President Donald Trump and Democratic challenger Joe Biden have dramatically different visions for the future of healthcare policy in the United States.
Healthcare, and specifically access to affordable care, has been a topic of fierce debate in recent presidential elections, and remains top of mind for voters this year, in part, due to the COVID-19 pandemic.
In fact, 29 percent of Americans say healthcare, not the economy, is the most important issue to them, according to a recent Economist and YouGov poll.
With early voting already underway in some states, Healthline spoke with nonpartisan healthcare policy experts to compare where each presidential candidate stands on key healthcare issues so voters can make the most informed decision possible when casting their ballot in this crucial election.
1. The COVID-19 pandemic
Over the last 8 months, the COVID-19 pandemic has shaped the ongoing debate about how to reform the U.S. healthcare system.
President Trump’s handling of COVID-19 so far raises questions about how a Biden administration, if elected, would manage the virus and its toll on our country going forward.
“We cannot talk about healthcare without talking about COVID-19,” said Jamila Taylor, director of healthcare reform and senior fellow at The Century Foundation.
“Trump has disputed the science around COVID. He undermines public health experts, scientists, and physicians who have been trying to address this issue, and he refuses to call for a national mask requirement. He has focused on reopening states and schools prematurely, before we have had a handle on the virus, before testing,” she said.
Many critics have strongly disapproved of the president’s response to the pandemic, including journalist Bob Woodward, who asserted in his recently published book, “Rage,” that Trump knew the new coronavirus was deadly, and intentionally misled Americans by de-emphasizing the dangers.
While the United States represents only 4 percent of the global population, the country has had 21.7 percent of the world’s confirmed COVID-19 cases and 20.6 percent of the planet’s deaths from the virus.
Taylor adds that another stark difference between Trump and Biden’s stance on the pandemic is how they’ve discussed and dealt with its impact on underserved communities.
“We know that the same families disproportionately affected by COVID from a health standpoint are also affected from an economic standpoint. So, under the current administration’s leadership, we have this mix of really dire circumstances largely relating to Black and brown people,” she said.
In contrast, Taylor says the Biden-Harris campaign has talked about the disproportionate effect COVID-19 has had on communities of color.
The campaign has also addressed the need for “targeted testing, ensuring access to healthcare services for those communities, and equitable access to a vaccine once it becomes available.”
Though the Biden-Harris campaign has been clear in its response to COVID-19 would be very different than President Trump’s, Rosemarie Day, CEO of Day Health Strategies and author of “Marching Toward Coverage: How Women Can Lead the Fight for Universal Healthcare,” points out that they wouldn’t have to reinvent how to fight the pandemic on a basic level.
“There’s a playbook for how to deal with the pandemic. It was created by the Obama administration for Ebola,” she said.
However, she says it will also take “a depoliticization of COVID” for the United States to effectively combat the pandemic on a larger scale.
Trump’s approach, in brief
- Has largely let states individually manage their responses to COVID-19.
- Does not support a federal mandate requiring face coverings.
- Has supported the reopening of states and the economy — sometimes despite global health recommendations.
- Signed emergency relief legislation that eliminated out-of-pocket costs for testing, prevention, and a potential vaccine.
- Increased the Medicaid Federal Medical Assistance Percentage (FMAP) — or the amount the federal government pays states for the program — by 6.2 percent.
- Expanded unemployment insurance, paid sick leave, and family leave.
- At the same time, has reduced U.S. engagement around the world on the pandemic, and has cut funding for and distanced the United States from the World Health Organization.
- Has prioritized fast tracking and expanding access to a vaccine for the virus.
Biden’s approach, in brief
- Would shift responsibility of the pandemic to the federal government.
- Has a seven-point plan to beat COVID-19, which includes ensuring access to free testing, increasing production of personal protective equipment (PPE), providing evidence-based guidance and resources on how communities can navigate the pandemic, a plan for equitable and effective distribution of treatment and potential vaccines, protecting older and high-risk Americans, rebuilding the country’s resources to defend against viral threats, and implementing mask mandates nationwide.
- Has pledged to put scientists and global health specialists front and center.
- Promised to expand COVID-19 relief to eliminate out-of-pocket costs for testing and treatment, increase Medicaid FMAP by at least 10 percent, and provide additional pay and PPE to essential workers.
2. The Affordable Care Act
The president, and the Republican Party in general, opposes the Affordable Care Act (ACA), or “Obamacare.”
