All the President's ... Health Policies

Where do the candidates stand on health policy?
September 14, 2020

Photos via U.S. Departments of Homeland Security and State

Updated Sept. 22, 2020

This fall, the United States has a decision to make: four more years of Donald Trump or a new administration led by Joe Biden. That decision could lead our country’s health care policies down two very different paths.

To help you understand those paths, we dug into President Trump’s record and former Vice President Biden’s health policy proposals. We talked with dozens of experts from across the ideological spectrum to understand the candidates’ goals, the major policies they’ve enacted or plan to pursue, and the impacts of those policies.

You can scroll through the issues, or click on one below to jump to that topic. Interspersed throughout the page are podcast episodes we devoted to breaking down the candidates’ health policies. Those will be released between Sept. 14 and Sept. 24. You can click on the player to listen or the link to read a transcript.

Health Insurance and the Affordable Care Act

President Trump

Goals

  • “Repeal and replace” the Affordable Care Act
  • Provide more choices for health care consumers
  • Limit federal government spending and control

Policies

Impacts

  • ACA marketplace enrollment on HealthCare.gov has declined every year since 2016
  • Overall marketplace enrollment (including state exchanges) has dipped, but remains steady
  • Enrollment in short-term plans increased 27% from 2018 to 2019
  • Administration projects 11 million people will have marketplace insurance via HRA by 2029

The Experts Say...

"The Trump administration has chipped away at the edges of the ACA — they've poked a hole here, knocked off a corner there. But all in all, the ACA has had tremendous staying power."
Emily Gee, PhD
Health Economist, Center for American Progress

Further Reading:

Former Vice President Biden

Goals

  • Restore and build on the Affordable Care Act
  • Move closer to universal health coverage 

Proposed Policies

  • Reverse Trump-era changes to the ACA including reinstating individual mandate
  • Institute “Medicare-like” public option insurance plan
  • Increase ACA subsidies by moving benchmark plan from Silver to Gold plans
  • Lower maximum individual contribution to health insurance coverage to 8.5% of income
  • Expand subsidies to people and families earning more than 400% of the federal poverty limit
  • Lower Medicare eligibility age from 65 to 60

Projected Impacts

The Experts Say...

"We're not talking about a major transformation or a move to a new health care system. This is about ensuring the affordability of existing options and closing some gaps that were left when the Affordable Care Act was enacted."
Christine Eibner, PhD
Senior Economist, RAND Corporation

Further Reading

Prescription Drug Costs

President Trump

Goals

  • Lower consumer and government spending on prescription drugs

Policies

Impacts

  • Consumer drug prices have not fallen
  • Many drug prices have continued to climb
  • Overall, prices are not going up as much as in previous years
  • FDA approved record number of generic drugs in 2017, 2018 and 2019
  • Experts say it’s difficult to connect any changes in drug prices to administration actions, especially because the biggest proposals have not been implemented

The Experts Say...

"We've seen a combination of relatively aggressive rhetoric and executive order action out of the White House, but much less legislation or actual rule changes."
Benedic Ippolito, PhD
Resident Scholar, American Enterprise Institute

Further Reading

Former Vice President Biden

Goals

  • Lower consumer and government spending on prescription drugs

Proposed Policies

  • Allow Medicare to negotiate prices with drugmakers
  • Establish independent review board to set prices for new specialty drugs to be paid by Medicare and the public option based on prices in other countries
  • Limit annual price increases of “all brand, biotech, and abusively priced generic drugs” to rate of inflation as condition of participation in Medicare
  • Allow consumers to buy prescription drugs from other countries

Projected Impacts

The Experts Say...

"This really is probably the area of health policy where [Trump and Biden's] proposals sound most similar. The key question for voters is whether they think Biden would be more aggressive or successful in implementing them."
Benedic Ippolito, PhD
Resident Scholar, American Enterprise Institute

Medicaid

President Trump

Goals

  • Reduce federal spending on Medicaid
  • Give states more flexibility to run their own programs 

Policies

  • Pursued failed legislation that would have:
    • Lowered and capped Medicaid funding to states
    • Eliminated Medicaid expansion and partially replaced it with block grants
  • Focused on increasing eligibility verification requirements for Medicaid recipients
  • Approved several state waiver applications to tie Medicaid eligibility to work requirements 
  • Encouraged states to apply for waivers to deviate from federal minimum requirements in exchange for capped financing
  • Revised “public charge” rule to make it harder for immigrants to get a green card if they are likely to use Medicaid or other safety-net services

Impacts

The Experts Say...

