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 Oct. 1, 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. You can click on the player to listen or the link to read a transcript.
We will attempt to keep this page updated as the candidates’ announce new plans and policies in the run-up to the election.
More Election-Related Episodes
- The Medicare Cliff, 10/15 — Medicare is usually a top campaign issue, but not this year, even though one of its trust funds is set to run out by 2024.
- Debate Do-Over, 10/1 — Harvard health economist Amitabh Chandra and University of Michigan Chief Health Officer Preeti Malani talk about the hard health care topics we wish we heard about during the first presidential debate
- Shifting Concerns, 9/29 — KFF pollster Ashley Kirzinger on health care’s evolving role in the 2020 election
- An Unpleasant Surprise, 9/3 — Michigan law professor Nicholas Bagley breaks down surprise billing
- It Takes A Toll, 6/2 — Pediatrician and scholar Rhea Boyd on the public health impacts of police violence
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
- Failed to repeal ACA in Congress
- Supporting lawsuit to overturn ACA at Supreme Court
- Eliminated ACA individual mandate in tax legislation
- Shortened open enrollment period and cut marketing and navigator funding
- Extended availability of non-ACA compliant short-term insurance plans
- Give employers ability to pay for employees’ marketplace insurance through Health Reimbursement Arrangements (HRAs)
- Signed symbolic executive order stating it’s U.S. policy to protect coverage for people with pre-existing conditions
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:
- Executive Order on America-First Health Plan (The White House)
- Back to the Future: Trump’s History of Promising a Health Plan That Never Comes (Victoria Knight, Kaiser Health News, 8/13/2020)
- Health Reform Progress: Beyond Repeal and Replace (Brian Blase, Galen Institute, 9/2019)
- How Trump’s Policies Have Hurt ACA Marketplace Enrollment (Charles Gaba and Emily Gee, Center for American Progress, 4/16/2020)
- New Congressional Investigation Of Short-Term Plans (Katie Keith, Health Affairs, 6/26/2020)
- The Value Of Short-Term Health Plans: Rebutting The Energy And Commerce Democratic Staff Report (Brian Blase and Doug Badger, Health Affairs, 8/17/2020)
- Obamacare Boost Expected From New Trump Administration Health Plans (Sara Hansard, Bloomberg Law, 9/11/2020)
- The Trump administration’s final HRA rule: Similar to the proposed but some notable choices (Christen Linke Young, Matthew Fiedler and Jason Levitis; USC-Brookings Schaeffer Initiative for Health Policy; 6/14/2019)
- What It Means To Cover Preexisting Conditions (Katie Keith, Health Affairs, 9/11/2020)
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
- Insures millions more people but still leaves sizable uninsured population
- Increases government spending on health care
- Could slightly raise or lower total health care spending
- Could lower out-of-pocket costs for some and increase them for others
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
- Joe Biden’s Health Care Plan — “Give Every American Access to Affordable Health Insurance” (JoeBiden.com)
- Joe Biden’s Obamacare opportunity (Dylan Scott, Vox, 8/20/2020)
- Understanding Joe Biden’s 2020 Health Care Plan (Committee for a Responsible Federal Budget, 8/31/2020)
- Options for Designing a Public Option (Michael Cohen, Al Bingham, Stan Dorn, Jodi L. Liu, Christine Eibner; The RAND Blog; 5/28/2020)
- Expanding Enrollment Without the Individual Mandate: Options to Bring More People into the Individual Market (Jodi Liu and Christine Eibner, Commonwealth Fund, 8/2018)
- Comparing Health Insurance Reform Options: From “Building on the ACA” to Single Payer (Linda Blumberg et. al, Commonwealth Fund, 10/16/19)
- Biden’s Health Play In A COVID-19 Economy: Lower Medicare’s Eligibility Age To 60 (Julie Rovner, NPR, 4/11/2020)
Prescription Drug Costs
President Trump
Goals
- Lower consumer and government spending on prescription drugs
Policies
- Announced legally questionable plan to send seniors $200 discount cards to seniors for prescription drugs
- Cut Medicare payments to hospitals that receive drug discounts under the 340B program
- Capped insulin co-pays at $35 a month for Medicare
- Signed bill banning pharmacist “gag clauses”
- Proposed but failed to or yet to implement:
- Tie prescription drug prices in Medicare to prices paid in other countries
- Allow states to import drugs from Canada
- Require drug rebates to be passed directly to consumers
- Require drugmakers include prices in TV ads
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, but many have not come to market in the U.S.