They’ve vowed to repeal it because they say it’s one step closer to socialized medicine, in that Americans who can afford higher premiums contribute to the premiums of those who can’t.
However, the COVID-19 pandemic has led to millions of Americans losing their jobs, and with them, their health insurance.
“We can’t look at where we are going without looking at the record. Trump has focused on taking away healthcare coverage for many Americans,” Taylor said.
“The list is endless, but first and foremost, his healthcare lawsuit to repeal the Affordable Care Act, as well as numerous efforts where he has used executive actions to roll back existing protections. And, unfortunately, the folks more likely to be underinsured are people of color,” she said.
The president’s attack on the ACA has also been criticized for how it jeopardizes Americans with preexisting conditions, a factor the ACA specifically protects.
On Thursday, the president announced that though he’s fighting to dissolve the ACA, he plans to sign a series of executive orders to force insurers to cover preexisting conditions — something many experts say he doesn’t have the power to do.
And on Saturday, Trump announced his intent to nominate Judge Amy Coney Barrett of the U.S. Court of Appeals for the Seventh Circuit, a vocal opponent of the ACA, to replace the late Justice Ruth Bader Ginsburg on the Supreme Court.
“The nomination of Judge Barrett increases the chances that the health law and its protections for people with preexisting conditions could be invalidated,” said Larry Levitt, Kaiser Family Foundation’s executive vice president for healthcare policy. “Preexisting condition protections will be front and center in the campaign.”
Biden hasn’t only vowed to make sure people with preexisting conditions remain covered, he’s also promised to restore aspects of the ACA that have been repealed under the Trump administration.
Nevertheless, he may have a difficult time undoing Trump’s healthcare changes.
While both leaders point to the goal of lowering out-of-pocket costs for Americans, Jay Wolfson, a University of South Florida distinguished service professor of public health medicine and pharmacy, notes that “as we transition back into Trump or into Biden, a long-term issue not resolved by anybody is, how are we going to pay for this?”
Trump’s approach, in brief
- Has fought to dismantle the ACA through a lawsuit currently in the courts, and through numerous executive actions since taking office.
- Has supported a congressional proposal to replace income-related premium tax credits with flat tax credits, and to allow states to waive essential health benefits.
- Has encouraged state waivers that promote subsidies to non-ACA-compliant policies.
- Cut funding to promote consumer enrollment to ACA, has shortened open enrollment, and limited midyear enrollments.
- Signed legislation repealing the ACA’s individual mandate penalty.
- Supports lowering out-of-pocket costs for Americans, but aims to do so through premiums related to reducing prescription drug costs through Medicare Part D, not through any support of the ACA.
- Announced plans to sign executive orders to force insurers to cover preexisting conditions — something many experts say he doesn’t have the power to do.
- Nominated Judge Amy Coney Barrett, whose writings oppose the ACA, to replace the late Justice Ruth Bader Ginsburg on the Supreme Court.
Biden’s approach, in brief
- If elected, aims to start by reinstating the aspects of the ACA that have been repealed under the Trump administration.
- This reinstatement would include expanding eligibility for financial assistance to people at more than 400 percent of the federal poverty level (FPL) — meaning families with more than a total annual income of $104,800 could be eligible for subsidies — as well as people with employer coverage and people in nonexpansion states.
- Plans to expand the ACA in numerous ways, ultimately ensuring medical coverage for more Americans, and lowering out-of-pocket costs overall.
- Has proposed capping health insurance premiums at 8.5 percent of a family’s income, with families making less than 400 percent FPL paying a lower percentage according to total income.
- Has vowed to restore funding for consumer enrollment assistance and reduce out-of-pocket cost sharing for enrollees.
- His plan to restore and expand the ACA also ensures that no one with a preexisting condition can be denied coverage or access to quality healthcare.
3. Lowering prescription drug prices
Both President Trump and former Vice President Biden see skyrocketing prescription drug prices as a crucial issue in need of reform, but Biden believes federal government intervention should play a bigger role in that reform process than Trump does.
Trump’s approach, in brief
- Supports a payment model under which drugs in Medicare parts B and D wouldn’t cost more than the “most-favored-nation price.” (For example, a 10-millileter (mL) vial of Lantus insulin currently costs $305.53 on Drugs.com in the United States, while the same 10-mL vial is listed at $141 on a Canadian Rx site. Trump’s payment model would ensure the future price of this drug in the United States would match the Canadian price.)
