Introduction

Many people require fertility assistance to have children. This could either be due to a diagnosis of infertility, or because they are in a same-sex relationship or single and desire children. While there are several forms of fertility assistance, many services are out of reach for most people because of cost. Fertility treatments are expensive and often are not covered by insurance. While some private insurance plans cover diagnostic services, there is very little coverage for treatment services such as IUI and IVF, which are more expensive. Most people who use fertility services must pay out of pocket, with costs often reaching thousands of dollars. Very few states require private insurance plans to cover infertility services and only one state requires coverage under Medicaid, the health coverage program for low-income people. This widens the gap for low-income people, even when they have health coverage. This brief examines how access to fertility services, both diagnostic and treatment, varies across the U.S., based on state regulations, insurance type, income level and patient demographics.

Diagnosis and Treatment Services

Infertility is most commonly defined¹  as the inability to achieve pregnancy after 1 year of regular, unprotected heterosexual intercourse, and affects an estimated 10-15% of heterosexual couples. Both female and male factors contribute to infertility, including problems with ovulation (when the ovary releases an egg), structural problems with the uterus or fallopian tubes, problems with sperm quality or motility, and hormonal factors (Figure 1). About 25% of the time, infertility is caused by more than one factor, and in about 10% of cases infertility is unexplained. Infertility estimates, however do not account for LGBTQ or single individuals who may also need fertility assistance for family building. Therefore, there are varied reasons that may prompt individuals to seek fertility care.

A broad array of diagnostic and treatment services may be necessary to assist in fertility (Table 1). Diagnostics typically include lab tests, a semen analysis and imaging studies or procedures of the reproductive organs. If a probable cause of infertility is identified, treatment is often directed at addressing the source of the problem. For example, if someone has abnormal thyroid hormone levels, thyroid medications may help the patient achieve pregnancy. If a patient has large fibroids distorting the uterine cavity, surgical removal of these benign tumors may allow for future pregnancy. Other times, other interventions are needed to help the patient achieve pregnancy. For example, if a semen analysis reveals poor sperm motility or the fallopian tubes are blocked, the sperm will not be able to fertilize the egg, and intrauterine insemination (IUI) or in-vitro fertilization (IVF) may be necessary. These procedures also facilitate family building for LGBTQ and single individuals, with use of donor egg or sperm, with or without a gestational carrier (surrogacy).

Utilization of Fertility Services

Our analysis of the 2015-2017 National Survey of Family Growth (NSFG) finds that 10% of women²  ages 18-49 say they or their partner have ever talked to a doctor about ways to help them become pregnant (data not shown).³  Among women ages 18-49, the most commonly reported service is fertility advice (Figure 2).

The CDC finds that use of IVF has steadily increased since its first successful birth in 1981. According to the most recent data, an estimated 1.8% of U.S. infants are conceived annually using assisted reproductive technology (ART) (e.g., IVF and related procedures).⁴  The proportions are highest in the Northeast (MA 4.7%, CN 3.9%, NJ 3.9%), and lower in the South and Southwest (NM 0.4%, AR 0.6%, MS 0.6%).

Utilization of fertility services has dropped drastically during the COVID-19 public health emergency. On March 17, 2020 the American Society for Reproductive Medicine (ASRM) issued guidelines to stop all new fertility treatment cycles and non-urgent diagnostic procedures. Since then, ASRM has provided updated guidance on what conditions should be met and measures should be taken before safely resuming fertility care. During this time, a study by Strata Decision Technology of 228 hospitals across 40 states found patient encounters for infertility services were down 83% from March 22 to April 4, 2020 compared to this time the year prior.

Cost of Services

Many patients lack access to fertility services, largely due to its high cost and limited coverage by private insurance and Medicaid. As a result, many people who use fertility services must pay out of pocket, even if they are otherwise insured. Out of pocket costs vary widely depending on the patient, state of residence, provider and insurance plan. Generally, diagnostic lab tests, semen analysis and ultrasounds are less expensive than diagnostic procedures (e.g., HSG) or surgery (e.g., hysteroscopy, laparoscopy). Meanwhile treatment using fertility medications is less expensive than IUI and IVF, but even the less costly treatments can still result in thousands of dollars of out of pocket costs. Many people must try multiple treatments before they or their partner can achieve a pregnancy (typically medication first, followed by surgery or fertility procedures if medications are unsuccessful). A study of nearly 400 women undergoing fertility care in Northern California demonstrates this overall trend, with the lowest out of pocket spending on treatment with medication only and the highest costs for IVF services (Figure 3). Prior research showed the cost of just one standard cycle of IVF was approximately $12,500 in 2009, but is likely higher today due to rising health care costs overall. Furthermore, many patients require several rounds of treatment before achieving a pregnancy, with costs accruing each cycle making these interventions financially inaccessible for many. In addition to costs for the actual treatment, patients can be saddled with out of pocket expenses for office visits, diagnostic tests/procedures, genetic testing, donor sperm/egg use and storage fees and wages lost from time off work.

Insurance Coverage

Insurance coverage of fertility services varies by the state in which the person lives and, for people with employer-sponsored insurance, the size of their employer. Many fertility treatments are not considered “medically necessary” by insurance companies, so they are not typically covered by private insurance plans or Medicaid programs. When coverage is available, certain types of fertility services (e.g., testing) are more likely to be covered than others (e.g., IVF). A handful of states require coverage of fertility services for some fully-insured private plans, which are regulated by the state. These requirements, however, do not apply to health plans that are administered and funded directly by employers (self-funded plans) which cover six in ten (61%) workers with employer-sponsored health insurance. States also have purview over the benefits covered by their Medicaid programs. The federal government has authority over benefit requirements in federal health coverage programs, including Medicare, the Indian Health Service (IHS) and military health coverage.

Private Insurance

Fifteen states have laws in effect requiring certain health plans to cover at least some infertility treatments (a “mandate to cover”) (Figure 4). Additionally, Colorado recently enacted a requirement for individual and group health benefit plans to cover infertility diagnosis, treatment and fertility preservation for iatrogenic infertility, effective January 2022. Among states that do not have a mandate to cover, nine states⁵  and DC have a benchmark plan that includes coverage for at least some infertility services (diagnosis and/or treatment) for most individual and small group plans sold in that state.⁶  Two states (CA and TX⁷ ) require group health plans to offer at least one policy with infertility coverage (a “mandate to offer”), but employers are not required to choose these plans.

However, in states with “mandate to cover” laws, these only apply to certain insurers, for certain treatment services and for certain patients, and in some states have monetary caps on costs they must cover (Appendix 1). For example, in OH and WV, the requirement to cover infertility services only applies to health maintenance organizations (HMOs). In other states, almost all insurers and HMOs are included in the mandate. Many states provide exemptions for small employers (<50 employees) or religious employers. In addition, state laws do not apply to self-funded (or self-insured) employer plans, which are regulated by federal law. Sixty-one percent of covered workers are enrolled in a self-funded plan.

Even in states with coverage laws, not all patients are eligible for infertility treatment. In HI, someone with unexplained infertility only qualifies for IVF after five years of infertility. In others, patients are eligible after 1 year. Some states place age limits on female patients who can access these services (e.g., ineligible if 46 or older in NJ or if under age 25 or older than 42 in RI). Others place restrictions based on marital status; for example, until May 2020, IVF benefits were only available to married women in MD. Recently enacted legislation now expands coverage to unmarried women. Additionally, it is not always made clear if LGBTQ individuals meet eligibility criteria for these benefits, without a diagnosis of infertility. Furthermore, many costs associated with surrogacy are often not covered by insurance.

States also vary in which treatment services they require plans to cover. Some states mandate insurers to cover cryopreservation for persons with iatrogenic infertility, while others do not. Four states with insurer mandates do not cover IVF. Eleven states do, but with a dollar limit on coverage (e.g., $15,000 lifetime max in AR and $100,000 in MD and RI) or a limit on the number of cycles they will cover (e.g., one cycle of IVF in HI and three cycles in NY).

Do state mandates for IVF coverage affect use of services?

IVF utilization appears to be higher in states with mandated IVF coverage. CDC data from 2016 showed that in three of the four states deemed by the CDC to have “comprehensive coverage”⁸  for IVF (IL, MA, NH), use of assisted reproductive technology was 1.5 times higher than the national rate. Similarly, a national study found that IVF availability and utilization⁹  were significantly higher in states with mandated IVF coverage. A study in MA found IVF utilization increased after implementation of their IVF mandate, but overutilization by patients with a low chance of pregnancy success was not found. State level mandates can also help reduce inequities in access. For example, a recent bill proposed in the CA legislature would reverse existing limitations on fertility coverage and make the benefit available to single women and women in same sex relationships.

