This article is part of a Wall Street Journal guide comparing President Trump and former Vice President Joe Biden on issues from climate change to health care and jobs.
WASHINGTON—Most of the differences between President Trump and Democratic presidential nominee Joe Biden on health care align on a central dispute: Mr. Trump wants to reduce the federal government’s role in Americans’ health care, while Mr. Biden wants to expand it.
Both agree that health-care costs should be reduced, but they disagree on how to address the coronavirus pandemic, health coverage, driving down prescription-drug prices and lowering insurance premiums.
Mr. Trump has backed much of a lawsuit to strike down the Affordable Care Act, which sought to set certain basic coverage thresholds nationwide while providing federal subsidies for people to pay for insurance. The president has moved to push decision-making away from Washington and back to the states. He has supported work requirements in Medicaid and backs letting states pursue new arrangements to pay for Medicaid. He also wants to let states import certain drugs from other countries such as Canada to spur competition and reduce prices.
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Mr. Biden has called for the federal government to subsidize insurance for some people in states that didn’t expand Medicaid by automatically enrolling them in a federal public option that would resemble Medicare. The former vice president has said he would seek to reverse Trump administration changes that have undermined the ACA, and has proposed expanding the program by allowing people to buy into the public option. Mr. Biden has argued for allowing Medicare to negotiate drug prices.
Mr. Trump, who this month tested positive for Covid-19, established a White House coronavirus task force in January to oversee the federal response to the pandemic, but he left many specific matters in the response, such as contact tracing and the acquisition of certain supplies, to the states. Mr. Biden has proposed that the federal government play a more centralized and active role in responding to the crisis.
Mr. Biden has said he would urge all Americans to wear masks and work with state leaders on mask mandates. Mr. Trump hasn’t called for mask mandates.
Mr. Biden would also restore funding to the World Health Organization. The president has been withdrawing the U.S. from the organization and redirecting the funding to other health programs.
Mr. Trump had pledged to repeal the ACA and replace it with a better alternative but has failed to do either during his time in office. Mr. Trump has supported key parts of a lawsuit from a coalition of Republican-led states to invalidate the ACA. The case is set to be heard by the Supreme Court on Nov. 10.
Mr. Trump signed two executive orders in September declaring it the policy of the U.S. to provide insurance protections for Americans with pre-existing conditions and directing the Department of Health and Human Services to work with Congress to pass legislation that would protect patients from surprise medical bills. He hasn’t detailed how specifically coverage for people with pre-existing conditions would be accomplished. He also announced recently that 33 million Medicare beneficiaries would soon receive a card in the mail that can be used to help pay for up to $200 in prescription drug costs.
Mr. Trump has said his actions have down insurance costs, such as expanding access to short-term health plans—insurance products that cost less because they don’t generally offer the same range of benefits that ACA-compliant plans do.
The focus on coverage and costs comes as the U.S. has lost some of the gains it made in reducing the ranks of uninsured people. The number of uninsured Americans grew by about two million people in 2018, according to the U.S. Census Bureau, marking the first increase in 10 years.
Mr. Biden has proposed bolstering the ACA by expanding federal subsidies. He wants to expand eligibility requirements for Medicare, and backs a public option plan that would let people buy into a government-run insurance plan. His plan would give everyone, including people with employer-provided health coverage, the choice to buy coverage like Medicare. That option would automatically cover low-income residents in states that didn’t expand Medicaid but would have been eligible for the program if they had.
Mr. Biden supports lowering Medicare’s age of eligibility to 60 years old from 65. This would increase Medicare spending overall, with estimates in the billions of dollars a year. But it would also shift some people from Medicaid to Medicare, and lower the number of people in employer-provided coverage, which could also reduce the cost of premiums. The plan aims to lower patient costs through the use of the program’s greater negotiating power with hospitals and other health organizations.
Lowering the Medicare age could make more than 20 million people eligible for the program, according to an analysis by Avalere Health, a Washington-based health-care consulting group. In contrast, the lawsuit to invalidate the ACA that Mr. Trump supports could result in 20 million Americans losing coverage.
Messrs. Trump and Biden differ over how to achieve a shared goal of lower drug prices. Mr. Trump, who campaigned on decreasing drug prices in 2016, has enacted a faster-paced approval process for new generic drugs that can drive down prices and has said on numerous occasions that he wants pharmaceutical companies to offer their drugs in Medicare at the lower prices they offer to other countries. He has also signed an executive order to import drugs from countries with lower prices and has backed ending rebates that drugmakers provide third parties that manage pharmacy benefits, with the aim of lowering list prices on government drugs. Under the current system, pharmacy-benefit managers negotiate confidential rebates and discounts on many branded prescription drugs. Those deals aren’t always passed along to customers at pharmacies.
Mr. Trump wants people in Medicare to pay the same, lower price for drugs as in Europe, and he backs an out-of-pocket spending limit for people in Medicare Part D prescription coverage.
Mr. Biden proposes letting Medicare negotiate large discounts for drugs. He would set up an independent review board to determine the value of new drugs by comparing their prices with what is charged for them in other countries.
He would impose a tax penalty on drugmakers that raise the prices of certain drugs over the general inflation rate.
Mr. Trump’s effort to reduce costs extends beyond drug pricing. He has also sought to end the secrecy around negotiated prices between providers such as hospitals and insurers and has urged Congress to end surprise medical billing, which typically occurs when a patient is treated at a hospital that is in their insurance network by a medical professional who isn’t. Mr. Trump has pledged to protect Medicare, which covers seniors and some people who are disabled, though he has supported the elimination of a payroll tax cut that funds the program. His previous budget proposal called for slowing the rate of growth in Medicare.
Mr. Biden also has proposed using antitrust actions to curb market concentration in the medical industry, which he says is driving up prices. He also advocates an end to surprise medical billing. He opposes actions that have eroded the ACA such as the expansion of short-term health plans. Mr. Biden also wants to increase subsidies that are available on the ACA exchanges.
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