- Has said he would also reduce drug costs by importing safe prescription drugs from foreign countries and reducing pharmacy kickbacks.
Biden’s approach, in brief
- Supports a bill passed by the House of Representatives last year that would allow Medicare to negotiate drug prices with pharmaceutical companies the same way private insurers do.
- Supports prohibiting new drug price increases beyond inflation, and capping out-of-pocket drug costs for Medicare Part D.
- Supports limiting launch prices for drugs that face no competition and limiting price increases of very expensive U.S. brand and biotech drugs to the prices reflected by inflation. (For example, a 10-milligram kit of the rheumatoid arthritis medication Humira is listed at $5,810 in the United States but may cost as little as a quarter of that in European countries. Biden supports limiting the cost of such drugs in the United States, bringing their cost closer to the price at which they’re available in other countries.)
4. Expanding Medicare and Medicaid
Medicare and Medicaid are two different healthcare programs run by combined efforts of the federal and the state governments.
Medicare helps U.S. citizens ages 65 and older pay for medical expenses, while Medicaid assists low-income groups with healthcare expenses.
“Trump has looked to make a number of administrative changes on Medicare, giving states more authority, many of which have been criticized,” said Levitt. “The biggest one is work requirements for Medicare enrollees.”
The president supports lowering prescription drug costs but hasn’t actively passed legislation on this yet, Levitt says.
Trump has broadened Medicare coverage of telehealth during the pandemic and expanded Medicare Advantage benefits.
Biden has said he aims to expand Medicare and Medicaid (both aspects of his plan to further expand the ACA) in an effort make healthcare coverage available to more than 97 percent of Americans.
Biden has said he would also offer premium tax credits for middle-class families.
Trump’s approach, in brief
- Supports limiting Medicaid by imposing work requirements and reducing funding for Medicare.
- Signed an executive order strengthening Medicare Advantage, the private insurer alternative to Medicare.
Biden’s approach, in brief
- Has proposed a new public option, like Medicare, as an alternative to private insurance.
- Has vowed to lower Medicare eligibility age from 65 to 60, and allow people between ages 60 and 64 to keep their current coverage financed separately from Medicare.
- Aims to restore and build on the ACA by expanding Medicaid provisions and allow Medicaid expansion enrollees to roll into the public option.
5. Transparency for medical pricing and network coverage
Both candidates support greater transparency in medical pricing and network coverage.
Both also support halting surprise billing for out-of-network costs.
Trump’s approach, in brief
- Signed an executive order on price transparency requirements in 2019, aiming for Americans to get accurate cost assessments before they receive medical care.
- Yet critics say that hasn’t truly effected change on the issue. “The president would like to see actual prices posted, not just the charge of master prices, and would like providers to be responsible for telling patients what their cost is going to be,” Wolfson said.
- Pledged to look for a way to further prevent surprise medical bills.
Biden’s approach, in brief
- Has proposed to stop surprise billing with government intervention, though he hasn’t been clear on exactly how he would do this.
- Promised to create greater transparency by giving government the power to negotiate drug prices with pharma companies.
- Aims to use antitrust measures to tackle market concentration in the healthcare industry, which he’s said would also bring prices down.
6. Healthcare equality for marginalized communities
Recognizing the needs of marginalized communities due to inequalities in healthcare is an area in which the two candidates vastly differ.
The president has focused on economic opportunity as a way to support the Black community.
On Friday, he announced the Platinum Plan, a $500 billion economic plan designed to increase opportunities for Black Americans.
The plan promises “better and cheaper healthcare” and investments in treatments for kidney disease, diabetes, and sickle cell anemia, conditions that disproportionately affect Black communities.
Taylor criticized the Platinum Plan as “a day late and a dollar short.”
“He is 4 years in and we have seen no comprehensive plan to address inequality for African Americans under the Trump administration. Furthermore, Trump policies have done nothing but deepen inequities for low-income people and people of color throughout this country,” she said.
Taylor said that Biden, in contrast, has been consistent and clear about “addressing health inequalities as well as ensuring coverage for those who have fallen into the gap.”
“Biden has talked about maternal mortality for women of color, ensuring mental health coverage regardless of sexual orientation, ensuring access to quality generics. The list goes on and on,” Taylor said. “All of these issues are essential to addressing disparities as well as the gap for folks of color.”
In fact, Trump has rolled back healthcare protections for LGBTQ people, actions Biden has pledged to reverse.