What does it cost to cover fertility benefits?

While the costs of fertility treatments can be very expensive for those who lack coverage, the cost of covering fertility benefits varies depending on the services covered and utilization with implications for state budgets, employers, and policy holders. For example, in 2019, New York passed a bill to require IVF and fertility preservation services for comprehensive private health insurance policies. The New York State Department of Financial Services estimated that premiums would increase 0.5% to 1.1% due to mandating IVF coverage, and 0.02% for mandating fertility preservation for iatrogenic infertility (caused by medical treatments).

An analysis of a bill proposed in CA to require private plans and Medi-Cal managed care plans to cover IVF services estimated that per member per month premiums would increase by approximately $5 in the private market and less than a $1.00 for Medi-Cal plans. Overall though, out of pocket spending for individuals seeking services would decrease substantially.

Data from MA, CT and RI suggest that mandating coverage does not appear to raise premiums significantly. All three states have been mandating infertility benefits for over 30 years, and estimate the cost of infertility coverage to be less than 1% of total premium costs. In 2017, California was considering a more limited bill that would require fertility preservation for iatrogenic infertility in certain individual and group health plans. As the bill was introduced, it was estimated to result in a net annual increase of $2,197,000 in premium costs or 0.0015% for enrollees in plans subject to the mandate.

While these costs could be modest in comparison to the costs of paying out-of-pocket for these services, there are other costs to coverage mandates. The ACA requires states to offset some of the costs for any state mandated benefits beyond essential health benefits (EHBs) in the individual and small group market. This requirement was estimated to cost NY $59 to $69 million per year if covering one cycle or $98 to $116 million per year if covering unlimited cycles of IVF.

What share of employers offer fertility benefits?

Large employers are more likely than smaller employers to include fertility benefits in their employer-sponsored health plans. According to Mercer’s 2017 National Survey of Employer-Sponsored Health Plans, 56% of employers with 500 or more employees cover some type of fertility service, but most do not cover treatment services such as IVF, IUI, or egg freezing. Coverage is higher for diagnostic evaluations and fertility drugs. Coverage is more common among the largest employers and those that offer higher wages (Figure 5).

Public Coverage

Medicaid

NSFG data show that significantly fewer women with Medicaid have ever used medical services to help become pregnant compared to women with private insurance. As of January 2020, our analysis of Medicaid policies and benefits reveal only one state, New York, specifically requires their Medicaid program to cover fertility treatment (limited to 3 cycles of fertility drugs) (Figure 6). However, some states may require Medicaid to cover treatments for conditions that impact fertility, while not directly stated in their policies. For example, states may cover thyroid medications, or cover surgery for fibroids, endometriosis or other gynecologic abnormalities if causing pelvic pain, abnormal bleeding or another medical problem, other than infertility. No state Medicaid program currently covers artificial insemination (IUI), IVF, or cryopreservation (Appendix 2).

Some states specifically cover infertility diagnostic services; GA, HI, MA, MI, MN, NH, NM and NY all offer at least one Medicaid plan with this benefit, but the range of diagnostics covered varies. For example, New York Medicaid specifically covers office visits, HSGs, pelvic ultrasounds and blood tests for infertility. Meanwhile, the infertility assessment covered by Georgia Medicaid includes lab testing, but not imaging or procedural diagnostics. Other states specifically do not cover infertility diagnostics, or more generally do not cover “infertility services,” which likely includes diagnostics. Others do not mention infertility diagnostics in their Medicaid policies, meaning the beneficiary would need to check with their Medicaid program to see if these services are covered (Appendix 2).

The Medicaid program’s lack of coverage of fertility assistance has a disproportionate impact on women of color. Among reproductive age women, the program covers three in ten (30%) who are Black and one quarter who are Hispanic (26%), compared to 15% who are White. Because eligibility for Medicaid is based on being low-income, people enrolled in the program likely could not afford to pay for services out of pocket.

The relative lack of Medicaid coverage for fertility services stands in stark contrast to Medicaid coverage for maternity care and family planning services. Nearly half of births in the U.S. are financed by Medicaid, and the program finances the majority of publicly-funded family planning services. Therefore, while there is broad coverage of many services for low-income people during pregnancy and to help prevent pregnancy, there is almost no access to help low-income people achieve pregnancy.

Medicare

While most beneficiaries of Medicare are over the age of 65+, Medicare also provides health insurance to approximately 2.5 million reproductive age adults with permanent disabilities. According to the Medicare Benefit policy manual, “reasonable and necessary services associated with treatment for infertility are covered under Medicare.” However, specific covered services are not listed, and the definition of “reasonable and necessary” are not defined.

Military

TRICARE: TRICARE, the insurance program for military families, will cover some infertility services, if deemed “medically necessary” and if pregnancy is achieved through “natural conception,” meaning fertilization occurs through heterosexual intercourse. Diagnostic services are covered, including lab testing, genetic testing, and semen analysis. Treatment to correct physical causes of infertility are also covered. However, IUI, IVF, donor eggs/sperm and cryopreservation are not typically covered, unless the service member had a serious injury while on active duty resulting in infertility.

Veterans Affairs (VA): Infertility services are covered by the VA medical benefits package, if infertility resulted from a service-connected condition. This includes infertility counseling, blood tests, genetic counseling, semen analysis, ultrasound imaging, surgery, medications and IVF (as of 2017). However, the couple seeking services must be legally married, and the egg and sperm must come from said couple (effectively excluding same sex couples). Donor eggs/sperm, surrogacy or obstetrical care for non-Veteran spouses are not covered.

Infertility Services In Publicly Funded Clinics

The CDC’s and Office of Population Affairs’ (OPA) Quality Family Planning recommendations address provision of basic infertility services. Family planning providers are recommended to provide at minimum patient education about fertility and lifestyle modifications, a thorough medical history and physical exam, semen analysis, and if indicated, referrals for lab testing of hormone levels, additional diagnostic tests (endometrial biopsy, ultrasound, HSG, laparoscopy) and prescription of medications to promote fertility. However, studies of publicly funded family planning clinics suggest that availability of infertility services is uneven. In a 2013-2014 study of 1615 publicly funded clinics, a high share reported offering preconception care (94% for women and 69% for men), but fewer offered any basic infertility services (66% for women and 45% for men). Provision of any infertility treatment was uncommon (16% of clinics), likely requiring referrals to specialists who may not accept Medicaid or uninsured patients.¹⁰  The majority of patients who rely on publicly funded clinics are low-income and would not likely be able to afford infertility services and treatments once diagnosed.

Per the Indian Health Services (IHS) provider manual, basic infertility diagnostics should be made available to women and men at IHS facilities, including a history, physical exam, basal temperature charting (to predict ovulation), semen analysis and progesterone testing. In facilities with OBGYNs, HSG, endometrial biopsy and diagnostic laparoscopy should also be available. However, it is unclear how accessible these services are in practice, and provision of infertility treatment is not mentioned.

Key Populations

Racial and ethnic minorities

The ability to have and care for the family that you wish for is a fundamental tenet of reproductive justice. For those who need it, this includes access to fertility services. The share of racial and ethnic minorities who utilize medical services to help become pregnant is less than that of non-Hispanic White women, despite research that has found higher rates of infertility among women who are Black and American Indian / Alaska Native (AI/AN). Our analysis of 2015-2017 NSFG data shows that while 13% of non-Hispanic White women reported ever going to a medical provider for help getting pregnant, just 6% of Hispanic women and 7% of non-Hispanic Black women did so (Figure 7). A higher share of Black and Hispanic women are either covered by Medicaid or uninsured than White women and more women with private insurance sought fertility help than those with Medicaid or the uninsured. A variety of factors, including differences in coverage rates, availability of services, income, and service‐seeking behaviors, affect access to infertility care. Furthermore, other societal factors also play a role. Misconceptions and stereotypes about fertility have often portrayed Black women as not requiring fertility assistance. Combined with the history of discriminatory reproductive care and harm inflicted upon many women of color over decades, some may delay seeking infertility care or may not seek it at all.

