President Donald Trump released a new executive order and used a Charlotte, North Carolina, speech to announce his America First Healthcare Plan. The announcement was light on details, but the message was clear that the President plans to use a potential second term to build on the healthcare policies implemented in his first term.
Trump's proposals share some overlap with the healthcare policy platform previously announced by Vice President Joe Biden, particularly in the area of prescription drug costs. Still, the proposals stand in sharp contrast including disagreements about the future of the Affordable Care Act (ACA) and the role of government in healthcare.
Neither Trump nor Biden have outlined a comprehensive set of proposals that describe their policies in considerable detail. Instead, both plans are primarily high-level principles meant mostly for messaging. Below we examine some of their key positions.
Future of the ACA
Trump has repeatedly called for the repeal of the ACA, saying it has failed to live up to its promises. He supported and signed legislation eliminating the law's individual mandate and has used his authority to advance alternatives to ACA-compliant health plans, like association health plans and short-term health plans. His administration has backed a legal challenge to the constitutionality of the ACA in a case set to be heard by the U.S. Supreme Court one week after the election. What Trump supports as a comprehensive ACA replacement plan remains unclear.
Biden has been an adamant supporter of the ACA, which he helped shepherd through Congress during his tenure in the Obama administration. Biden proposes to strengthen the ACA by:
Increasing subsidies for individual policies on the ACA marketplace
Allowing higher wage earners to qualify for subsidies
Establish a public option health insurance policy to compete with private policies on the ACA marketplaces
Encourage the expansion of Medicaid, as permitted by the ACA, and allow those who would be eligible in states without expansion to enroll in the public option at no cost.
Single-payer healthcare and employer-sponsored coverage
Both Trump and Biden have expressed opposition to single-payer healthcare that would eliminate employer-sponsored coverage, including what is often referred to as Medicare for All.
Public option
A public option is one of the cornerstones of Biden's proposal. The public option would be a government-run insurance option that would compete with private insurance policies in the ACA marketplaces. The details of how the public option would operate remain unclear and will be subject to hard-fought battles if Biden wins in November. There are four major policy choices for a public option that could have a significant impact on employer-provided plans:
Who is eligible?
What is the reimbursement rate for providers?
How expansive are the benefits?
How much does the public option cost?
Trump opposes a public option and his administration has equated it to being no better than single-payer. There is concern that private policies could not compete with the public option, eventually leaving the public option as the only option.
Reduction of Medicare age
Biden supports reducing the age at which people become eligible for age-based Medicare enrollment to 60, while Trump does not. Like the public option, this has been a core tenant of the Biden campaign, the final details of which could significantly impact employers. For example, the consequences to employers could be more significant if the reduction in age includes a modification of the Medicare Secondary Payer rule that prohibits employers from forcing their Medicare-eligible employees off the employer plan and onto Medicare.
Prohibitions on preexisting condition exclusions
Both candidates have supported prohibitions on preexisting condition exclusions, but how they would do so differs. Biden would maintain the existing prohibition found in the ACA. Trump has voiced his support for policies that protect those with preexisting conditions, including signing an executive order stating it is the policy of the federal government to do so. Still, he has not defined how he would preserve the protection if his administration is successful in dismantling the ACA.
Prescription drug reform
Prescription drug reform has been a major talking point for both presidential candidates. It is an area with significant overlap, at least at a high level.
Both candidates support the importation of drugs from other countries and encourage the development of more generic drugs. Both Trump and Biden support capping out-of-pocket costs for Medicare beneficiaries and allowing Medicare to negotiate drug costs, though the Democratic platform proposes to allow Medicare to negotiate on behalf of private purchasers.
Biden proposes to place limits on launch prices for drugs and to cap price increases for brands and certain generic drugs at the rate of inflation.
In addition, Biden proposes to end pharmaceutical corporations' tax breaks for advertisement spending.
Trump has proposed other policies specific to Medicare, including prohibiting rebates paid from drug manufacturers to pharmacy benefit managers and capping drug prices at rates paid in certain other countries.
Expansion of Medicaid
Biden supports Medicaid expansion while Trump has argued against it. The Trump administration has allowed states to enforce Medicaid work requirements and to place target spending rates on parts of the Medicaid population.
Women's health
Trump has vocally supported overturning Roe v. Wade and subsequent Supreme Court cases that have protected abortion rights. In addition, the Trump administration has issued regulations allowing businesses with religious or moral exemptions to avoid providing no-cost contraceptives to female health plan participants and beneficiaries as part of the ACA. Biden, on the other hand, supports abortion rights and a more limited religious exemption to the ACA's contraceptive mandate.
Surprise medical billing
Both Trump and Biden have called for prohibitions on surprise medical bills when a patient does not have an effective opportunity to choose an in-network provider. In general, surprise medical billing refers to instances when a patient inadvertently receives care from a healthcare provider outside of the patient's health plan network (e.g., at an in-network hospital where one or more of the doctors providing care is out-of-network), and receives a bill for the cost of the services that exceeds the in-network cost.
Congress has been working on legislation prohibiting surprise medical bills for the last two years. While there is broad, bipartisan consensus to cap the consumer's financial exposure, agreement on financial obligations for insurers and out-of-network providers has been more elusive. Neither presidential candidate has taken a position on how the reimbursement rate should be determined.
Price transparency
Trump has championed two actions (opens a new window) his administration has taken to increase price transparency. In general, these rules require hospitals to publish their negotiated rates and require health plans to disclose information that allows insureds to know the cost of services before receiving care, including disclosure of negotiated rates with providers. The rule applicable to hospitals is final but subject to legal challenges. The rule applicable to health plans has been proposed, and the administration is reviewing comments before it is finalized. Trump has vowed to defend these rules and has called for adding more requirements to the rule applicable to hospitals.
Although Biden has expressed support of transparency in healthcare, it is unclear whether he would defend these two rules.
Summary
Both presidential candidates view increased access to care and reduced costs as essential healthcare policy aims. However, Trump and Biden approach the path to those goals differently. Trump sees a role for government in healthcare policy, but he prizes consumerism and flexibility for states, health plans, employers and consumers. Biden, while not promoting a wholesale rejection of consumerism and flexibility, sees a larger role for government.
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