“You could characterize this election as Biden looking to roll back so much of what Trump has done, and protections for LGBTQ people is one of those areas,” Levitt said.
“If elected, the question is not which regs would he try to roll back, but which would he try to get to first, and how quickly he could work through the whole list,” he said.
Trump’s approach, in brief
- Has made few public statements on healthcare inequalities for people of color in his first term, but last week announced the Platinum Plan, a $500 billion economic plan to elevate Black Americans.
- Has eliminated healthcare protections for LGBTQ people.
- Has restricted access to healthcare for immigrants who aren’t already insured.
Biden’s approach, in brief
- Has pledged to reduce the maternal mortality rate, which disproportionately affects women of color.
- Pledged to defend healthcare protections for all Americans regardless of gender, gender identity, or sexual orientation.
- Pledged to expand healthcare access for immigrants through restoration of the ACA.
7. Increase funding for community health programs
“We are at an important time in our country when racial injustice is threaded into all issues: criminal justice, economics, healthcare,” Taylor said.
She added that “racial justice is not a priority” for the current administration. Whereas, with the Biden campaign, “racial justice is built into their platform on all threads.”
Day believes the Biden-Harris ticket will address this issue in practical terms.
“I don’t think this duo is going to defund the police,” she said, “but I do think they are going to look at reallocating funding toward other things that activists find important. It’s radical incrementalism.”
Trump’s approach, in brief
- Has made clear he has no plan to reallocate funds from policing to healthcare for underserved populations.
- Signed an executive order to increase funding for police to improve misconduct practices.
- Announced he would prosecute the KKK and antifa groups as terrorist organizations.
- Proposed $500 billion economic plan announced last week to uplift Black Americans, which also promises to “partner with local leaders in black communities to ensure maximum federal support for neighborhood revitalization.”
Biden’s approach, in brief
- Pledged to reform the criminal justice system and double investment in community health centers, providing care to underserved populations.
8. Reproductive health
In the arena of reproductive and women’s health, Trump and Biden couldn’t be more polarized.
Future Supreme Court picks could affect women’s reproductive rights, potentially reversing a woman’s right to choose.
Under a Biden-Harris administration, Taylor said she believes “we would see pro-choice nominees, someone who supports expanding reproductive healthcare coverage.”
Before joining the Republican Party, Trump publicly supported abortion, but since running for president, he’s worked to chip away at abortion access, making it a primary platform of his campaign and administration.
Abortion is a key issue among Trump supporters, and the president has made personal and policy decisions accordingly, including being the first president to attend a national March for Life, and attacking funding for Planned Parenthood and reproductive health services.
He’s also appointed conservative-leaning judges to the Supreme Court, and on Saturday nominated Judge Amy Coney Barrett (whose judicial record favors restrictions on abortion access) to replace the late Justice Ruth Bader Ginsburg, a vocal defender of abortion rights and access.
“Reproductive rights and the future of the Affordable Care Act are on the line with this nomination,” Taylor said. “President Trump could not have picked a nominee more opposite to the values and legacy of the late Justice Ruth Bader Ginsburg.”
Biden, a Catholic, has also shifted his public views on abortion over the 50 years he’s been in public service, but for decades now he’s supported protecting the constitutional right to choose through every branch of government.
Trump’s approach, in brief
- Supports restricting federal funding for abortion except in cases of rape, incest, or endangerment of the woman.
- Opposes federal funding for reproductive health services.
- Has prohibited federal Title IX family planning funds for clinics that provide or refer for abortion.
- Opposes the landmark Supreme Court decision Roe v. Wade, which protects a woman’s right to choose.
- Has appointed two Supreme Court judges who have voted against protecting abortion rights, and nominated a third, Judge Amy Coney Barrett, last week, whose judicial decisions have restricted access to abortion.
- Reinstated “the Mexico City policy,” aka the global gag rule, which bars the federal government from supporting healthcare organizations that offer abortion services.
- Has exempted employers from the ACA’s requirement to offer plans that include no-cost contraceptive (birth control) coverage.
Biden’s approach, in brief
- Opposes Trump’s policy agenda in most every way.
- Opposes restricting federal funding for abortion.
- Supports protecting a woman’s right to choose, and wants to make legal and safe abortion a statute, not a court decision.
- Pledged to expand and ensure access to affordable birth control and abortion through restoration of the ACA.
- Vowed to restore federal funding for Planned Parenthood.
