The 2020 Presidential Election: Implications for Women’s Health

Michelle Long, Amrutha Ramaswamy, and Alina Salganicoff
Published: Oct 15, 2020

Introduction

While all elections have consequences, the outcome of the 2020 presidential election will shape many health issues of importance to women for years to come. From the ongoing COVID-19 pandemic, to the uncertain future of the Affordable Care Act, to threats to reproductive health care, the outcome of this election will have major consequences for women and the nation as a whole. The track records and the positions of the candidates on these issues offer a stark contrast to voters. This brief reviews the key issues that are likely to have a direct impact on women’s health as well as their access to coverage and care, and summarizes the presidential candidates’ stated positions and records on these issues.

President Donald Trump’s positions reflect his record during his presidency, his 2020 campaign website, and the Republican party platform, which is unchanged from 2016. Joe Biden’s positions reflect the policy agenda articulated on his 2020 campaign website, the Democratic party platform, the Unity Task Force Recommendations, and his record as a U.S. senator and as Vice President during the administration of President Barack Obama.

The Affordable Care Act

The Affordable Care Act (ACA) made many changes that have strengthened access to coverage for millions of women in the U.S. The law did away with longstanding policies that insurance plans used to discriminate against women. Today, all plans must include maternity care – which was the norm in employer plans but not in individually-purchased insurance before the ACA – and no-cost recommended preventive services including mammograms, prenatal and well woman care, and contraceptive services and supplies. Medicare beneficiaries also benefit from no-cost coverage for preventive services recommended for older women such as mammograms and bone density testing. Plans are not permitted to charge women more for coverage than men. The law also established consumer protections that guarantee people with a pre-existing health condition (including pregnancy) are not denied or charged more for individual insurance, and made coverage more accessible and affordable by expanding Medicaid and providing subsidies to many people purchasing coverage on their own in the ACA Marketplace.

The ACA’s future is uncertain, as the law’s constitutionality will once again be considered by the Supreme Court, scheduled for one week after the election. If the Supreme Court ultimately decides that all or most of the ACA must be overturned, as the Trump Administration now argues, the consequences would be complex and far-reaching.

Table 1: Comparing the Candidates on the Affordable Care Act
Donald Trump (R)	Joe Biden (D)
Supported numerous unsuccessful Republican-led legislative efforts to ‘repeal and replace’ the ACA. Signed legislation that reduced the individual mandate penalty to $0, effectively eliminating the requirement to hold qualified health coverage. Is supporting a lawsuit before the Supreme Court to overturn the entire ACA, with no plan to replace it. Promoted and expanded access to short-term plans which typically lack many of the protections that were included in the ACA reforms, including maternity care, mental health, or prescription drugs. Cut funding for consumer outreach and enrollment assistance programs in the ACA Marketplace while redirecting some of those funds to promote short-term health plans.	Supports retaining and expanding upon the ACA. Proposed creating a new federal public health insurance option similar to Medicare, referred to as the “public option,” and would automatically enroll uninsured adults who live in a state that has not expanded Medicaid, with no premium and full Medicaid benefits. Has called for increasing financial assistance available to families through the ACA marketplaces and broadening eligibility for these subsidies. Does not support a Medicare for All health care system and supports the continued role of private insurance in health care.

Reproductive Health

Reproductive health care is a core element of women’s health and has been at the center of many partisan debates, particularly with regard to abortion and contraception.¹

CONTRACEPTION
The ACA, Medicaid policy, and the federal Title X family planning program shape women’s access to a broad range of contraceptive services. However, access to and funding for contraception has been at the center of heated political disputes.

Contraceptive Coverage. The ACA requires most individual and employer-sponsored health insurance plans to cover certain preventive services, including FDA-approved, prescribed contraception, at no cost to enrollees. Although the public largely supports this requirement, it has been controversial among some religious employers since it took effect in 2012 and has been the focus of three major Supreme Court cases.

Title X. For more than 50 years, the Title X family planning program has supported the delivery of reproductive health services, including contraception and STI testing and treatment, to millions of low-income women, men, and teens at low or no cost. Two-thirds of Title X clients are people of color. Over the past decade, federal budget reductions and freezes have resulted in significant financial cutbacks to the Title X program. In addition, some congressional leaders have questioned the need to continue to fund the program, the types of services that the program can cover, and the types of providers that qualify for reimbursement.

