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Compare the Candidates on Health Care Policy

Updated: July 15, 2024

The general election campaign has commenced, spotlighting President Biden and former President Trump as the presumptive nominees for their respective parties and the currently viable contenders for the presidency. While this is not an election like in the past where health care reform is a central issue being debated, health care is an important issue for voters and Biden and Trump have sharply divergent records and positions. This side-by-side analysis serves as a quick resource for understanding each candidate’s record as president, positions, public statements, and proposed policies. It will be continuously updated as new information and policy details emerge throughout the campaign.

From Drew Altman: Unraveling The Mysteries of Biden vs Trump on Health Care

Affordable Care Act


  • In 2017, unsuccessfully attempted to repeal and replace the ACA with various plans that would have increased the number of uninsured Americans to 51 million
  • Deprioritized enforcement of the individual mandate penalty, then reduced the penalty to $0. 
  • Stopped payments for cost-sharing subsidies (CSRs), which contributed to premiums increasing, as well as federal subsidies growing. 
  • Reduced funding for outreach, which may have contributed to enrollment stagnating
  • Expanded non-ACA-compliant short-term plans, which restrict coverage for pre-existing conditions.  
  • Allowed Enhanced Direct Enrollment in ACA plans through online brokers. 
  • In budget plans, proposed changes to the ACA that would weaken pre-existing protections and reduce funding substantially through a block grant to states. 
  • As a candidate for this election, he called to “never give up” on repealing the ACA, later adding “Obamacare Sucks” and that he would replace it with “much better healthcare.” He also said he was not running on terminating the ACA and would rather make it “much much better and far less money,” though has provided no specific plans.  
  • Signed the American Rescue Plan Act (ARPA), which temporarily expanded eligibility for and increased ACA Marketplace subsidies. These were extended by the Inflation Reduction Act (IRA) through 2025. 
  • Fixed the “family glitch,” allowing dependents of people with unaffordable employer-based family coverage to receive ACA subsidies. 
  • Reversed Trump administration expansion of short-term plans and restored outreach and enrollment assistance and funding. 
  • Achieved record-high enrollment in ACA Marketplace plans. 
  • Biden proposes to build on legislation passed during his term and make expanded subsidies offered under the IRA permanent.  
  • Proposed a public option health plan during the 2020 campaign but did not issue a formal plan once in office. 

Medicaid


  • Supported unsuccessful efforts to repeal and replace the ACA, including the Medicaid expansion, and proposed restructuring Medicaid financing into a block grant or a per capita cap as well as limiting Medicaid eligibility and benefits. These proposals, included in Trump budget plans as president, were estimated to reduce federal Medicaid spending by roughly $1 trillion over 10 years.  
  • Approved waivers that included work requirements as a condition of Medicaid eligibility, premiums, and other eligibility restrictions.  
  • Took administrative action to relax Medicaid managed care rules and increase eligibility verification requirements. 
  • Signed legislation that included a continuous enrollment requirement in exchange for enhanced federal Medicaid funding during the COVID-19 public health emergency. 
  • Supported legislation to establish a federal option to close the coverage gap that was not passed by Congress and signed legislation with a fiscal incentive for states to newly adopt the ACA Medicaid expansion.  
  • Withdrew demonstration waivers approved in the Trump Administration related to work requirements, and encouraged waivers to expand coverage, reduce health disparities, address the social determinants of health, and help individuals transition out of incarceration. 
  • Issued comprehensive regulations and guidance to streamline enrollment, promote continuity of coverage and to help bolster access in Medicaid fee-for-service and managed care. 