- 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
- American Patients First: The Trump Administration Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs (Department of Health and Human Services, 5/2018)
- On Drug Pricing, The President’s Numbers Are Still Off (Shefali Luthra, Kaiser Health News, 2/5/2020)
- Trump Administration Salutes Parade Of Generic Drug Approvals, But Hundreds Aren’t For Sale (Sydney Lupkin and Jay Hancock, Kaiser Health News, 2/7/2019)
- Drug prices steadily rise amid pandemic, data shows (Sarah Owerhmole, POLITICO, 7/7/2020)
- Trump unveils plan to slash drug costs tied to what’s paid abroad (Sarah Owermohle, POLITICO, 9/13/2020)
- As He Woos Drugmakers on Virus, Trump Demands Drug Price Controls (Margot Sanger-Katz, Noah Weiland and Katie Thomas; New York Times; 7/24/2020)
- 10 FAQs on Prescription Drug Importation (Meredith Freed, Tricia Neuman and Juliette Cubanski; Kaiser FamilyFoundation; 3/19/2020)
- What are the recent and forecasted trends in prescription drug spending? (Rabah Kamal, Cynthia Cox and Daniel McDermott; Kaiser Family Foundation; 2/20/2019)
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
- Price negotiation and inflation limits could significantly lower federal spending on prescription drugs
- Basing prices off other countries’ would likely lower costs and cause some reduction in new drug development
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
Further Reading
- Joe Biden’s Health Care Plan — “Stand Up to Aubse of Power By Prescription Drug Corporations” (JoeBiden.com)
- What a Biden Presidency Could Mean for Drug Pricing (Karen Andersen and Damien Conover, Morningstar, 7/17/2020)
- Budgetary Effects of H.R. 3 (Congressional Budget Office, 12/10/2019)
- Examining Two Approaches to U.S. Drug Pricing: International Prices and Therapeutic Equivalency (Bipartisan Policy Center, 10/2019)
- Understanding The Senate Finance Committee’s Drug Pricing Package (Rachel Sachs, Health Affairs, 7/26/19)
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
- Medicaid enrollment had decreased slightly pre-pandemic, especially among children
- Courts have blocked work requirements in most states
- Only one state (Oklahoma) applied for capped financing waiver, and it later withdrew
- Reports of decreased participation because of public charge rule
- Seven states adopted Medicaid expansion, despite administration opposition
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
- 5 Things To Know About Trump’s Medicaid Block Grant Plan (Rachana Pradhan and Phil Galewitz, Kaiser Health News, 1/31/2020)
- Medicaid Program Integrity and Current Issues (Samantha Artiga and Robin Rudowitz, Kaiser Family Foundation, 12/10/2019)
- Medicaid 1115 Work Experiments: The Current State of Play (Sara Rosenbaum, Alexander Somodevilla, Maria Velasquez, Morgan Handley and Sara Rothenberg; Commonwealth Fund; 1/28/2020)
- Medicaid Work Requirements In Arkansas: Two-Year Impacts On Coverage, Employment, And Affordability Of Care (Benjamin D. Sommers, Lucy Chen, Robert J. Blendon, E. John Orav, and Arnold M. Epstein; Health Affairs; 9/2020)
Former Vice President Biden
Goals
- Close coverage gap for people eligible for Medicaid expansion living in non-expansion states
Proposed Policies
- Automatically enroll expansion-eligible population in non-expansion states into the public option with no premium
- Increase federal funding to pay for home and community-based long-term services for 800,000 Medicaid recipients on waitlist
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
Further Reading
- Joe Biden’s Health Care Plan – “Give Every American Access to Affordable Health Insurance” (JoeBiden.com)
- The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid (Rachel Garfield, Kendal Orgera and Anthony Damico; Kaiser Family Foundation; 1/14/2020)
- Biden Makes Big Commitment To Home-Based Medicaid Long-Term Care, But Gaps Remain (Howard Gleckman, Forbes, 7/21/2020)
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
- Estimated 70,000-126,000 women could lose access to contraception coverage
- Planned Parenthood withdrew from Title X program, affecting 410 clinics
- About 25% of Title X clinics left the program, impacting an estimated 1.6 million women
- NGOs declined more than $150 million in U.S. aid because of Mexico City Policy
- More conservative Supreme Court and federal judiciary could lead to further abortion restrictions
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
Further Reading
- The Status of Participation in the Title X Federal Family Planning Program (Kaiser Family Foundation, 12/20/2019)
- Supreme Court Upholds Trump Administration Regulation Letting Employers Opt Out of Birth Control Coverage (Adam Liptak, New York Times, 7/8/2020)
- Judicial appointments in Trump’s first three years: Myths and realities (Russell Wheeler, Brookings Institution, 1/28/2020)
- The Mexico City Policy: An Explainer (Kaiser Family Foundation, 6/29/2020)
- The Trump campaign is touting its anti-abortion record. It could preview what a second term could bring. (Shefali Luthra, The 19th, 9/11/2020)
Former Vice President Biden
Goals
- Expand access to contraception
- Protect abortion rights
Proposed Policies
- Enshrine Roe v. Wade in law
- End the Hyde Amendment, which bans federal funding for abortion
- Reverse Trump expanded exemptions to ACA birth control mandate
- Use Justice Department to oppose anti-abortion state laws
- Reverse Trump changes to Title X funding
- Rescind the Mexico City Policy
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
- Joe Biden’s Health Care Plan — “Ensure Health Care is a Right for All, Not a Privilege for Just a Few” (JoeBiden.com)
- The Hyde Amendment and Coverage for Abortion Services (Alina Salganicoff, Laurie Sobel and Amrutha Ramaswamy; Kaiser Family Foundation; 9/10/2020)
- Democratic Candidates Have Promised to ‘Codify’ Roe v. Wade. What Does That Mean? (Marie Lodi and Erica Schwiegershausen, The Cut, 10/16/2019)
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
- More than 6 million cases and 200,000 deaths from COVID-19 in the U.S.