Other research has found that use of fertility testing and treatment also varies by race. An analysis of NSFG data found that among women who reported using medical services to help become pregnant, similar shares of Black (69%), Hispanic (70%) and White (75%) women received fertility advice. However, less than half (47%) of Black and Hispanic women who used medical services to become pregnant reported receiving infertility testing, compared to 62% of White women, and even fewer women of color received treatment services. According to an analysis of surveillance data of IVF services, use is highest among Asian and White women and lowest among American Indian / Alaska Native (AI/AN) women. Racial inequities may exist for fertility preservation as well; a study of female patients in NY with cancer found disproportionately fewer Black and Hispanic patents utilized egg cryopreservation compared to White patients. On average, more Black, Hispanic, and AI/AN people live below the federal poverty level than people who are White or of Asian/Pacific Islander descent. The high cost and limited coverage of infertility services make this care inaccessible to many people of color who may desire fertility preservation, but are unable to afford it.

Iatrogenic Infertility

Iatrogenic, or medically induced, infertility refers to when a person becomes infertile due to a medical procedure done to treat another problem, most often chemotherapy or radiation for cancer. In these situations, persons of reproductive age may desire future fertility, and may opt to freeze their eggs or sperm (cryopreservation) for later use. The American Society for Reproductive Medicine (ASRM) encourages clinicians to inform patients about fertility preservation options prior to undergoing treatment likely to cause iatrogenic infertility.

However, the cost of egg or sperm retrieval and subsequent cryopreservation can be prohibitive, particularly if in the absence of insurance coverage. Only a handful of states (CT, DE, IL, MD, NH, NJ, NY, and RI) specifically require private insurers to cover fertility preservation in cases of iatrogenic infertility. No states currently require fertility preservation in their Medicaid plans.

LGBTQ populations

LGBTQ people may face heightened barriers to fertility care, and discrimination based on their gender identity or sexual orientation. Section 1557 of the Affordable Care Act (ACA) prohibits discrimination in the health care sector based on sex, but the Trump Administration has eliminated these protections through regulatory changes. Without the explicit protections that have been dropped in the current rules, LGBTQ patients may be denied health care, including fertility care, under religious freedom laws and proposed changes to the ACA. However, these changes are being challenged in the courts because they conflict with a recent Supreme Court decision stating that federal civil rights law prohibits discrimination based on sexual orientation and gender identity.

In a committee opinion, ASRM concluded it is the ethical duty of fertility programs to treat gay and lesbian couples and transgender persons, equally to heterosexual married couples. They write that assisted reproductive therapy should not be restricted based on sexual orientation or gender identity, and that fertility preservation should be offered to transgender people before gender transitions. This allows transgender individuals the ability to have biological children in the future if desired. Despite this recommendation, in aforementioned states with mandated fertility preservation coverage for iatrogenic infertility, it remains unclear if this benefit extends to transgender individuals, whose gender affirming care can result in infertility. Additionally, many state laws regarding mandates for infertility treatment contain stipulations that may exclude LGBTQ patients. For example, in Arkansas, Hawaii and Texas and at the VA, IVF services must use the couple’s own eggs and sperm (rather than a donor), effectively excluding same sex couples. In other states, same-sex couples do not meet the definition of infertility, and thus may not qualify for these services. Data are lacking to fully capture the share of LGBTQ individuals who may utilize fertility assistance services. Research studies on family building are often not designed to include LGBTQ respondents’ fertility needs.

Single Parents

Single persons are often excluded from access to infertility treatment. For example, the same IVF laws cited above that require the couple’s own sperm and egg, effectively exclude single individuals too, as they cannot use donors. Some grants and other financing options also stipulate funds must go towards a married couple, excluding single and unmarried individuals. This is in opposition to the ASRM committee opinion, which states that fertility programs should offer their services to single parents and unmarried couples, without discrimination based on marital status.

Looking Forward

On a federal level, efforts to pass legislation to require insurers to cover fertility services are largely stalled. The proposed Access to Infertility Treatment and Care Act (HR 2803 and S 1461), which would require all health plans offered on group and individual markets (including Medicaid, EHBP, TRICARE, VA) to provide infertility treatment, is still in committee (and never made it out of committee when proposed during the 115th congress). There has been some more movement on the state level. Some states require private insurers to cover infertility services, the most recent of which was NH in 2020. Currently, NY continues to be the first and only state Medicaid program to cover any fertility treatment.

For those who desire to have children, obtaining fertility care can be a stressful process. Stigma around infertility, intensive and sometimes long or painful treatment regimens, and uncertainty about success can take a toll. On top of that, in the absence of insurance coverage, infertility care is cost prohibitive for most, particularly for low-income people and for more expensive services, like IVF or fertility preservation. Significant disparities exist within access to infertility services across, dictated by state of residence, insurance plan, income level, race/ethnicity, sexual orientation and gender identity. Achieving greater equity in access to fertility care will likely depend on addressing the needs faced by low-income persons, people of color and LGBTQ persons in fertility policy and coverage.

 

1. The evaluation of fertility can start after six months if the woman is over the age of 35. ↩︎
2. Data and research often assume cisgender identities and may not systematically account for people who are transgender and non-binary. The language used in this brief attempts to be as inclusive as possible while acknowledging that the data we are citing uses gender labels that we cannot change without misrepresenting the data. ↩︎
3. The CDC reports the percentage of women (ages 15-49) who have ever received “infertility services” (12.7%) which also includes medical help to prevent miscarriage. We report on the percentage of adult women (ages 18-49) who have ever received medical help to become pregnant, excluding medical help once women are already pregnant. ↩︎
4. The CDC does not track the number of births as a result of other fertility assistance, like fertility medications or IUI. However, in the 2012 CDC National Public Health Action Plan for the Detection, Prevention and Management of Infertility, they recommended the development of surveillance systems which would monitor the utilization and health outcomes of non-IVF treatment for infertility. ↩︎
5. AZ, IA, MI, MO, NV, NC, PA, TN, and VA. ↩︎
6. IL has a mandate to cover that applies only to group plans; however, the state’s benchmark plan includes coverage for infertility treatment, so individual plans in IL also cover these services. ↩︎
7. The TX benchmark plan includes coverage for diagnosis of infertility, so individual plans in TX also cover this service. ↩︎
8. “Comprehensive coverage” for ART defined by CDC as covering at least four oocyte (egg) retrievals. ↩︎
9. Availability was judged by the number of physicians performing IVF per 1,000 reproductive age women, and utilization was calculated by number of IVF cycles per 100,000 reproductive age women. ↩︎
10. Definitions of preconception care, basic infertility services and infertility treatment were left up to the interpretation of the respondent. ↩︎

Since taking office, President Trump has laid down an extensive record on health care, beginning on day one with his clearly-stated intention to repeal and replace the Affordable Care Act, and continuing through his most recent response to the COVID-19 pandemic. In addition, the Trump Administration has made or proposed many changes to health policies and programs that could have a significant impact on health coverage and health care.

President Trump’s record on health care illustrates his priorities. An incumbent president’s record is always relevant, but especially so for President Trump, who has not released more conventional campaign policy proposals. Moreover, the President’s response to the COVID-19 crisis, and its economic consequences could influence how voters view the president in terms of his character, his leadership and his ability to protect the nation – particularly given widespread and ongoing transmission of the virus in the U.S. and evidence that the U.S. has fared relatively poorly compared to peer nations.

From the start of his presidential term, President Trump took aim at the Affordable Care Act, consistent with his campaign pledge leading up to the 2016 election. He supported many efforts in Congress to repeal the law and replace it with an alternative that would have weakened protections for people with pre-existing conditions, eliminated the Medicaid expansion, and reduced premium assistance for people seeking marketplace coverage. While the ACA remains in force, President Trump’s Administration is supporting the case pending before the U.S. Supreme Court to overturn the ACA in its entirety that is scheduled for oral arguments one week after the election.

The Trump Administration has moved forward on many other health care fronts. The Administration has proposed spending reductions for both Medicaid and Medicare, along with proposals that would promote flexibility for states but limit eligibility for coverage under Medicaid (e.g., work requirements). The President has made prescription drug prices a top health policy priority and has issued several executive orders and other proposals that aim to lower drug prices; most of these proposals, however, have not been implemented, other than one change that would lower the cost of insulin for some Medicare beneficiaries with diabetes, and another that allows pharmacists to tell consumers if they could save money on their prescriptions. The Trump Administration has also moved forward with an initiative to improve price transparency in an effort to lower costs, though it is held up in the courts. President Trump has made other policy changes that have had a direct impact on reproductive rights, immigration, and on other health care issues that convey his priorities for the future.