Abortion


  • Takes credit for overturning Roe v. Wade by appointing three anti-choice judges to the Supreme Court, claiming, “After 50 years of failure, with nobody coming even close, I was able to kill Roe v. Wade.” 
  • Has said he would consider a national 15 or 16-week ban on abortion, but more recently has said he supports leaving abortion policy to states, which allows full bans to stay in effect. 
  • Administration issued regulations that blocked clinicians from providing counseling that includes abortion information or referrals in clinics that receive federal Title X family planning funds.    
  • Reinstated and expanded Mexico City Policy prohibiting U.S. global health funds from going to foreign NGOs that perform or promote abortions. 
  • Supports a federal law to restore Roe v. Wade’s standard of abortion legality up to viability.  
  • Biden Administration’s FDA revised restrictions on medication abortion pills, allowing dispensing via certified pharmacies and telehealth.  
  • Issued an Executive Order and guidance affirming that abortions performed to stabilize the health of people experiencing pregnancy-related emergencies are protected by the federal Emergency Medical Treatment and Active Labor Act (EMTALA), even in states that ban abortions. 
  • Defended abortion access in two major Supreme Court cases. 
  • Strengthened HIPAA protections for data privacy, added nondiscrimination protections for people seeking abortion care, and defends right to travel to seek abortion.  
  • Revoked Trump’s Mexico City Policy restrictions. 

Contraception


  • Prohibited family planning clinics such as Planned Parenthood that also offer abortion services (with separate funding) from receiving funds from the federal Title X family planning program, leading to the disqualification or departure of approximately 1000 sites – about 25% of participating clinics. 
  • Issued regulations allowing nearly any employer with a religious or moral objection an exemption from the ACA’s contraceptive coverage requirement.   
  • Approved Texas’s Medicaid program waiver blocking Medicaid payments to Planned Parenthood and other clinics for non-abortion family planning services and excluding coverage of emergency contraceptive pills in state’s family planning program. 
  • Supports ACA and its contraceptive coverage requirement and has defended challenge to the preventive services requirements in the Braidwood case.  
  • Restored rules of federal Title X family planning program requiring participating entities to offer full range of contraceptives, pregnancy options counseling (including abortion referral), and re-allowing clinics that also offer abortion services (with non-federal funds) to qualify for the program. 
  • Biden Administration’s FDA approved first over-the-counter oral contraceptive pills and supports increased access.  
  • Supports policies to expand access to contraceptives for military members and dependents. 

LGBTQ Health


  • Worked to restrict or remove LGBT rights and access to health care. 
  • Issued revised regulations on Section 1557 of the ACA removing protections in health care based on gender identity and sexual orientation.  
  • Created Division of Conscience and Religious Freedom at HHS and issued final conscience regulation broadening nondiscrimination protections for health care entities to include conscience and executive order directing federal agencies to expand religious protections, actions that created opportunities for LGBTQ-based discrimination in certain circumstances.  
  • Removed and sought to curtail data collection on sexual orientation and gender identity in federal surveys.  
  • Proposes to prohibit gender-affirming care for young people and limit for people of any age nationwide, including prohibiting the use of federal funds for these services.  
  • Worked to expand and protect LGBT rights and access to health care. 
  • Issued guidance and regulations on Section 1557 of the ACA providing the broadest protections to date in health care based on gender identity and sexual orientation, for transgender people, and for gender-affirming care.  
  • Issued regulation providing protections for LGBTQ people in HHS grants and services. 
  • Rescinded Trump administration regulatory expansions of conscience regulations that had created potential opportunities for LGBTQ-based discrimination (which multiple federal courts had found to be unlawful).  
  • Intervened, through DOJ, to support plaintiffs in lawsuits challenging state bans on youth access to gender-affirming care and has requested SCOTUS review of the state law. 
  • Issued executive order seeking to advance equity for LGBTQ people
  • Adopted a Federal Evidence Agenda on LGBTQ Equity and an HHS-wide action plan promoting sexual orientation and gender identity data collection and equity in federal programs and surveys.  
  • Voiced support for LGBTQ people, especially young transgender people, and urged Congress to pass the Equality Act – which would add protections based on sexual orientation and gender identity to the Civil Rights Act —  in 2021, and in the 2022, 2023, and 2024 State of the Union addresses.  

