Let’s not forget the yawning chasm between Trump and Biden on health care

Make no mistake, health care will loom large in the lives of American families no matter who wins the White House next year. Ever since Barack Obama’s first presidential campaign back in 2007, the topic of health care has grown steadily not only as campaign fodder but as the stuff of intense policy discussions. What direction those discussions will head next, of course, depends on who wins, and this year the candidates have very different approaches to repairing all that ails American health care. 

I looked at what Donald Trump and Joe Biden have said about five important heath policy issues likely to be on the table in the next administration.

1) Maintaining and expanding coverage under the ACA.   

This one is the biggy, given the impending U.S. Supreme Court case set to be heard on November 10. The court will decide on the constitutionality of the Affordable Care Act. An adverse decision could result in millions of Americans once again unable to buy health insurance. That figure includes at least 3.4 million people under age 65 who have likely become uninsurable because they’ve had the coronavirus, which in these cases would qualify as a “preexisting condition.”

Trump’s goal is to completely repeal Obamacare, a point he made loud and clear in an interview with 60 Minutes where he said he would like to see the Supreme Court “end” the ACA, adding he would announce his own plan after the court has ruled. It’s “fully developed,” he said, and “will take care of people with preexisiting conditions.” He repeated that pledge to wipe out the ACA again in last Thursday’s debate, saying, “I’d like to terminate Obamacare, come up with a brand new beautiful health care,” whatever that meant. White House Press Secretary Kayleigh McEnany gave 60 Minute’s Leslie Stahl a large binder purportedly containing Trump’s health care plan, but it “was filled with executive orders and congressional initiatives, but no comprehensive health care plan,” Stahl reported. 

His website meanwhile offers a brief list of Republican talking points. They include such “solutions” as allowing people to fully deduct health insurance premium payments on their tax returns, selling insurance across state lines, and allowing people to use health savings accounts, none of which will boost coverage in any significant way. 

Biden has been fairly specific about his health care agenda. His core strategy is to build on the ACA and expand coverage through a public option, a popular provision during the debate on the ACA, but it was ultimately dropped because of strong opposition from medical and insurance stakeholders, the same groups opposing it now. It’s likely to be popular again. Last week, a New York Times Siena College poll of likely voters found that 67% supported a public option compared to 55% who said they supported the ACA. Biden’s website is short on the details of his public option plan but suggests that those unhappy with their current insurance as well as the uninsured will have a public option to choose. A public option would not end the employer-based health system as some have suggested, but give people a choice of coverage through a competing government-backed plan.

The candidates also have very different visions of using Medicaid to expand health coverage. Recall that the Supreme Court’s 2012 decision left it up to the states to decide whether to expand Medicaid to a larger segment of their low income populations. Currently all but 12 states have either expanded their programs or are beginning to implement expansion approved through ballot initiatives. Trump’s website says his administration would pay its share of Medicaid through block grants to the states, an approach that has been criticized for years as having the potential to reduce rather than increase enrollment in many states, especially during economic downturns. 

Biden says states that have already expanded Medicaid will have a choice of moving people in the expansion group to the public option, where they’ll pay no premiums as long as the states pay their current share of cost for covering them. Furthermore, for those with incomes below 138% of poverty who are now ineligible for Medicaid in many states because their state didn’t expand the program, a Biden administration would automatically enroll them presumably in the public plan when they interact with institutions like schools. He has also said he favors allowing Americans age 60 to 64 to join Medicare.

2) Controlling overall medical costs and surprise billing reform.

Trump’s proposals here include Republican dogmas such as repealing Obamacare, allowing people to fully deduct their health insurance premium payments on their tax returns, allowing people to use health savings accounts, and requiring price transparency from health care providers, the latter a measure that the administration has already proposed but is tied up in court.

Biden’s most far-reaching proposal for cost containment is to allow Medicare to negotiate drug prices, which I discuss below. His website also notes that a Biden administration would tackle concentration in the health marketplace which continues to grow, giving big hospital systems and provider groups increasing market power in many areas. Biden says his administration will “aggressively use” its existing antitrust authority to tackle this problem.

When it comes to the knotty problem of surprise billing that Congress has been unable to fix, Trump would presumably build on his executive order issued this fall that directs Congress to figure out a legislative solution by the end of the year. If it doesn’t, the order directs the Department of Health and Human Services to solve the problem. Biden’s website says he will bar health care providers from charging patients out-of-network rates when the patient doesn’t have control over which provider the patient sees — such as when someone is in the hospital due to an emergency. There’s not much specificity here, and the sticking point in fixing this problem has been figuring out exactly how out-of-network doctors would be paid. 