This issue brief provides a detailed overview of the Trump Administration’s record on health care issues, including major proposals and actions on health care during his tenure in office relating to: the Administration’s response to the COVID-19 pandemic, the ACA and private insurance markets, Medicaid, Medicare, reducing prescription drug and other health care costs, sexual and reproductive health, mental health and substance use, immigration and health, long-term care, HIV/AIDS policy, and LGBTQ health. A separate resource compares President Trump’s record and proposals to those of former Vice President Biden.

COVID-19 Response

The COVID-19 pandemic, the worst health crisis facing the global community in more than a century, has taken a particular toll on the United States. Although the U.S. only represents 4% of the global population, it accounts for 23% of all COVID-19 cases and 21% of all deaths as of early September and ranks number one among high income countries as measured by cases per capita. The Trump administration has not established a coordinated, national plan to scale-up and implement public health measures to control the spread of coronavirus, instead choosing to have states assume primary responsibility for the COVID-19 response, with the federal government acting as back-up and “supplier of last resort.” The President has downplayed the threat of COVID-19, given conflicting messages and misinformation, and often been at odds with public health officials and scientific evidence. Despite this, the Administration has taken a number of actions to address the pandemic, including declaring federal emergencies to free up resources and flexibilities, signing emergency spending bills passed by Congress, providing emergency use authorization for hundreds of tests and other devices, issuing guidance documents, and announced “Operation Warp Speed”, to produce and deliver coronavirus vaccines. On the global front, the Administration has reduced U.S. engagement in addressing the pandemic, including ended funding for the World Health Organization (WHO) and announcing withdrawal from WHO membership.

Affordable Care Act – Private Health Insurance

President Trump’s record on the Affordable Care Act (ACA) marketplaces and private insurance began on his first day in office, when he issued an executive order stating, “It is the policy of my Administration to seek the prompt repeal of the Patient Protection and Affordable Care Act.” Pending such repeal, he ordered executive branch agencies to exercise all authority and discretion available to waive, defer, grant exemptions from or delay implementation of any provision that would impose a fiscal or regulatory burden on any state, individuals, families, health care providers or health insurers. A few days later, the Administration cancelled advertising and outreach activities already scheduled and paid for to promote signups during the final week of Open Enrollment in 2017; enrollment during that week declined compared to the same period in 2016. In addition to supporting Congressional repeal of the ACA and a federal lawsuit to overturn it, the Trump Administration has taken other steps to modify how it operates.

Medicaid

Overall, the Trump Administration has made efforts to reduce federal spending for Medicaid and limit eligibility through proposed legislation and budget proposals, new state demonstration waivers and its support of litigation to overturn the ACA.

Medicare

In his most recent State of the Union address, President Trump said his Administration will “protect” Medicare just as he has vowed to protect Social Security. President Trump signed into law multiple pieces of legislation that had the effect of accelerating the insolvency of the Medicare Hospital Insurance Trust Fund. The Trump Administration has proposed changes to the Medicare program, including reductions in Medicare spending through changes (or proposed changes) to provider payments, and regulatory requirements for providers and Medicare private plans (Medicare Advantage and Part D).  The Administration has issued many proposals relating to Medicare prescription drug costs, most of which have not been implemented (See more in Reducing Prescription Drug and Other Health Care Costs Section).

Reducing Prescription Drug and Other Health Care Costs

The Trump Administration has issued many proposals to lower prescription drug prices and spending, although most have not been adopted by the Congress or implemented by the Administration through the regulatory process, and pending proposals are unlikely to be adopted prior to the November election. President Trump signed into law legislation passed by Congress that banned “pharmacy gag” clauses and accelerated the phase out of the Medicare Part D “donut hole” and is moving forward with an Innovation Center model that will lower insulin costs for some Medicare beneficiaries (to take effect in 2021). In addition, the Trump Administration has moved forward on a hospital price transparency initiative that aims to give consumers better information to help lower costs.

Sexual and Reproductive Health

The Trump Administration has made efforts to reduce access to contraception by issuing regulations that allow employers to opt out of the ACA’s requirement to offer no-cost contraception in its health plans and that exclude family planning clinics that provide or refer for abortion from the Title X family planning program for low-income people. The Administration has also sought to limit access to abortion coverage and care by appointing judges opposed to abortion rights and issuing restrictive rules and regulations.

Mental Health and Substance Use

The Trump Administration has taken steps to address the opioid epidemic and high suicide rates among veterans. The Administration also supports overturning the ACA and increased the duration of short-term health plans, steps that would ultimately reduce coverage of mental health and substance use disorder services and limit the scope of mental health parity rules. President Trump also proposed budget reductions to the Substance Abuse and Mental Health Services Administration (SAMHSA) and Medicaid, key funders for substance use disorder services. Most recently, during the COVID-19 pandemic, President Trump signed legislation providing some additional funding to SAMHSA and to support mental health services for isolated veterans.

Immigration and Health

Since taking office, the Trump Administration has taken numerous actions to reshape immigration policy. These efforts have included limiting entry into the country, including restrictions for humanitarian immigrants such as refugees and asylees; enhancing interior enforcement efforts and expanding the scope of individuals targeted for removal; and discouraging legal immigrants from using public programs for which they are eligible, including Medicaid. A number of these actions have particularly significant implications for the health and well-being of immigrant families, including their children, who are primarily U.S.-born citizens.

Long-term Care

The Trump Administration has proposed changes to Medicaid financing that would have affected the program’s ability to pay for long-term services and supports. In addition, the Administration supported repeal of the ACA which would eliminate some options for states to expand access to Medicaid home and community-based services. Prior the onset of COVID-19, the Administration proposed changes to relax certain requirements for nursing homes, and subsequently relaxed additional requirements at the onset of the pandemic while imposing new ones to prevent the spread of the virus. Since March, as the number of COVID-19 deaths in long-term care facilities increased substantially, the Trump Administration issued new guidance and waivers, established a new commission to make recommendations, required nursing facilities to report cases, deaths and shortages, distributed tests to facilities and made additional funds available to nursing facilities and assisted living facilities.

HIV/AIDS Policy

President Trump has taken steps to address the domestic HIV epidemic. In 2019, he launched a new effort, the Ending the HIV Epidemic (EHE): A Plan for America, which aims to drive down new HIV infections, especially in hard hit areas, and includes new funding for domestic HIV programs. It has helped to focus new attention and resources on HIV in the United States. At the same time, other actions of the Administration, such as ongoing attempts to overturn the ACA, which has helped to expand insurance coverage for people with HIV, and the removal of protections for LGBTQ people in health care, threaten to undermine the reach of the EHE. On the global front, the President has publicly supported PEPFAR, but called for significant budget cuts to PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria each year.

LGBTQ Health

The Trump Administration has implemented or supported several policies that remove or reduce protections for LGBTQ people in in health care. Many of these actions have occurred against the backdrop of protections for “provider conscience.” In some cases, these policies have been halted or are still being considered by the courts.

Introduction

The first cases of a novel coronavirus were reported by the World Health Organization (WHO) in early January. Since then, the COVID-19 pandemic has become the worst health crisis facing the global community in more than a century. It has also taken a particular toll on the United States. Although the U.S. only represents 4% of the global population, as of early September, it accounts for 23% of all COVID-19 cases and 21% of all deaths, and ranks number one among high-income countries as measured by cases per capita.  In addition, most states in the U.S. are considered “hotspots”, with ongoing, widespread community transmission; shortages of testing and other needed supplies also continue. COVID-19 has significantly affected daily life in America, including the economy and school closures, and has emerged as an important factor in the 2020 Presidential election.  Polling data indicate that a majority of voters disapprove of President Trump’s handling of the outbreak and prefer Democratic candidate Joe Biden when it comes to tackling the pandemic. To gain a better understanding of how the candidates differ on their approach to addressing COVID-19, this document compares Trump’s record with Biden’s proposals. It starts with a broad overview of each candidate’s approach, followed by a detailed, side-by-side comparison.

Donald Trump

To date, in place of a coordinated, national plan to scale-up and implement public health measures to control the spread of coronavirus, the Trump Administration has chosen to rest the main responsibility for the COVID-19 response with the states, with the federal government serving as “back-up” and “supplier of last resort.” While this in part reflects federalism and the decentralized nature of U.S. public health, the lack of a national plan and strong federal guidelines have significantly contributed to a patchwork of policies, supplies, and outbreak trajectories across the country, and worsening community spread.

Early on, the President’s initial response to the new outbreak was focused on sealing U.S. borders and preventing entry of the virus.  President Trump moved to suspend entry from China on January 31, followed by others since. However, with community transmission already underway in the U.S., and challenges with screening arriving passengers,  travel restrictions were not effective in curtailing spread in the U.S. Meanwhile, the federal government was slow in bolstering public health capacities, such as testing and contact tracing, at the time the virus began to circulate domestically. As cases and deaths escalated, the gulf between what was needed and what was available grew quickly.