- U.S. has more than 20% of global COVID-19 deaths with only 4% of the population
- Unemployment rose to nearly 15% as tens of millions have lost their jobs, and some, their health insurance
- Insufficient testing capacity without a national strategy
- Continued shortages of personal protective equipment (PPE)
- About one-third of Americans say they would not take a COVID-19 vaccine if it was available today
- Millions of Americans accessed care via telehealth
- Several promising vaccine candidates have begun production with federal support
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
- Trump Scorns His Own Scientists Over Virus Data (Peter Baker, New York Times, 9/16/2020)
- How the Pandemic Defeated America (Ed Yong, The Atlantic, 8/4/2020)
- Operation Warp Speed promised to do the impossible. How far has it come? (Helen Branswell, Matthew Herper, Lev Facher, Ed Silverman and Nicholas Florko; STAT; 9/8/2020)
- Comparing Trump and Biden on COVID-19 (Kaiser Family Foundation, 9/11/2020)
- Timeline: The Trump Administration’s Decisive Actions to Combat the Coronavirus (DonaldJTrump.com, 4/27/2020)
- Why virtual care will outlast the pandemic (Mohana Ravindranath, POLITICO, 6/12/2020)
- What Have Pandemic-Related Job Losses Meant for Health Coverage? (Cynthia Cox and Danield McDermott, Kaiser Family Foundation, 9/11/2020)
- Why the U.S. Still Has a Severe Shortage of Medical Supplies (Daniel Joseph Finkenstadt, Robert Handfield and Peter Guinto; Harvard Business Review; 9/17/2020)
- Why Can’t America Make Enough N95 Masks? 6 Months Into Pandemic, Shortages Persist (Joel Rose, NPR, 9/17/2020)
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
- Set up a national strategy to develop and distribute rapid tests
- Double the number of drive-through testing sites
- Have the federal government pay for regular rapid testing for all workers
- Guarantee paid sick leave related to COVID-19
- Establish “rigorous emergency temporary standard for worker protection”
- Hire 100,000 public health workers
- Establish national mask mandate wearing through executive order or urging state and local action
- Use Defense Production Act to produce and distribute PPE and medical supplies
- Begin ongoing review of country’s supply chain vulnerabilities
- Rebuild domestic manufacturing capacity of critical products
- Proactively develop nationwide vaccine campaign
- Restore relationship with World Health Organization
Projected Impacts
- Mask mandates have proven effective at limiting spread, but some remain strongly opposed to mask wearing
- Many experts say widespread rapid testing is the key to controlling spread pending a vaccine, although some worry about the tests being less accurate
- 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
Further Reading
- Joe Biden’s Plan to Beat COVID-19 (JoeBiden.com)
- The Biden Plan to Coordinate Critical Materials for All 50 States and U.S. Territories (JoeBiden.com)
- The Biden Plan to Rebuild U.S. Supply Chains and Ensure the U.S. Does Not Face Future Shortages of Critical Equipment (JoeBiden.com)
- Here’s how Joe Biden would combat the pandemic if he wins the election (Yasmeen Abutaleb and Laurie McGinley, Washington Post, 9/11/2020)
- Legislative and Regulatory Steps for a National COVID-19 Testing Strategy (Mark McClellan, Caitlin Rivers and Christina Silcox; Duke-Margolis Center for Health Policy; 8/5/2020)
- The Plan That Could Give Us Our Lives Back (Robinson Meyer and Alexis C. Madrigal, The Atlantic; 8/14/2020)
- Universal Masking in the United States: The Role of Mandates, Health Education, and the CDC (Lawrence Gostin, Glenn Cohen and Jeffrey P. Koplan; JAMA; 8/10/2020)
- What I want to hear from Joe Biden on his plans for handling the pandemic (Leana Wen, Washington Post, 8/18/2020)
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