- Would rescind the Mexico City policy, allowing the federal government to support healthcare organizations that offer abortion services.
9. HIV education, research, and treatment
Both Trump and Biden say they’re committed to effecting major change in the HIV epidemic by 2025 through funding of education and prevention, but their opposing approaches to the ACA yield different results in access to treatment and services.
Trump’s approach, in brief
- Launched a plan to end the HIV epidemic, aiming to reduce transmissions by 90 percent by 2030.
- Increased domestic HIV funding but cut global aid.
- Implemented a “deploy or get out” policy in the military, effectively attempting to discharge service members with HIV.
- Actively fighting to repeal the ACA, thereby reducing coverage and access to HIV services for people who are living with HIV.
Biden’s approach, in brief
- Would recommit to ending the HIV epidemic by 2025, and would reinstate funding for HIV under the ACA.
- Pledged to reverse the Trump administration’s policies discriminating against LGBTQ patients, who are disproportionately affected by HIV.
10. Mental health
“It’s troubling that in the middle of a pandemic where mental health needs have increased dramatically, there has been little discussion of what to do about it [under the current administration],” Levitt said.
Levitt points out that there are also big differences between Trump and Biden on the issue of mental healthcare.
“Biden has pledged to enforce mental health [inclusion] with coverage. [That inclusion] would roll back dramatically if the ACA is repealed,” he said.
However, despite their different approaches, Wolfson says one issue on which President Trump and Biden are essentially on the same page is mental healthcare for U.S. military veterans.
“They are both looking to address veterans, help the folks in service and out, and, once they become vets, address the depression and suicide that has grown in epidemic proportions,” Wolfson said.
“Outside of that, the president doesn’t have an interest in behavioral health, whereas Biden thinks behavioral health issues are related to physical health and well-being,” he added.
Wolfson also points out that Biden has said he would support more resources for psychologists, psychiatric nurses, and counselors across the healthcare field.
Trump’s approach, in brief
- Signed an executive order in 2019 to develop a strategy to end suicide among veterans.
- Announced a plan this year to raise mental health awareness among veterans and reduce the risk of suicide in veterans.
- However, has also cut funding for Medicaid, which critics say is the nation’s largest funder of mental health services.
Biden’s approach, in brief
- As vice president under Barack Obama, prioritized funding for mental health services.
- If elected, has pledged to expand funding for mental health services and reinforce mental healthcare parity laws.
11. The opioid crisis
The president and the former VP have both publicly declared opioids a national crisis, and already have or intend to allocate federal funding to the issue.
Trump’s approach, in brief
- Declared the opioid crisis a national emergency and unveiled the Initiative to Stop Opioid Abuse in 2018. The initiative included reducing demand and overprescription, educating Americans about opioid risks, cracking down on illegal drug supply chains, and offering evidence-based treatment and recovery services.
- Also signed legislation allocating funds of $1.8 billion to combat the epidemic.
Biden’s approach, in brief
- Released a five-point plan to address the opioid crisis, which proposes to hold pharma companies accountable; invest $125 billion in prevention, treatment, and recovery services; work with the medical industry to stop overprescribing while improving access to pain management; reform the criminal justice system to avoid incarceration related solely to substance use; and stem the flow of illegal heroin and fentanyl into the United States.
You can download a printable copy of our Healthcare Comparison Guide here:
How Healthline determined these comparisons
The Healthline News team analyzed the healthcare policies and proposals of both presidential candidates to date.
We based our analysis on the published policy outlines on each candidate’s official website, as well as public statements made by the candidates and their administration and/or campaign.
From there, we worked with our independent panel of health policy experts and senior editorial team to present where each candidate stands on key healthcare issues.
Our panelists:
- Rosemarie Day, CEO of Day Health Strategies and author of just-released “Marching Toward Coverage: How Women Can Lead the Fight for Universal Healthcare” (Beacon, 2020)
- Larry Levitt, executive vice president for health policy at Kaiser Family Foundation
- Dr. Jamila K. Taylor, director of healthcare reform and senior fellow at The Century Foundation
- Dr. Jay Wolfson, senior associate dean of Morsani College of Medicine and associate vice president of University of South Florida Health
Elizabeth Wallace contributes to Healthline, CNN Underscored, Architectural Digest, Domino, and Us Weekly, and is the author of “The Ambition Decisions: What Women Know About Work, Family, and the Path to Building a Life” (Viking, 2018).
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