Table 2: Comparing the Candidates on Access to Contraception
Donald Trump (R)	Joe Biden (D)
Issued regulations that allow nearly any employer with a religious or moral objection to be exempt from the ACA’s requirement to include no-cost contraceptive coverage. Signed legislation nullifying Obama administration rule that prohibited exclusion of abortion providers in the Title X family planning program. Issued regulations that disqualify any provider that offers or refers for abortion services from Title X. Since the rules have been promulgated, 26% of Title X clinics have left the network, including all Planned Parenthood clinics, and the number of people served by the program has dropped from nearly 850,000 to 3.1 million. Redirected Title X family planning funds to crisis pregnancy centers, also known as pregnancy resource centers, which do not provide contraception. Sought to terminate the Teen Pregnancy Prevention Program (TPPP) and redirect funding to abstinence-until-marriage educational programs which have been demonstrated to be ineffective in preventing teen pregnancy and STIs and potentially harmful. Rescinded 2016 “free choice of provider” guidance that had barred state Medicaid programs from excluding abortion providers without evidence of wrongdoing Approved a waiver from Texas’s Medicaid program to block Medicaid payments to Planned Parenthood and other providers affiliated with an abortion provider for non-abortion family planning services.	Has pledged to work to ensure people with employer-sponsored insurance have access to no-cost contraceptive coverage regardless of their employer’s beliefs, with Obama-era exemptions for houses of worship and accommodations for religious non-profits. The new ‘public option’ he has envisioned would cover no-cost contraception for enrollees. Would reverse the Trump administration’s Title X rule and restore funds to family planning clinics that also provide or refer for abortion. Would reinstate “free choice of provider” guidance that prohibits states from excluding qualified abortion providers such as Planned Parenthood from their Medicaid programs without evidence of wrongdoing.

Abortion

Access to abortion is a hotly debated women’s health issue in any presidential election, and even more so this election with the nomination of a new Supreme Court justice. In the years since the Supreme Court ruling on Roe v. Wade legalizing abortion in all states, a number of state and federal laws have been enacted to restrict access to abortion services, including waiting periods, gestational limits, and regulating which procedures may be offered and by which types of providers.

Roe v. Wade. Several states have enacted abortion restrictions that effectively outlaw abortion, hoping the new conservative majority at the Supreme Court will reconsider the precedents set in Roe v. Wade, Planned Parenthood v. Casey, and Whole Woman’s Health v. Hellerstedt and ultimately weaken or overturn the rulings, allowing states to ban or regulate abortion without demonstrating that the benefit to women outweighs the burden. It is widely expected that the Supreme Court will review such a case in the coming term or soon after.

Hyde Amendment. Soon after the Roe v. Wade decision, the Hyde Amendment was added to federal appropriations laws to limit federal funding for abortion to only those pregnancies that are the result of rape or incest, or that pose a threat to the life of the pregnant person. The Hyde Amendment is not permanent law, but rather a “rider” to appropriations bills that has been renewed annually by Congress. The Hyde Amendment drastically limits coverage of abortion under Medicaid and other federal programs, disproportionately impacting women of color and those who are low-income and covered by Medicaid.