Gun Violence


  • Banned bump stocks in response to the 2017 Las Vegas mass shooting, though the ban has since been overturned by the Supreme Court.
  • Reversed Obama-era regulations that required those eligible for Social Security Administration mental disability payments to be blocked from buying guns and made it easier for gun-safety devices to be more widely accessible.
  • Asked the Supreme Court to overturn New York City’s restrictions on transporting handguns in New York State Rifle & Pistol Association, Inc. v. City of New York, New York.
  • On multiple occasions, has suggested that armed citizens could stop mass shootings, including after the Pulse nightclub shooting stating, “you wouldn’t have had the tragedy that you had.” At times, he has partially walked back this suggestion.
  • Has frequently attributed community gun violence and violent crime to both mental illness and immigration, stating that “they’re not humans, they’re animals.”
  • Signed the Bipartisan Safer Communities Act into law, which enhanced background checks for individuals under 21, funds crisis intervention orders, and invests in mental health services.
  • Issued executive actions to reduce gun violence, including rules to curb the proliferation of “ghost guns,” reclassify some firearms to require more strict regulation, and promote the use of Extreme Risk Protection Orders or “red flag laws.”
  • Launched cross-jurisdictional strike forces to reduce illegal firearm trafficking in key regions affected by gun violence and stepped up enforcement against firearm dealers who sold firearms illegally or did not abide by background check requirements.
  • Through both executive action and the American Rescue Plan Act, has funded and supported local public safety and community violence prevention programs.
  • Established the first ever White House Office of Gun Violence Prevention.
  • Has expressed his desire to ban assault weapons and high-capacity magazines, establish universal background checks, require safe storage for firearms, and end immunity for the firearm industry.
  • On multiple occasions, has referred to gun violence as a “public health epidemic.” The Surgeon General appointed by Biden also issued an advisory that declared firearm violence a national public health crisis. Recommendations from the Surgeon General include expanding research and data collection, implementing community violence interventions and education on safe storage, implementing universal background checks and banning assault weapons for civilian use, and increasing mental health access.

Public Health


  • Despite creating Operation Warp Speed, which successfully developed effective COVID-19 vaccines within record time, and initially promoting vaccines, regularly questioned science and public health. 
  • Consistently downplayed COVID-19 as a health threat and routinely countered federal agency and expert advice on pandemic response, including on school re-openings, testing, and masking. Touted the use of unproven therapies such as hydroxychloroquine and suggested that applying ultraviolet light to or inside the body, or injecting disinfectant, could combat coronavirus. 
  • Delegated most responsibility for the COVID-19 response to the states, with the federal government serving as “merely a back-up” and “supplier of last resort.”   
  • Proposed significant budget cuts to CDC and other federal public health programs. 
  • Has vowed to “stop all COVID mandates” and said he would cut federal funding to schools with a “vaccine mandate or a mask mandate.”  
  • Said he “probably would” disband the White House Office of Pandemic Preparedness and Response Policy, established by Congress in 2023.  

Prescription Drug Prices


  • Established a voluntary model allowing participating Medicare Part D plans to limit monthly insulin costs to $35 (in effect from 2021 through 2023). 
  • Created a new pathway to allow states to import prescription drugs from Canada. 
  • Proposed to eliminate drug rebates in Medicare Part D, which was projected to increase Part D premiums and Medicare spending while lowering out-of-pocket costs (implementation subsequently delayed by legislation until 2032). 
  • Proposed to establish a “Most Favored Nation” system of international reference prices for some Medicare-covered drugs (blocked by court action and later rescinded), and to require drug manufacturers to disclose drug prices in television ads (blocked by court ruling). 
  • Proposed several Medicare Part D benefit design changes, including an out-of-pocket cap and weaker formulary standards (proposals not implemented). 
  • Signed the Inflation Reduction Act, which requires the government to negotiate prices for some Medicare-covered drugs (with the number growing over time), requires drug companies to pay rebates if prices rise faster than inflation, caps out-of-pocket drug spending, and limits monthly insulin costs to $35 for Medicare beneficiaries in Part B and all Part D plans, improves financial assistance for low-income beneficiaries, and other changes. 
  • Proposes to expand the number of drugs selected for government price negotiation and extend $35 insulin copay cap and drug out-of-pocket cap to people with commercial insurance.
  • Approved Florida’s plan to import some prescription drugs from Canada; implementation contingent on further action by Florida. 
  • Delayed implementation of the Trump Administration’s drug rebate rule until 2032, which will delay projected increases in Medicare spending. 
  • Established a voluntary model to increase access to cell and gene therapies for people with Medicaid. 