By mid-March, facing growing case numbers and seeing what had happened in other countries, several U.S. state and local jurisdictions began implementing stay-at-home orders and other social distancing policies. After conflicting messages from the President, who minimized the threat of the virus, the White House issued federal social distancing guidelines on March 16 for a 15-day period. Soon after, the President began pushing toward reopening, tweeting on March 22, for example, that “We cannot let the cure be worse than the problem itself. At the end of the 15 day period, we will make a decision as to which way we want to go!” and saying he hoped the country would reopen by Easter, with “packed churches.” The White House  extended the social distancing period through the end of April, and issued reopening guidelines for states on April 16. Still, even before the end of April, the President began encouraging Governors to reopen, although key reopening metrics were not yet met in most places. The President has also pushed for schools to re-open in-person even though community transmission has remained high in many places, and is much higher than it was in other countries that moved to re-open in-person schooling.

There have been ongoing challenges with COVID-19 testing in particular. These started with an early, faulty test developed by the Centers for Disease Control and Prevention (CDC) that resulted in a significant delay in scaling-up testing as coronavirus spread quickly in the U.S. They have continued through to the present with ongoing shortages of critical testing supplies; significant delays in turn-around times for results; and shifting and sometimes confusing federal guidelines that have been reported to be subject to political pressure. Yet the President said in March that “Anybody that wants a test can get a test,” and in May, “As far as Americans getting a test, they should all be able to get a test right now.” More recently, while Administration officials have continued to say that anyone who needs a test could get one, they have acknowledged the need to reduce turn-around times and continue to work to increase testing capacity.

Throughout the pandemic, and even as cases and deaths increased, the President has downplayed the threat of COVID-19. For example:

• On January 22, in response to a question about whether he was worried given the first report of known U.S. case, he said, “No. Not at all. And– we’re– we have it totally under control. It’s one person coming in from China, and we have it under control. It’s—going to be just fine.”
• On February 2, “We pretty much shut it down coming in from China.”
• On February 25, “We have very few people with it.”
• On April 28, “But I think what happens is it’s going to go away. This is going to go away.”
• On June 17, he said it was “fading away.”
• On July 19, “I think we’re gonna be very good with the coronavirus. I think that at some point that’s going to sort of just disappear. I hope.”
• On August 5, “It’s going away. Like things go away. No question in my mind that it will go away, hopefully sooner rather than later.”

The President has also given conflicting messages and conveyed misinformation about coronavirus and has sometimes been at odds with public health officials (including those in the government) and scientific evidence. For example:

• He has touted the use of the drug, hydroxychloroquine to treat COVID-19, despite the lack of evidence of its effectiveness, warnings of potential harms, and even after federal COVID-19 treatment guidelines recommended against its use.
• He suggested that applying ultraviolet light to or inside the body, or injecting disinfectant, could combat coronavirus.
• He has attributed rising COVID-19 cases to increased testing, despite the fact that this claim is not backed up by the data.
• He has questioned the use of face masks, and given inconsistent messages about their use, even after CDC guidelines recommended them. It was only in July that he began to wear one in public at times and talk about their importance.
• In pushing schools to re-open in person, he has said that children are “almost immune” and “don’t have a problem,” despite evidence to the contrary.
• He called the FDA’s issuance of an emergency use authorization for convalescent plasma, a potential treatment for COVID-19, “historic” and a “breakthrough,” even though the FDA itself said it “may be effective” and the National Institutes of Health COVID-19 treatment guidelines panel concluded that there were insufficient data to recommend either for or against it and at this time, it “should not be considered standard of care for the treatment of patients with COVID-19.”

President Trump and White House officials often publicly disagreed with the recommendations being made by federal officials and public health scientists. The CDC, which in previous national public health emergencies was very much in the public eye, did not give press conferences. The President has also publicly criticized Dr. Anthony Fauci, who has been the Director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health since 1984, and generally not appeared in public with him recently, unlike earlier in the pandemic.

Even as the administration’s primary strategy was to rely on states, it has taken a number of actions to address the pandemic. The President established a White House COVID-19 Task Force on January 27, even before the WHO had declared COVID-19 to be a Public Health Emergency of International Concern (PHEIC) (although leadership of the Task Force has shifted and its public-facing and internal activities have diminished). Three federal emergencies have been declared, enabling the authorization of funds and allowing the mobilization of resources and enhanced flexibilities to respond, as follows: HHS declared a public health emergency (PHE) on January 31 (renewed since then) and the President declared national emergencies under the Stafford Act and the National Emergencies Act, on March 13.

The President has also signed four emergency spending bills passed by Congress, which provide trillions to address COVID-19 and offer new flexibilities and relief for individuals, businesses, states, and localities.  He has activated the use of the Defense Production Act (DPA) to expand production, prioritize, and allocate supplies in the U.S., if needed, and this authority has been used in select cases. The Food and Drug Administration (FDA) has provided emergency use authorization for hundreds of tests and other devices and the CDC has issued more than 170 guidance documents on COVID-19. In addition, the U.S. has launched “Operation Warp Speed”, a significant initiative to expedite research, development, and distribution of coronavirus vaccines. Finally, numerous other federal agencies have acted to help ease the burden of COVID-19, such as granting state Medicaid programs additional flexibilities, accelerating Medicare payments to hospitals and other health care providers, instituting new protections for nursing home residents, and issuing a strategy for “Accelerating Progress Towards Reducing COVID-19 Disparities and Achieving Health Equity.”

These measures are taking place against the backdrop of other non-COVID-19 specific Administration actions that could significantly affect the response, such as a continued push before the Supreme Court to overturn the Affordable Care Act (ACA), which has provided millions of Americans with insurance coverage and expanded access to health care.

On the global front, two of the emergency spending bills included funding for other countries, and the Administration had already begun sending international assistance to countries in need before the bills were passed. Following a more general foreign policy approach of “America First”, the Administration has chosen not to participate in several high-level international efforts to address COVID-19, has ended funding for the WHO, and has announced its intent to withdraw from WHO membership, actions that mark a significant departure from the role the U.S. has historically played, including its major role in combating the 2014 Ebola outbreak.

As part of his second term agenda, the President recently released the following goals for his proposal to “eradicate COVID-19”:

• “Develop a Vaccine by The End Of 2020.”
• “Return to Normal in 2021.”
• “Make All Critical Medicines and Supplies for Healthcare Workers in The United States.”
• “Refill Stockpiles and Prepare for Future Pandemics.”

Joe Biden

Former VP Biden has outlined a number of proposals for how he would address the coronavirus pandemic as President. VP Biden was also part of the Obama Administration’s response to the 2009 H1N1 outbreak, the 2014 Ebola outbreak, and 2016 Zika outbreak.  During his tenure, the Obama Administration played a lead role in creating the “Global Health Security Agenda,” a multilateral initiative that aims to serve as “a catalyst for progress toward the vision of attaining a world safe and secure from global health threats posed by infectious diseases.” In addition, as follow-up to the 2014 Ebola outbreak, the Obama Administration established the Directorate for Global Health Security and Biodefense at the National Security Council (NSC) to lead the federal government’s pandemic response (the Directorate was disbanded by the Trump Administration in 2018).

VP Biden has put forth the following principles for his proposed response to COVID-19:

• “Restoring trust, credibility, and common purpose”.
• “Mounting an effective national emergency response that saves lives, protects frontline workers, and minimizes the spread of COVID-19”.
• “Eliminating cost barriers for prevention of and care for COVID-19”.
• “Pursuing decisive economic measures to help hard-hit workers, families, and small businesses and to stabilize the American economy”.
• “Rallying the world to confront this crisis while laying the foundation for the future”.

VP Biden’s plan states that “The federal government must act swiftly and aggressively” and that “Public health emergencies require disciplined, trustworthy leadership grounded in science.” His approach calls for the federal government, not the states, to assume primary responsibility for many aspects of the COVID-19 response, including for scaling up testing and contact tracing, providing and managing the distribution of critical supplies, and setting strong national standards. For example, VP Biden has said he would call on all Americans to wear masks and work with governors and mayors to mandate mask wearing. He would appoint a “Supply Commander” to oversee national supply chain of essential equipment, medications, protective gear, directing distribution of critical equipment as cases peak at different times in different states or territories, and make more aggressive use of the DPA to direct companies to produce needed supplies. Additionally, in recognition of the disproportionate toll COVID-19 has taken on racial and ethnic minorities in the U.S.,  VP Biden would establish a “COVID-19 Racial and Ethnic Disparities Task Force”.