3) Controlling pharmaceutical prices.

Biden’s proposal here could have a big impact. He advocates that the government negotiate prices for drugs for beneficiaries under the Medicare program, which the 2003 law that authorized the Part D drug benefit prohibited. Late last year the House of Representatives passed legislation that would do just that, but it has stalled in the Republican-controlled Senate. Many other countries engage in such price negotiations and as a result drugs cost far less for patients. Biden says his administration would also negotiate prices paid to providers under the public option plan, so people have a less expensive option for health insurance.

For his part, President Trump has issued four executive orders aimed at reducing drug prices. As I have pointed out, those orders “appear to be little more than symbolic political gestures designed to distract from the current political realities.” The orders include allowing some drugs to be imported from Canada and basing U.S. drug prices on what a selected group of countries are paying for the drugs. The problem with executive orders is that don’t really do much unless they are followed by details and rules to implement them. The president has also offered seniors $200 drug discount cards to help them defray some of their drug costs. Those hit a snag when the top lawyer at the Department of Health and Human Services said the cards could violate election laws. That’s putting aside the question of whether a discount card worth a couple hundred bucks really solves the problem of ever-rising prices, especially for extremely expensive new biologic drugs.

The president’s website also calls for removing barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products. There’s no explanation of what that means in practice.

4) Securing Medicare’s long-term solvency.

This one is a real sleeper that has received very little media attention, but in some ways it may be the most important health policy issue of all in the year to come, after the pandemic of course. The 2020 Medicare trustees report released last spring noted that the Part A trust fund which finances beneficiaries’ hospital costs “is not adequately financed over the next 10 years.” The fund is now expected to be short by 2024. “People are getting concerned about the 2024 projection. By the time a new Congress settles in, it will be three years, so it will require immediate attention,” says Tricia Neuman, senior vice president of the Kaiser Family Foundation. “We haven’t seen a four year countdown since 1997.” If Congress doesn’t allocate additional funding for the trust fund, hospital benefits may be reduced, leaving seniors to pay more out-of-pocket for those services.

In a recent interview with Trump, the AARP Bulletin asked the president how he could protect beneficiaries from benefit cuts and improve the program. Trump ducked the question, instead focusing on his executive orders on drug prices and telling readers: “The one thing that is so important and that I’ve done like nobody else: cut the cost of prescription drugs.” 

Biden answered the question by noting that the ACA had extended the life of the trust fund and closed the donut hole to make prescriptions for seniors more affordable. “For me, preserving and defending Medicare is a sacred trust between our seniors and government,” he said, reiterating his plan to negotiate drug prices in the Medicare program. 

5) Improving long term care.

The Center for Medicare Advocacy just released, or I should say, tried to release, a comparison of the candidates’ ideas for improving long-term care. The Center said it had a hard time figuring out the president’s positions because the Republican party did not release a new platform for 2020, the official campaign website does not include policy positions, and the campaign’s six-page agenda for a second term does not address long-term care. 

The Center presented Biden’s proposals and provided a list of actions the Trump administration has taken regarding long-term care during the pandemic that include: waiving residents’ protections and a nurses’ aide training requirement. Biden’s proposals would enhance protections for improper discharges, require an infectious disease expert in every facility and reinstate the Obama-Biden ban on forced arbitration agreements. 

The AARP Bulletin explored one more long-term care issue on the minds of millions of families — financial help if an in-home caregiver is needed for a family member. When the Bulletin asked the president if Medicare or Medicaid should pay for in-home care, he said, “We’re looking at that very seriously. We’re looking at doing something to help out and very substantially.” No specifics here, but he did praise the home care workers for being “incredible” people “unrecognized for the job they do.” Biden, on the other hand, told the Bulletin that if he is elected, he will invest $450 billion, presumably for caregiving to help more Americans choose to live at home.  His administration would also offer as much as a $5,000 tax credit for families who are providing that care.

No presidential candidate spells out the exact details of legislation, and their proposals are often vague and written to avoid serious controversy before they are even elected. However, in the case of this year’s presidential race, one candidate presents a framework for dealing with the country’s most pressing health care needs. The other leaves a lot of speculation and blank spaces for the public to make their own guesses.

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care column.