While President Trump and former vice president Biden hardly talked about their healthcare policy at their two debates, both have a distinct vision for how healthcare in the U.S. should change. The two candidates are about as far apart as they can get on the subject. Below is a primer on their plans for healthcare policy, COVID-19, and the opioid crisis.
Biden’s healthcare plan
Biden has a reliably liberal laundry list of healthcare policies that build on President Obama’s legacy Affordable Care Act. This includes a desire to pay home healthcare workers more and halve the egregious U.S. maternal mortality rate of 17.4 per 100,000. Below are some of his key policies.
— Uphold and expand the Affordable Care Act: Biden promises to create a public health insurance option that is “like Medicare,” would reduce the overall cost of healthcare, and make primary care visits co-pay free. The option would also be available to small businesses that want to provide healthcare to their employees but have a hard time affording it.
— More tax credits that help people afford health insurance: “No family buying insurance on the individual marketplace, regardless of income, will have to spend more than 8.5% of their income on health insurance,” Biden’s stance on health insurance reads. For a family of four earning $100,000 a year, that would mean spending $700 a month on health insurance for the whole family. For an individual making $50,000 a year, monthly insurance rates would come to $354 per month.
— Going over state legislators’ heads: Back in 2014, under the Affordable Care Act, Medicaid expanded to include people whose income is up to 133% of the federal poverty level. However, not all states opted into this expansion. Today, 12 states still have not adopted expanded Medicaid. Biden promises that if he’s elected president he’ll automatically enroll people making below 138% of the federal poverty level through an automatic enrollment process.
— A moratorium on surprise billing: Sometimes you go to a hospital in your insurance network, but you unwittingly see a doctor who is not covered by your insurer. You then get stuck with paying whatever the out-of-network cost is for that doctor, which can be expensive. Biden says he’ll stop healthcare providers from charging patients out-of-network rates when they don’t choose the doctor.
— Cheaper drugs: Biden says he will repeal a law that prevents the Center for Medicare and Medicaid Services from negotiating prices with drug manufacturers. On top of that, he wants to limit the price of drugs that face no competition. He also plans to allow Americans to buy drugs from other countries and improve the cost and availability of generics.
— More contraception and the codification of Roe: Biden wants to ensure access to birth control, restore federal funding for Planned Parenthood, and cement Roe v. Wade as law.
Trump’s healthcare plan
Trump has two main healthcare policies: to cut drug prices and to repeal and replace the Affordable Care Act. Both of these initiatives are leftover promises from his first term, which he failed to achieve. Below are the three main ways Trump is seeking to reduce the cost of healthcare.
—Repeal the Affordable Care Act: Republicans have twice failed to deliver a repeal of the ACA. The main problem was finding a consensus on a replacement program that suits the needs of both moderate and conservative Republicans. However, President Trump has been able to make changes to the ACA through executive orders. He has rolled back the insurance mandate, meaning Americans no longer have to pay a tax if they’re uninsured. He also introduced association plans, which allow small and medium-sized employers to come together to purchase narrow inexpensive insurance for their employees, as well as high-deductible, low-premium, and low-coverage short-term plans.
Since Trump has been in office, the number of uninsured Americans has grown from under 27.3 million in 2016 to nearly 29.6 million in 2019, according to Census data. However, the CDC’s National Health Interview Survey suggests the number of uninsured Americans under 65 was as high as 32.8 million in 2019.
— Cut drug prices: Under Trump, the Food and Drug Administration has approved a record number of generic drugs, which Trump says will bring down the overall cost of prescriptions. However, according to a recent Kaiser Family Foundation poll, roughly a quarter of Americans have a hard time paying for their medications. Within that group, 58% pay more than $100 per month on prescriptions. The pandemic has also put pressure on drug prices, forcing them upward, according to data from discount drug seller GoodRx.
— No surprise billing: Like Biden, Trump also wants to avoid surprising billing. In a June executive order, Trump directed Health and Human Services to make health systems publish pricing so patients can comparison shop. It has 60 days to propose rules that would require health systems to share prices for services that they’ve negotiated with insurers, not just rates they charge to the uninsured. But the proposal will have to go through public feedback, and it could take years before it becomes a rule. Health systems will almost certainly fight it.