VP Biden has also called for adopting measures that go beyond what have been passed by Congress or supported by the Administration to further extend fiscal relief to individuals, schools, and businesses, provide enhanced insurance coverage, support states in providing COVID-19 related services, and eliminate cost-sharing for COVID-19 treatment. For example, VP Biden would reopen enrollment for marketplace plans and cover COBRA at 100% for those who lose their jobs and health insurance due to COVID-19. In addition, VP Biden would further expand paid leave for sick workers and those caring for family members, among others, due to COVID-19, and provide additional pay for frontline/essential workers. On vaccine pricing, he would authorize the federal government to approve the price of any COVID-19 vaccine developed with federal resources, in contrast to the Trump Administration, which has said it does not want to pursue price controls. On schools, a key difference between Biden and Trump is Biden’s emphasis on the need to get the virus under control before reopening in-person education. More broadly, VP Biden proposes to expand and protect the ACA.

On the global front, VP Biden would “re-embrace international engagement,” leadership, and cooperation. His platform states that “Even as we take urgent steps to minimize the spread of COVID-19 at home, we must also help lead the response to this crisis globally. In doing so, we will lay the groundwork for sustained global health security leadership into the future.” He would act to restore the Directorate for Global Health Security and Biodefense at the NSC and work to help create a Global Health Emergency Board to harmonize crisis response for vulnerable communities around the world. Finally, he would restore funding to and fully resource the WHO and reverse the Trump Administration’s decision to withdraw from WHO membership.

Sources

Unless otherwise noted, the following are the primary sources for this side-by-side:

President Trump:

• https://www.donaldjtrump.com/media/timeline-the-trump-administrations-decisive-actions-to-combat-the-coronavirus/
• https://www.whitehouse.gov/briefings-statements/president-trumps-historic-coronavirus-response/
• https://www.whitehouse.gov/briefings-statements/president-donald-j-trump-is-taking-decisive-action-to-protect-vulnerable-citizens-in-americas-nursing-homes/

Vice President Biden:

• https://joebiden.com/covid19-leadership/#issue-0-4
• https://joebiden.com/covid19/:
• https://joebiden.com/reopening/
• https://joebiden.com/fact-sheet-how-joe-biden-would-help-you-get-health-insurance-coverage-during-the-coronavirus-crisis/
• https://medium.com/@JoeBiden/statement-by-vice-president-joe-biden-and-the-biden-for-president-public-health-advisory-committee-6407f37c93da
• https://www.nytimes.com/2020/04/12/opinion/joe-biden-coronavirus-reopen-america.html
• https://www.documentcloud.org/documents/6982369-Biden-Supply-Chain-Fact-Sheet-07-07-20.html

Federal Emergency Power

Travel Restrictions

Emergency Spending Bills

Coordinating a Federal Response

Federal Social Distancing and Reopening Guidelines

Reopening Schools

Scaling up COVID-19 Testing and Contact Tracing

Addressing the Costs of COVID-19 Testing, Prevention, Treatment and an Eventual Vaccine

Health Insurance Coverage During the Emergency Period

Helping Workers/Workplaces

Helping Hospitals/Health Care Facilities & Providers

Building the Strategic National Stockpile & Critical Supplies

Research & Development/ Treatment and Vaccine Distribution

International Cooperation and Global Health Security

Key Findings:

• The economy has now secured a spot as the top issue in the 2020 election with one-third of registered voters (32%) saying it will be the most important issue in deciding their vote for president, followed by the coronavirus outbreak (20%), criminal justice and policing (16%), and race relations (14%). There is a strong partisan divide, with Republican voters prioritizing the economy followed by criminal justice and policing, and Democratic voters prioritizing coronavirus followed by race relations. The share of voters who say health care will be the most important issue in deciding their vote has dropped 16 percentage points since February (from 26% to 10%), and outside of coronavirus, health care now ranks 5^th as an issue for voters (and ranks 3^rd for Democrats).
• In light of recent protests following the police shooting of Jacob Blake in Kenosha, Wisconsin and President Trump’s focus on violence in cities as a campaign issue, the share of voters who now say violence caused by protestors is a “big problem” in the U.S. has increased 15 percentage points since June (52% compared to 37%). The increase in the share who say violence caused by protesters is a big problem is particularly large among Republican and independent voters as well as among white voters (which is mostly driven by white Republicans rather than Democrats).
• Recently, the Centers for Disease Control and Prevention (CDC) issued a notice to states to start preparing to distribute a coronavirus vaccine by November 1^st, 2 days before the 2020 election. Most adults (81%), including majorities across partisans, do not think a vaccine for coronavirus will be widely available in the U.S. before the presidential election in November.
• Many (62%) are worried that the political pressure from the Trump administration will lead the FDA to rush to approve a coronavirus vaccine without making sure that it is safe and effective – including 85% of Democrats and 61% of independents. Fewer Republicans (35%) express this level of concern. About four in ten adults overall say both the FDA (39%) and the CDC (42%) are paying “too much attention” to politics when it comes to reviewing and approving treatments for coronavirus or issuing guidelines and recommendations.
• The latest KFF Health Tracking Poll finds a shift in the public’s attitudes on the coronavirus outbreak. More than six months into the pandemic, about four in ten (38%) now say “the worst is yet to come” (down nearly half from 74% in early April), while an equal 38% say “the worst is behind us” (up from 13% in April).
• Nearly half of adults hold at least one misconception about coronavirus prevention and treatment, including one in five who say wearing a face mask is harmful to your health and one in four who say hydroxychloroquine is an effective treatment for coronavirus. Three in four Republicans have at least one misconception, compared to 46% of independents and one in four Democrats. At the same time, trust in some official sources of information on coronavirus has declined since April, including a particularly steep drop in Republicans’ trust of Dr. Anthony Fauci and the CDC.

One-Third Of Voters Say Economy Is Most Important Issue For 2020 Election; Health Care Ranks Lower

With less than two months before the 2020 November election, one-third of registered voters (32%) say the economy is going to be the most important issue in deciding their vote for president. About one-fifth of voters say the coronavirus outbreak (20%) is the top issue, while about one in seven say criminal justice and policing (16%) or race relations (14%) are the top issues. Fewer voters choose health care (10%) or immigration (4%) as the most important issue in deciding their vote for president.

The economy is overwhelmingly the top issue for Republican voters with more than half (53%) choosing it as the most important issue in making their decision about who to vote for president, and it is also the top issue for independent voters (29%). Nearly four in ten Democratic voters (36%) say the coronavirus outbreak is the top issue in deciding their vote, followed by race relations (27%). Few Republican voters say the coronavirus outbreak (4%) or race relations (2%) is their top issue in the election.

The latest KFF Health Tracking Poll was conducted soon after the police shooting of Jacob Blake in Kenosha, Wisconsin (fielded August 28-September 3) and amidst the nation struggling with the health and economic effects of the coronavirus pandemic. Besides coronavirus, which ranks second as a voting issue, the issue of health care in general (which dominated the presidential campaign in early 2020), has fallen as a priority for voters and now ranks behind the economy, coronavirus, criminal justice and policing, and race relations. Democrats continue to prioritize the issue of health care more highly than independents or Republicans, ranking it third (tied with the economy, and ranking behind the coronavirus pandemic and race relations).

Swing voters

The economy is also now the top issue for swing voters, the crucial group of voters who say they are “probably” going to vote for either President Trump or former Vice President Biden but haven’t made up their minds yet or say they are still “undecided” about who they are going to vote for (24% of voters are “swing voters”).

About one-third (35%) of swing voters say the economy is their top issue, followed by criminal justice and policing (17%), the coronavirus outbreak (15%), and race relations (14%). About one in ten swing voters (11%) say health care is their top issue while few swing voters (2%) choose immigration is their top issue.

Recent events May Be shifting Voters’ priorities

The recent police shootings of unarmed black Americans and subsequent protests have resonated with voters with both criminal justice and policing and race relations ranking among the top election issues, depending on party identification. About one-fourth of Democratic voters (27%) say race relations is going to be the most important issue in deciding their vote for president while a similar share of Republicans (23%) say criminal justice and policing will be the top issue in to their vote.