Medicare


  • Proposes to “protect Medicare for future generations” in part by extending solvency of the Medicare Part A Trust Fund by raising Medicare taxes on high earners and closing tax loopholes. 
  • Signed into law the Inflation Reduction Act, which included several provisions to lower Medicare prescription drug expenses, including negotiated drug prices and a $35 monthly insulin cap (see also Prescription Drug Prices). 
  • Expanded coverage of mental health services and access to additional mental health providers. 
  • Extended broader coverage of telehealth through December 2024. 
  • Established new rules for Medicare Advantage insurers, including restrictions on prior authorization and marketing practices. 
  • Established new staffing requirements for Medicare-certified nursing facilities (see also Long-Term Care). 

Health Care Costs


  • Signed the bipartisan No Surprises Act into law, protecting patients from unexpected medical bills when receiving out-of-network care unknowingly. 
  • Issued an executive order on price transparency, leading to a rule requiring hospitals to post negotiated charges for their services online using authority from the ACA.
  • Proposed establishing a “Most Favored Nation” system of international reference prices for some Medicare-covered drugs. However, this was blocked by court action and later rescinded. 
  • Supported efforts to repeal and replace the Affordable Care Act, and in 2024 says he would make the ACA much less expensive (more details in ACA section). 
  • On his 2024 campaign site, he vows to continue his earlier efforts regarding surprise medical bills, price transparency, and prescription drug prices. He also promises to lower health insurance premiums but does not provide details on how he plans to do so. 
  • Under his administration, the Consumer Financial Protection Bureau proposed a rule that would remove medical debt from consumer credit reports. Biden also proposes that in the first 100 days of his next term, he would “wipe out” medical debt for “pennies on the dollar.”
  • In 2021, began implementing the No Surprises Act, establishing processes to determine payments for out-of-network bills and resolving payment disputes
  • Proposed expanding surprise billing protections to ground ambulance providers. 
  • Expanded the Trump-era rules on price transparency to address implementation challenges and enforce the legislation. 
  • Signed the Inflation Reduction Act, empowering Medicare to negotiate prices for certain drugs with pharmaceutical companies and increase subsidies for ACA marketplace plans (more details in Prescription Drug Prices section). 
  • Proposed a public option health plan during the 2020 campaign but did not issue a formal plan once in office. 

Mental Health


  • Proposes a return to mental institutionalization, stating, “for those who are severely mentally ill and deeply disturbed, we will bring them back to mental institutions, where they belong” — moving away from longstanding policies that provide treatment and living in community settings. 
  • Supported repeal of the ACA and cuts to Medicaid, which would reduce coverage and access to behavioral health services, and issued an executive order to expand non-ACA-compliant short-term policies that often limit or exclude mental health services.
  • Signed pandemic legislation (CARES Act) that included an expansion of Certified Community Behavioral Health Clinics (CCBHCs), signed legislation that established the 988 hotline, and issued an executive order on veteran suicide.   