Table 3: Comparing the Candidates on Abortion
Donald Trump (R)	Joe Biden (D)
Has expressed strong opposition to abortion and support for overturning Roe v. Wade. Has pledged to nominate “pro-life” judges. Appointed two Supreme Court Justices since taking office, both of whom have anti-abortion records, and who most recently ruled to uphold a Louisiana hospital admitting privileges law that would have made it nearly impossible for abortion providers to keep practicing in the state. Has nominated Judge Amy Coney Barrett to fill the vacancy left by the death of Justice Ruth Bader Ginsburg. Judge Barrett has gone on record criticizing the Roe v. Wade decision and opposes abortion. Has pledged to make the Hyde Amendment, which prohibits federal funding for abortion except in cases of rape, incest, or life endangerment of the pregnant person, permanent law. Has made many false and inflammatory statements about abortion, including falsely equating abortions that occur later in pregnancy with infanticide. Signed executive order requiring that infants born prematurely or that survive an abortion receive medical care. Similar federal laws already exist. Issued regulations (not currently in effect) which add new billing and payment requirements for ACA Marketplace plans that cover abortion, which may reduce the number of plans with coverage for abortion services. Eliminated anti-discrimination regulatory protections in health care for patients who have terminated a pregnancy. Reinstated and expanded the Mexico City Policy which prohibits U.S. global health funding assistance from going to foreign non-governmental organizations that perform or promote abortion as a method of family planning, even with their own funds.	Would work to codify Roe v. Wade. Pledged in a 2019 Democratic presidential candidate survey on abortion to nominate federal judges who will uphold Roe v. Wade. Pledged that his Justice Department will stop state laws that restrict access to abortion, including mandatory waiting periods and targeted restrictions on abortion providers (TRAP) laws. Called for repeal of the Hyde Amendment from congressional appropriations bills. Proposes requiring coverage of abortion services in at least some circumstances in his public option health insurance plan. Would reverse Trump administration policies that permit health care providers to discriminate against patients who have terminated a pregnancy and allows providers to refuse to provide abortion care. Would rescind the Mexico City Policy, also referred to as the “global gag rule.”

Maternal Mortality

Approximately 700 women die each year in the U.S. as a result of pregnancy or delivery complications, most of which are preventable. The maternal mortality rate has risen over the past few decades, with pronounced racial and ethnic disparities and gaps in maternity care services in many rural communities.

To improve maternal health, Congress has taken up several bills that include proposals to extend Medicaid postpartum coverage from 60 days to one year, which would help connect low-income women to prenatal and postpartum care; fund clinical training on health equity and implicit bias; enhance data collection; diversify the perinatal workforce; and develop broader maternity care provider networks in rural areas.

Table 4: Comparing the Candidates on Maternal Mortality
Donald Trump (R)	Joe Biden (D)
Signed the Preventing Maternal Deaths Act of 2018 which provides funding and new federal infrastructure to state, local, and tribal maternal mortality review committees to collect, analyze, and report data related to pregnancy-associated deaths. Implemented the Maternal Opioid Misuse (MOM) model, a program that aims to improve systems of care for low-income pregnant and postpartum women struggling with opioid use disorder. Released a rural health action plan that, among other goals, aims to improve access to pregnancy care in rural communities. No stated positions on campaign website.	Supports the ACA’s Medicaid expansion, which helps connect women to care before, during, and after childbirth. Research has found that the maternal mortality ratio is lower in states that have adopted Medicaid expansion compared to non-expansion states. Would automatically enroll uninsured adults who live in a state that has not expanded Medicaid into proposed public health insurance option, without premiums or cost sharing. This includes postpartum women who may be dropped from Medicaid after 60 days postpartum in non-expansion states. Has pledged to address maternal mortality by adopting California’s model, which established a public-private partnership to investigate maternal deaths and has helped reduce the state’s maternal death rate by half. Platform highlights the need to address the wide racial disparities in maternal mortality, particularly among black and Native American women.

Sexual Violence

1 in 3 women and 1 in 4 men in the U.S. report experiencing sexual violence involving physical contact in their lifetimes. In recent years, the issue of sexual and domestic violence has gained more recognition as a preventable health problem that disproportionately affects women’s health outcomes.

Violence Against Women Act. The most notable law that addresses sexual violence is the Violence Against Women Act (VAWA), signed in 1994. VAWA helps establish many violence prevention efforts, such as funding rape crisis centers, shelters for those who have experienced domestic violence, and other support services for survivors. VAWA expired in 2018, although some VAWA programs are still funded at their usual level. The House of Representatives passed the VAWA Reauthorization Act of 2019; however, it has stalled in the Republican-controlled Senate because of objections to a new provision that prohibits perpetrators of domestic violence from purchasing or possessing a firearm.

Title IX. Another source of partisan conflict has been the Department of Education’s changing guidance on Title IX investigations, which, as part of the federal Civil Rights Act of 1964, prohibits sexual assault and sexual harassment in education. In 2011, the Obama administration issued the Dear Colleague letter, which discouraged perpetrators from being able to personally cross-examine their accusers and lowered the evidentiary burden on the victim to match that of other student conduct cases. In 2017, the Trump administration reversed these changes.