In addition, large majorities of voters view racism, police violence, and violence caused by protestors as at least “somewhat of a problem” in the U.S. About six in ten (58%) say racism is a “big problem” while about four in ten say the same about police violence against the public (43%). Over the past three months, there has been a 15 percentage point increase in the share of voters who say violence caused by protestors is a “big problem,” 52% compared to 37% in June. This comes as national attention has focused on protests and acts of violence in cities like Kenosha, Wisconsin and Portland, Oregon, and as President Trump has made tamping down violence in cities a central issue in his campaign.

The partisan divisions in perceptions of these problems, especially views about the violence caused by protestors, have also shifted since June. While a large majority of Democratic voters and six in ten independent voters continue to say racism is “big problem” in the U.S. today, compared to 33% of Republican voters; now eight in ten Republican voters (81%) and half of independent voters (52%) say violence caused by protestors is “big problem,” compared to 62% of Republican voters and 35% of independent voters back in June. One-fourth of Democratic voters say this is a “big problem” – relatively unchanged since June (21%).

This shift is notable among all white voters with now similar shares of white voters saying that violence caused by protestors (56%) and racism (53%) are each a “big problem” in the U.S. today. The share of white voters who say violence caused by protestors is a “big problem” is up 17 percentage points since June, mostly driven by the views of white Republicans and independents and less of a change among white Democratic voters. About four in ten (37%) white voters say police violence against the public is a big problem.

Health Care As A Voting Issue

In the early months of 2020 and during the height of the Democratic primary contest, health care was consistently rated as one of the top issues for voters and was the top issue for Democratic primary voters in all of the seventeen Democratic contests analyzed by KFF researchers. But the latest KFF poll finds voters’ priorities have shifted during the last six months with the coronavirus outbreak, the closing of businesses due to the spread of the virus and subsequent recession, the police shootings of unarmed Black Americans, and violence occurring around protests. When asked what about health care is important to their vote, voters offer responses related to increasing access to health insurance coverage (18%) such as universal coverage, the cost of health care (15%) including issues around affordability and the cost of prescription drugs, the coronavirus outbreak (8%), and Medicare or senior concerns (7%).

A health care issue that no longer seems to be resonating with voters, especially Republican voters, is the 2010 Affordable Care Act (ACA). The latest KFF Health Tracking Poll finds 5% of Republican voters offering responses related to opposing or getting rid of the ACA as a top health care issue (compared to 29% of Republican voters who said the same prior to the 2016 presidential election).

A recent analysis of the Republican National Convention found only one mention of the ACA during the 2020 convention, compared to 13 mentions in 2016 and 23 mentions in 2012. The future of the ACA is still in question as the U.S. Supreme Court case will hear arguments for Texas v. California, the court case challenging the law’s constitutionality, one week following the November election.

Overall views towards the 2010 health reform law remain similar to July, with half of the public (49%) continuing to hold favorable views of the ACA while 42% view the law unfavorably (up slightly from 36%). The increase in the share with an unfavorable view was mostly driven by independents (41% now view it unfavorably compared to 35% in July) while a majority of Democrats continue to favor the law and most Republicans continue to hold unfavorable views with 79% saying they have an unfavorable opinion, showing that it is still unpopular among Republicans even if it is no longer a top issue in the 2020 election. KFF has been tracking views of the ACA since April 2010.

Half Of Voters Say Biden Has Better Approach On Most Health Care Issues

At least half of voters think former Vice President Biden has a better approach than President Trump to handle a variety of different health care issues including making decisions about women’s reproductive health choices and services (55%), determining the future of the ACA (54%), maintaining protections for people with pre-existing health conditions (52%), and ensuring access to health care and insurance (52%). On all of these health care issues, a larger share of voters say Biden has the better approach than say the same about President Trump. Voters are more divided on which candidate has the best approach lowering the cost of health care for individuals and protecting people from surprise medical bills with nearly half of voters saying they think Biden has the better approach compared to four in ten who say President Trump does.

When it comes to overseeing the development and distribution of a COVID-19 vaccine, voters are more closely divided with Biden having a slight, but not statistically significant, advantage. About half (49%) of voters say Biden has the better approach for the COVID-19 vaccine while 44% say President Trump does. Voters are also divided on who has the better approach to lowering prescription drug costs, an issue that President Trump has been focusing on throughout his presidency.

As expected, views on which candidate has the better approach largely fall down party lines with vast majorities of Democratic voters saying Biden has the better approach (93%) and nine in ten Republican voters (91%) saying President Trump has the better approach. Independent voters are equally divided with about four in ten saying each candidate has the better approach to the development and distribution of a vaccine.

Few Expect A Coronavirus Vaccine Before The November Election

On September 2^nd, the Centers for Disease Control and Prevention alerted states that they should be ready to distribute a coronavirus vaccine by November 1^st, two days before the 2020 election. The latest KFF Tracking Poll finds most adults (81%) – including majorities of Democrats (90%), independents (84%), and Republicans (75%) –  do not think a vaccine for coronavirus will be widely available in the U.S. before the presidential election in November. Moreover, if a coronavirus vaccine was indeed approved by the FDA before the election and was made available and free to everyone who wanted it, just four in ten adults (42%) say they would want to get vaccinated while a slight majority (54%) say they would not want to get vaccinated under those circumstances. Notably half of Democrats (50%) say they would get vaccinated if a vaccine were available before the election while majorities of independents (56%) and Republicans (60%) say they would not get the vaccine.

A majority of the public (62%) is worried that the political pressure from the Trump Administration will lead the FDA to rush to approve a coronavirus vaccine without making sure that it is safe and effective. A third of adults (33%) say they are “very worried” the FDA will rush to approve a vaccine while a further 29% say they are “somewhat worried.” Across partisans, 85% of Democrats and six in ten independents (61%) say they are worried the FDA will rush to approve a vaccine, while fewer Republicans (35%) express this level of concern. Notably, women are more likely than men to say they are worried the FDA will rush to approve a vaccine (70% vs. 55%).

Public’s Views On Coronavirus Outbreak May Be Shifting

More than six months into a pandemic that has killed more than 180,000 Americans, the public is divided on whether the worst is behind us or yet to come. This comes on the heels of a Republican National Convention in which President Trump was lauded for his handling of COVID-19 and with conflicting information about the availability of a vaccine this fall. About four in ten (38% each) say “the worst is behind us” or “the worst is yet to come.” The share of adults who think the worst is yet to come has decreased by 22 percentage points since July.

Across partisans, a majority of Republicans (56%) say the worst of the coronavirus outbreak is behind us (up from 31% in July). While a majority of Democrats (58%) say the worst is yet to come, the share who expect the worst still lays ahead has decreased by 21 percentage points since July.

In addition, President Trump is now receiving slightly better marks on his handling of the coronavirus, with the share of the public who approve of his handling of the outbreak in the U.S. up 9 percentage points since July 2020. A slight majority (55%) still disapprove of his handling of the current coronavirus outbreak (down from 62% in July).

The Public Is Divided In Who They Trust For Coronavirus Information, Some Misconceptions Exist

CDC and Fauci Are Most Trusted Information Sources, But Trust In Both Has Become Increasingly Partisan

About two in three adults say they have at least a fair amount of trust in Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases (68%), and in the U.S. Centers for Disease Control and Prevention (CDC) (67%) to provide reliable information on coronavirus. About half say they trust Dr. Deborah Birx, the Coronavirus Response Coordinator for the White House Coronavirus Task Force (53%) as a reliable source of information. Half of the public say they trust Joe Biden to provide reliable information on coronavirus while about four in ten say the same about President Trump (52% vs. 40%).

While majorities across partisans continue to trust the CDC, there are large partisan differences on trust in other sources, with Democrats more likely to trust Joe Biden and Dr. Anthony Fauci, and Republicans more likely to trust President Trump and Dr. Deborah Birx.

Notably, the share of adults who trust the CDC to provide reliable information has decreased by 16 percentage points since April. Similarly, the share of adults who say they trust Dr. Anthony Fauci has declined by 10 percentage points since April. Trust in the CDC has decreased from April across partisans, though the decrease has been among Republicans in particularly steep, with 60% now saying they trust the CDC, down 30 percentage points from April when 90% said they trusted the CDC to provide reliable information. Likewise, there has been a steep decline in trust of Dr. Anthony Fauci among Republicans. While the share of Democrats who say they trust Dr. Fauci has increased slightly since April (86%, up from 80%), among Republicans, the share who trust Dr. Fauci has decreased by 29 percentage points (48%, down from 77%).