Opioid Use Disorders


  • Declared the opioid crisis a public health emergency, signed bipartisan legislation (SUPPORT Act)
  • 2024 campaign proposes a heavier-handed law and order response to opioids, including reviving restrictive border policies, increasing federal law enforcement involvement in local drug investigations, and seeking the death penalty for drug smugglers and drug dealers.  
  • Plans to support faith-based substance use treatment and job placement but emphasizes a forceful approach for homeless people with mental health and substance use needs, stating ending “the nightmare of the homeless, drug addicts, and dangerously deranged” by arresting or relocating individuals to “tent cities” staffed with health workers on large parcels of inexpensive land. 
  • Increased access to medication treatment through several methods, including changes to dispensing methadone, extending relaxed telehealth rules, creating pathways for providers to improve their treatment knowledge and reduce treatment barriers, and permanently requiring state Medicaid plans to cover medication-assisted treatment (through the 2024 Consolidated Appropriations Act). 
  • Supported increased access to Narcan in order to reverse overdoses.
  • Established the White House Challenge to Save Lives from Overdose, which promotes access to and training on overdose reversal medications.

Long-term Care


  • Issued regulations relaxing oversight for nursing facilities, including removing the requirement to employ an infection preventionist.  
  • Suspended routine inspections in nursing facilities during early months of COVID-19.  
  • Launched the Pharmacy Partnership for Long-Term Care Program to facilitate COVID-19 vaccinations in facilities with residents ages 65+. 
  • Issued guidance to delay the implementation of the “Settings Rule,” which established new protections for people using Medicaid home and community-based services (HCBS). 
  • Required reporting of COVID-19 vaccination rates in nursing facilities.   
  • Established minimum staffing requirements for nursing facilities, with other requirements to support nursing facility workers; issued regulations to increase transparency of private equity ownership of nursing facilities. 
  • Signed legislation increasing federal funding for Medicaid HCBS; proposed $400 billion in new Medicaid funding for HCBS; established requirements to increase access to Medicaid HCBS, promote higher payment rates for home care workers, and reduce the time people wait for services. 
  • Issued an executive order to support long-term care workers. 

Global Health


  • Pursued an “America First” approach to foreign policy, including for global health, prioritizing sovereignty and disengaging from multilateral agreements.  
  • Halted U.S. funding for the World Health Organization and initiated a process to withdraw U.S. membership in the organization. 
  • Significantly expanded the Mexico City Policy to apply to virtually all U.S. bilateral global health funding. When in place, the policy requires foreign NGOs to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source as a condition of receiving U.S. funding. 
  • Chose not to join COVAX, the global initiative to distribute COVID-19 vaccines. 
  • Proposed eliminating/significantly reducing funding for most US global health programs in multiple Presidential budget requests; ended funding for United Nations Family Planning Agency (UNFPA). 
  • Dissolved the National Security Council’s stand-alone Directorate for Global Health Security and Biodefense, moving its functions into other parts of the NSC. 
  • Supported extending the Global Health Security Agenda (GHSA) initiative for an additional five-year period. 

Immigrant Health Coverage


  • Issued regulatory changes to public charge policies that newly considered the use of non-cash assistance programs, including Medicaid, in public charge determinations for people seeking to enter the U.S. 
  • Issued a proclamation suspending entry of immigrants into the United States unless they provided proof of health insurance
  • Rescinded the Deferred Action for Childhood Arrivals (DACA) program, but the Supreme Court ruled the rescission unlawful in 2020. 
  • Rescinded the Trump Administration’s public charge changes and, in 2022, issued regulations that largely codified 1999 guidance, which exclude the use of non-cash assistance programs, including most Medicaid coverage, from public charge determinations. 
  • Revoked the Trump Administration’s proclamation that suspended entry of immigrants unless they provided proof of health insurance. 
  • Issued regulations that extend Marketplace eligibility to DACA recipients, which is estimated to lead to 100,000 DACA recipients gaining coverage.  

Proposals by Trump to carry out mass deportations of millions of immigrants and executive action by both Biden and Trump to have stricter border enforcement may increase fears among immigrant families, making them reluctant to access health coverage and care. 

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