the ACA’s requirement to offer health insurance plans that include no-cost contraceptive coverage.
Trump has removed anti-discrimination protections in health care for LGBTQ+ patients and those who have terminated a pregnancy (so people who are seeking an abortion or who have had an abortion might not be protected if they're discriminated against by health care providers). He’s added new payment requirements for those who enroll in an ACA Marketplace plan that includes coverage for abortion. And he supports the Hyde Amendment, which prohibits federal funding for abortion except in terms of rape, incest, or life endangerment.
Biden supports the repeal of the Hyde Amendment from Congressional appropriations bills. He supports Roe v. Wade, and he’s pledged to reverse the Trump administration’s Title X rule. He wants to bar states from refusing Medicaid payments to reimburse Planned Parenthood and other providers for family planning services.
Biden aims to ensure that people with employer-sponsored health insurance have access to no-cost contraceptive coverage, and he wants to reverse policies that permit discrimination of LGBTQ patients seeking health care. “We can expect that a President Biden would seek to expand reproductive choices, options and services, rather than constrict them,” Rom says.
Both Biden and Trump agree that mental health for veterans needs attention. Trump created a task force to focus on suicide prevention for veterans and proposed more VA funding for suicide prevention, and Biden has proposed expanding and strengthening mental health programs inside and outside the VA.
Both candidates have also focused on the opioid epidemic, with Trump declaring it a national public health emergency in 2017. But from there, the two candidates diverge.
Trump stands behind repealing the ACA, which would result in a reduction in coverage for mental health services for people enrolled in marketplace plans. If the ACA is overturned, mental illnesses could become one of the most common pre-existing conditions in America, meaning people might be denied coverage from private insurance plans because of it—or offered insurance without coverage for mental health treatment.
Trump’s proposed 2021 budget also shrinks total funding for the Substance Abuse and Mental Health Services Administration and to Medicaid, which is the largest payer for mental health services in the US.
Biden supports enforcing existing mental health parity laws and expanding funding for mental health, as well as raising the bar for mental health coverage, including rehabilitative services.
His education plan promises to double the number of psychologists, guidance counselors, nurses, social workers, and other health professionals in schools. He proposes increased funding for the National Health Services Corp (a federal program that pays school loans for primary health care workers and awards scholarships for students training to become health care workers). Biden also wants to develop partnerships among high schools, community colleges, and health centers to inspire youths to pursue jobs in health care.
Health care equality refers to the ability of all people to access equitable treatment at health care facilities, free of discrimination and with inclusive patient services. The Human Rights Campaign, for instance, publishes a Healthcare Equality Index that promotes equitable and inclusive care for LGBTQ patients and their families.
In early October, Trump unveiled a Platinum Plan that promises to deliver, among other things, “better and cheaper health care” to Black Americans, including investments into the causes and cures of kidney disease, high blood pressure, diabetes, sickle cell disease, maternal mortality, and other diseases and conditions that disproportionately affect the Black community. The Trump administration also finalized a rule in June that would remove nondiscrimination protections for LGBTQ+ people regarding health care and health insurance.
Biden pledges to expand access to high-quality health care for LGBTQ+ individuals, and specifically to reverse Trump administration policies that permit discrimination of LGBTQ+ patients seeking health care. Biden’s proposed public option would offer health coverage to the 16% of Black Americans who make too much for Medicaid but not enough for tax credits to help them pay for health coverage.
For more information on how, when, and where you can vote this year visit usa.gov/how-to-vote. You can also head to vote.org to find your nearest polling place, request an absentee ballot, verify your registration status, and even get election reminders (so you never miss an opportunity to have your voice heard). Too young to vote this year? Pledge to register, and vote.org will send you a text message on your 18th birthday—because we fought too hard for this right not to use it.