Public mostly knows key facts about coronavirus, though some MISCONCEPTIONS remain

A large majority of the public (87%) is aware that there is no FDA-approved vaccine to prevent coronavirus and that it is possible for children under 18 to transmit coronavirus to other people (88%). Similarly, eight in ten (80%) know that there is no cure for coronavirus and that wearing a face mask helps to limit the spread of coronavirus (81%). Three in four adults (77%) know that wearing a face mask is not harmful to your health, though notably, one in five adults say wearing a face mask is harmful. While 55% of adults say hydroxychloroquine is not an effective treatment for COVID-19, one in four (24%) say it is an effective treatment. Nearly half of adults (48%) hold at least one misconception about coronavirus prevention and treatment, giving an incorrect answer to at least one of these questions.

There are some notable partisan differences on some key coronavirus facts. While majorities across partisans say wearing a facemask is not harmful to your health, Republicans (36%) are more likely than Democrats (7%) and independents (17%) to say wearing a face mask is harmful. Similarly, while majorities across partisans say wearing a face mask helps to limit the spread of coronavirus, Republicans (32%) are more likely than Democrats (3%) and independents (17%) to say masks do not help to limit the spread. Perhaps reflecting the difference among partisans in who they trust for reliable information, the largest partisan gap is on hydroxychloroquine, which President Trump has touted as a treatment for coronavirus. Most Democrats (78%) and independents (57%) say it is not an effective treatment for COVID-19. However, half of Republicans (51%) say it is an effective treatment.

In August, the U.S. Food and Drug Administration (FDA) issued an emergency use authorization for convalescent plasma in the treatment of COVID-19. In a press conference with President Trump, FDA commissioner Stephen Hahn misstated the benefits of convalescent plasma and has since clarified his remarks. A slight majority of the public (55%) has heard about convalescent plasma receiving emergency authorization from the FDA. Among those who have heard about this new treatment for COVID-19, about three in four (74%) say more studies are needed to determine how effective it is. Majorities across partisans say more studies are needed to determine the effectiveness of convalescent plasma for treating people who are sick from coronavirus.

Commissioner Hahn’s misstatement in his press conference with President Trump and his subsequent clarification has highlighted the issue of potential political pressure impacting the work of organizations such as the FDA and the CDC. The public is divided on whether the FDA pays enough attention to science when approving treatments for coronavirus with 43% saying it pays about the right amount of attention to science while 46% say it does not pay enough attention. The public is similarly divided on whether the CDC pays enough attention to science when issuing guidelines and recommendations related to coronavirus with 43% saying it pays about the right amount of attention and 46% saying it does not pay enough attention to science.

However, when asked about the amount of attention these two organizations pay to politics, pluralities say they pay too much attention. About four in ten (39%) say the FDA pays too much attention to politics when reviewing and approving treatments for coronavirus, while a similar share say the CDC pays too much attention to politics when issuing guidelines and recommendations related to coronavirus.

Majorities of Democrats say that under the Trump Administration, the FDA and the CDC pay too much attention to politics. About four in ten independents say these organizations pay too much attention to politics. Among Republicans, about one in five (19%) say that under the Trump Administration, the FDA pays too much attention to politics when approving treatments for coronavirus while about a third (35%) say the CDC pays too much attention to politics when issuing guidelines and recommendations related to coronavirus.

These additional findings were released October 1.

In previous KFF surveys, large shares of public have reported putting off or postponing different types of care due to cost. Since the outbreak of the coronavirus pandemic in the U.S., many hospitals and medical offices have had to close for periods of time, limited capacity, and many elective procedures have been postponed. Moreover, with adults across the nation urged to social distance, the coronavirus pandemic and its related safety concerns have kept many adults from seeking medical and dental care. The September KFF Health Tracking Poll asks people whether they have put off medical care for any reason in the past six months, and then drills down to find out the reasons why people may have skipped or postponed care, the type of care that was skipped, and whether they anticipate getting the delayed care in the coming months. Compared to June, fewer people now report skipping care due coronavirus-related office closures and safety concerns, suggesting that as medical offices have reopened, some people are now getting care they postponed earlier this year. However, the ongoing outbreak – along with concerns over the cost and affordability of care – continue to keep some adults from seeking the medical and dental care they may need.

Four In Ten Adults Say Someone In Their Household Skipped Or Postponed Care

As the country continues to deal with the ongoing coronavirus pandemic and its public health and economic impacts, four in ten adults (42%) say that they or a family member living in their household skipped or postponed some type of medical or dental care in the past six months (including 18% who say they personally skipped or postponed care, 7% who say it was only a family member, and 17% who say both they and a family member).

When asked what type of care they or a family member skipped or postponed, 13% say it was dental care only, 8% say it was only medical care, and one in five (21%) say they or family member skipped both dental and medical care. Notably, about one-third of those who say they or a family member skipped or postponed care (14% of all adults) report a worsening condition as a result.

People report different reasons for skipping or postponing care. Most commonly, 28% say they or a family member skipped or postponed care because the medical facility was closed or offering limited appointments, followed by 21% who say it was because they felt unsafe visiting a medical facility during the coronavirus outbreak. Amidst a coronavirus related economic recession and with unemployment currently at 8.4 percent, 17% of adults say they or a family member skipped or delayed care because they couldn’t afford it or were concerned about the cost. Previous KFF research indicates that this may be an underestimation of the true share of adults who are delaying care or relying on over-the-counter or home remedies to treat conditions instead of seeking care.

Fewer Say They Have Skipped Care Due To Coronavirus-related Closures or fears

While the coronavirus pandemic continues to have an impact on people seeking medical and dental care, survey trends indicate that as many medical facilities re-open with safety precautions in place, fewer people are now skipping care for coronavirus-related reasons compared to earlier this summer. The share of adults who say they or a family member skipped or postponed care due to office closures has decreased by 15 percentage points since June (28%, down from 43%). Similarly, the share who say they or a family member skipped or postponed medical or dental care because they felt unsafe seeking care during the coronavirus outbreak is also down from June (21%, down from 27%).

Groups that tend to go to the doctor more routinely are also the groups that have higher shares saying they put off care for coronavirus-related reasons. Women are more likely than men to put off care either because of office closures or because they felt unsafe going to an appointment during the pandemic, and the same is true for people living in households with chronic medical conditions and those with health insurance, compared to those without. On the other hand, younger adults, who typically go to the doctor less often, report lower levels of putting off care for coronavirus-related reasons.

Cost Concerns Keep About One In Five Women, Younger Adults, from Getting Medical or Dental Care

While coronavirus-related medical office closures and fear about the safety of visiting medical office is contributing to number of people delaying getting care, cost also continues to be a factor, and affects a different segment of the population than those skipping care for coronavirus-related reasons. Overall, 17% of adults say the inability to afford the care or concern about the cost was a reason they skipped or postponed getting medical or dental care in the last six months. Notably, adults under age 65 and those with lower household incomes are more likely than their counterparts to say they or a family member have delayed getting care due to cost concerns. Women are more likely than men to say they or family member have skipped or postponed care due to cost.

Though coronavirus and cost concerns are contributing to some delays in people getting the medical or dental care they need, most of those who say they or a family member skipped or postponed care say they expect to get the care within the next year. Indeed, 10% say they or a family member have already gotten the care that was postponed while nearly half (46%) say they expect to get the care within the next 3 months. Just 6% of those who said they or someone in their household delayed getting medical or dental care say they do not expect to get the care that was skipped or postponed.

This KFF Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted August 28-September 3, 2020, among a nationally representative random digit dial telephone sample of 1,199 adults ages 18 and older, living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). The sample included 290 respondents reached by calling back respondents that had previously completed an interview on the KFF Tracking poll at least nine months ago. Computer-assisted telephone interviews conducted by landline (295) and cell phone (904, including 652 who had no landline telephone) were carried out in English and Spanish by SSRS of Glen Mills, PA. To efficiently obtain a sample of lower-income and non-White respondents, the sample also included an oversample of prepaid (pay-as-you-go) telephone numbers (25% of the cell phone sample consisted of prepaid numbers) as well as a subsample of respondents who had previously completed Spanish language interviews on the SSRS Omnibus poll (n=6). Both the random digit dial landline and cell phone samples were provided by Marketing Systems Group (MSG). For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone. KFF paid for all costs associated with the survey.

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s March 2019 Supplement of the U.S. Census Population Survey (CPS) on sex, age, education, race, Hispanic origin, and region along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the January- June 2019 National Health Interview Survey. The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample, and design modifications, namely, the oversampling of prepaid cell phones and likelihood of non-response for the re-contacted sample. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.