Table 5: Comparing the Candidates on Sexual Violence
Donald Trump (R)	Joe Biden (D)
No stated position on campaign website. Rescinded Title IX Obama administration guidance aimed at protecting survivors of sexual assault on college campuses, permitting colleges to allow perpetrators to cross-examine their accusers and use a stricter standard of evidence for sexual assault cases than for all other student conduct cases (including felony assault).	Senator, was the original sponsor of the Violence Against Women Act (VAWA), in effect from 1994-2018. Supports reauthorizing and expanding the law, including the provision that would prohibit perpetrators of domestic violence from purchasing or possessing a firearm. Has several policy proposals to address violence against women, including protecting survivors of sexual assault from housing discrimination and guaranteeing paid safe leave to survivors who need time off work to address needs associated with domestic violence, sexual assault, or stalking. Would work to reinstate the 2011 Title IX protections for survivors of sexual assault on college campuses. As Vice President, championed It’s On Us, a campaign to end sexual violence on college campuses.

Paid Leave

While most U.S. workers have access to paid sick leave, few are offered paid family leave. Lower-wage and part-time workers are less likely to have access to these benefits than their counterparts. In the absence of a federal law, many states and localities have implemented their own paid leave programs.

Paid leave has gained new urgency during the coronavirus pandemic as thousands of people have fallen ill with COVID-19 or have needed to take time off of work to care for an ill family member or a child whose school or day care has closed. To reduce the risk of having to take unpaid leave in these situations, the Families First Coronavirus Response Act, passed in March 2020, provides short-term paid sick leave and longer-term, partially-paid family leave for absences related to coronavirus, through December 31, 2020. The law excludes the millions of workers at businesses with 500 or more employees.

Table 6: Comparing the Candidates on Paid Leave
Donald Trump (R)	Joe Biden (D)
Has called for some type of national paid parental leave and has allocated funds for it in his FY 2020 budget, but has not issued any formal proposal. Signaled his support for a 2019 Senate bill that would allow new parents to borrow from their future child tax credits while they took time off work, a different approach from most other paid family leave proposals. The bill has stalled. Signed legislation granting federal employees up to 12 weeks of job-protected paid leave for the birth or adoption of a child. Signed legislation that temporarily provides eligible workers with short-term paid sick leave and longer-term paid family leave for specified reasons related to coronavirus. Subsequently elected to exempt virtually all health care workers and emergency responders, as well as employees at firms with fewer than 50 employees, from some or all provisions of the law. No stated position on campaign website.	Has proposed adopting the national paid family and medical leave program envisioned in the FAMILIES Act, which would guarantee workers up to 12 weeks of job-protected leave at partial pay for the birth or placement of a child or to care for family members with a serious illness. Has called for passage of the Healthy Families Act, which would allow workers to accrue and use up to seven job-protected days of paid sick leave per year. Supports expanding the coronavirus emergency paid sick and family leave benefits to include all workers regardless of industry, sector, or employer size, closing many of the gaps in the existing law. As Senator, voted for the Family and Medical Leave Act of 1993 (FMLA), which provides eligible employees up to 12 weeks of job-protected, unpaid leave for qualified medical and family reasons.

Conclusion

There is much at stake for women in the 2020 presidential election and the candidates’ differences on women’s health are stark. President Donald Trump has not released a conventional set of campaign policy proposals, but his record in office illustrates his priorities, which include supporting efforts to repeal the ACA, prioritizing the religious beliefs of employers, including their objections to contraception, and promulgating regulations that limit access to abortion. In contrast, former Vice President Joe Biden supports retaining and strengthening the ACA and expanding access to the full range of reproductive health care, including contraception and abortion. Regardless of the outcome, the 2020 election cycle has significant ramifications for the policy agenda that will shape women’s health for years to come.

Endnotes

Although this brief focuses on domestic policy, the outcome of the 2020 election also has implications for global reproductive health issues, particularly as they relate to the Kemp-Kasten amendment and the Mexico City Policy.

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