"Many of the major proposals did not go into effect. Of course, the litigation around the ACA is still pending. That change would certainly be lasting for Medicaid as well as the broader health care system."
Robin Rudowitz
Co-Director, Kaiser Family Foundation Program on Medicaid and the Uninsured

Further Reading

Former Vice President Biden

Goals

  • Close coverage gap for people eligible for Medicaid expansion living in non-expansion states

Proposed Policies

Projected Impacts

  • Provide coverage to more than 4 million people currently ineligible for Medicaid

The Experts Say...

"Those 4.5 million people who remain uninsured because states didn’t expand Medicaid, Biden would offer the public option for free to this group and take aggressive steps to get them enrolled."
Christine Eibner, PhD
Senior Economist, RAND Corporation

Reproductive Health

President Trump

Goals

  • Limit access to abortion
  • Increase ability of companies to not offer contraception coverage if it conflicted with their religious or moral beliefs

Policies

  • Significantly expanded the number of companies who could opt out of ACA mandate to cover contraception for employees
  • Required clinics receiving federal family planning (Title X) funding to not offer abortion referrals and establish complete physical and financial separation from any abortion services
  • Reinstated and expanded Reagan-era “Mexico City Policy” denying U.S. global health funds to any organization that “perform or actively promote abortion as a method of family planning” 
  • Appointed conservatives Neil Gorsuch and Brett Kavanaugh to the Supreme Court
  • Appointed around 200 federal judges to lifetime appointments

Impacts

The Experts Say...

"Conservative administrations have always aimed to restrict abortion, but the attack on contraception wasn't there in the same way that we're seeing it from the Trump administration."
Maya Manian, JD
Visiting Professor, American University Washington College of Law

Former Vice President Biden

Goals

  • Expand access to contraception
  • Protect abortion rights

Proposed Policies

Projected Impacts

  • Would likely increase access to abortion, especially for low-income and women of color covered by Medicaid
  • Limit number of companies that can deny employees contraception coverage
  • Restore Title X funding to hundreds of clinics
  • Expand U.S. global health funding 

The Experts Say...

"Biden would accomplish this goal of expanding access to reproductive health care in part by increasing insurance coverage of both contraceptives and abortion care."
Maya Manian, JD
Visiting Professor, American University Washington College of Law

Further Reading

COVID-19

President Trump

Goals

  • Develop a vaccine in record time
  • Limit negative economic consequences
  • Downplay severity of pandemic

Policies

  • Implemented travel restrictions to China on Jan. 31 and Europe on March 11
  • Signed four legislative relief packages totaling nearly $3 trillion
  • Expanded access to and reimbursements for telehealth
  • Slow and limited early response, especially around testing
  • Spent at least $10 billion on Operation Warp Speed to fast-track vaccine development, including advanced purchase agreements with several top vaccine candidates
  • Shifted most responsibility for pandemic response to states and local health officials
  • Announced intention to leave the World Health Organization
  • Encouraged states to “reopen” as soon as possible
  • Disregarded and undercut messaging and evidence from public health experts

Impacts

The Experts Say...

"We still don't have anything approaching a national strategy for something even as basic as testing. And now we're six, seven months, eight months into this pandemic. We've seen what happens as a result of that."
Leana Wen, MD
Emergency Physician and Public Health Professor, George Washington University

Further Reading

Former Vice President Biden

Goals

  • Implement widespread testing and contact tracing
  • Establish sustainable supply chain for PPE and medical supplies
  • Accelerate development of treatments and vaccines
  • Reopen safely
  • Protect older and high-risk people

Proposed Policies

Projected Impacts

  • Mask mandates have proven effective at limiting spread, but many remain strongly opposed to mask wearing
  • Experts say widespread rapid testing is the key to controlling spread pending a vaccine
  • Other countries have returned to more normal activity through widespread testing, contact tracing and mask wearing
  • Federal government will likely incur significant costs to implement proposals
  • Continuous review of supply chain vulnerabilities could better prepare the country for the next crisis
  • Restoring public trust in federal pandemic response could pose a challenge

The Experts Say...

"I think the the big North Star difference between the Trump execution and the Biden plan is around the role of the federal government."
Nicolette Louissaint, PhD
Executive Director, Healthcare Ready

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