— More Health Spending Accounts: Trump is big on high-deductible health plans and health savings accounts. In the same executive order from June, he called for HSAs to be made more accessible, particularly to those with chronic conditions. In the executive order, he also said that HHS should allow HSAs to cover the costs of direct primary care, which doesn’t accept insurance, and payments to healthcare sharing ministries, cost-sharing collectives that cover members’ health costs. Both healthcare sharing ministries and direct primary care function in a similar way to insurance in that they require regular payment for future care. Historically, HSAs don’t cover insurance premiums.
President Trump’s response to the pandemic has largely been to defer to the states. This has at times pitted governors against each other in their search for constrained resources such as personal protective equipment and other medical needs. It has also created a patchwork of responses to the virus, with some states forcing nonessential businesses to close and mandating mask-wearing among residents while others do precious little to contain the virus. Under Trump, the U.S. was slow to get testing for COVID-19 together. In April, the CDC sent out contaminated test kits, which set back testing efforts by weeks. There was also a very low supply of tests. By July, testing was more widespread. However, labs had difficulty processing large volumes of tests, and results were at times delayed up to a week, rendering them useless. To date the U.S. has conducted 137 million tests.
President Trump has waffled on how harmful COVID-19 is to human health, at times comparing it to the flu. Trump is also in favor of completely reopening the U.S. economy.
In the conversation with Martin Kulldorff, PhD (Harvard), Jay Bhattacharya, MD, PhD (Stanford), and Sunetra Gupta, PhD (Oxford), we heard strong reinforcement of the Trump Administration’s strategy of aggressively protecting the vulnerable while opening schools and the workplace.
— Secretary Alex Azar (@SecAzar) October 5, 2020
By contrast, Biden is very firm that COVID-19 is a major threat to American health. The candidate promises to do more testing, secure more personal protective equipment, and build a national contact tracing force.
One of the more interesting initiatives Biden wants to roll out is a clinical trial network for emerging infectious disease. He says such a platform would allow scientists to identify the most promising drugs and vaccines to focus on, therefore streamlining efforts and lowering competition for resources and patients.
Deaths from opioid overdose began in 2013. Since taking office, Trump has put $6 billion toward efforts to track and quell the opioid crisis, but scientists say the funding is not sufficient. To that point, while access to care has grown under the Trump administration, drug overdose deaths have also reached an all-time high.
The National Institute on Drug Abuse estimates that substance abuse costs the country $600 billion annually. Its data indicates that investing in both addiction treatment and healthcare for those suffering from substance use disorders would actually save the country money. Even conservative estimates show that for every dollar invested in addiction care, the country saves $4 to $7 in costs related to drug crime, court costs, and theft. When someone with a substance disorder is also able to get access to healthcare, “total savings can exceed costs by a ratio of 12 to one.”
The Affordable Care Act brought addiction care under the umbrella of insurance coverage. It also expanded Medicaid, which has been associated with reductions in opioid deaths, according to physician Leana S. Wen and medical student Nakisa B. Sadeghi, who wrote about this issue for the medical journal The Lancet. So while Trump has pledged $6 billion to those suffering from opioid addiction, he also wants to repeal the ACA. Ending the ACA would reduce insurance coverage for Americans, reduce Medicaid, and pull addiction care out from under the insurance umbrella, all of which would fundamentally work against those suffering from opioid use disorders, write Wen and Sadeghi.
Under Biden, the ACA would stay and theoretically expand. He proposes that the federal government make a $125 billion investment in prevention, treatment, and recovery for those suffering from substance abuse. The Democratic candidate also says he wants to hold drug companies accountable for the crisis. That would mean further investigating drug companies creating and selling opioids, making the Drug Enforcement Agency more closely monitor drug distributor shipments for diversion, and getting rid of tax breaks for drug advertising. In addition, the Department of Health and Human Services expanded access to buprenorphine, a drug that helps treat opioid addiction, during the Obama Administration. This would likely continue if Biden is elected.
It’s worth noting the health insurers have become more profitable under Trump, according to the National Association of Insurance Commissioners. The industry achieved a 3.3% profit margin in 2018. The pandemic has also proved fruitful, allowing insurers to cash in. Under the ACA, which caps health insurer profits, some of that money will have to come back to patients. But if the ACA is repealed, that money stays in insurers’ pockets.