With the Presidential Election just weeks away, healthcare has once again come front and center of national political discourse, as voters rank healthcare as an important issue,¹ and Vice President Kamala Harris and former President Donald Trump tout their respective healthcare agendas. While details related to future healthcare proposals have been light, both candidates do have political track records that can be examined for clues as to their priorities should they become president. This Health Capital Topics article explores where the candidates stand on various issues related to healthcare.

Healthcare reform in the U.S. became a highly politicized concept in the 20^th century. In the 21^st century, several issues brought healthcare to the forefront of both consumer and political discourse, which led to the passage of the 2010 Patient Protection and Affordable Care Act (ACA), including the persistent disproportionate rise in the cost of healthcare, the perceived disproportionate breakdown of healthcare costs across industry segments, the socioeconomic disparities in access and quality, the falling rank of U.S. health status as compared to other developed nations, and the perceived threats of budget deficits and national debt related to the cost of care for the aging Baby Boomer population. As summarized by Professor Paul Starr:

“The search for a remedy to America’s problems in health care has turned into a peculiarly arduous struggle – peculiar in its duration, its rancor, and its salience and centrality in national politics. Other democracies long ago resolved whether they have an obligation to provide care for the sick and protection against medical costs. For a century the United States has been fighting over that issue, and instead of subsiding, the disagreements have intensified and at times shaken the political arena.”²

On the whole, the two presidential candidates are “polar opposites” in their views of the government’s role in healthcare and how to address healthcare spending.³ In general, Harris has focused on expanding healthcare coverage and affordability, while Trump has stressed reducing government spending.⁴

The ACA

During the Trump Administration, Republican legislators were unsuccessful in their attempted repeal of the ACA, but did pass a bill negating the penalty for noncompliance with the Individual Mandate.⁵ However, a public may be far less receptive to a full ACA repeal, as the law has grown in popularity over the past decade, with 62% of adults having a favorable view of the ACA as of April 2024.⁶ Trump has stated he would replace the ACA only if there was a better alternative, but to date has provided no detail regarding any potential alternative.⁷ Harris, on the other hand, has pledged to protect, and expand, the ACA. This is a step back from her support for a “Medicare for All” plan during her Democratic presidential campaign in 2019, which a spokesperson has since stated she “will not push…as president.”⁸ In particular, Harris has proposed permanently extending ACA marketplace premium subsidies that are currently set to expire in December 2025.⁹ Additionally, Harris supports an increase on taxes for Americans earning over $400,000 annually to support Medicare solvency.¹⁰

Healthcare Costs

Both Trump and Harris seem interested in decreasing the costs of prescription drugs, but their approaches in achieving that goal would likely diverge. In 2020, Trump signed multiple executive orders that, among other things, allowed pharmacies and wholesalers to import drugs from Canada and attempted to force pharmacy benefit managers (PBMs) to pass large discounts to beneficiaries.¹¹ Later in 2020, Trump signed into law the No Surprises Act, which seeks to protect patients from unexpected out-of-network medical bills; the Biden Administration implemented the law and even enacted stronger penalties for noncompliance.¹² During her 2019 campaign, Harris similarly proposed allowing the Department of Health & Human Services (HHS) the authority to use international reference prices to set the prices of various drugs, which would reduce the prices for those drugs at lower prices in other developed countries.¹³ As Vice President, Harris cast the tie-breaking vote on the Inflation Reduction Act (IRA), which allowed HHS to negotiate prices for select drugs for the first time ever and capped insulin prices for Medicare beneficiaries at $35 per month and Plan D prescription drug out-of-pocket costs at $2,000 per year;¹⁴ Trump has stated his desire to roll back the IRA.¹⁵ Further, Harris supports extending these drug cost protections to non-Medicare beneficiaries.¹⁶

Medicaid

Harris has worked during her vice presidency to encourage states to adopt the postpartum Medicaid coverage extension (increased from two months to 12), included in the American Rescue Plan Act, in an effort to reduce maternal mortality and morbidity; as of August 1, 2024, 46 states and the District of Columbia have implemented the 12-month extension, and two additional states plan to implement it.¹⁷ Additionally, Harris is expected to work on expanding Medicaid in the last ten states that have not yet expanded.¹⁸ During his presidency, Trump proposed restructuring Medicaid financing into a block grant or per capita cap; he also proposed limiting Medicaid eligibility and benefits.¹⁹ None of these proposals, which would have cut Medicaid spending approximately $1 trillion over 10 years, ultimately moved forward.²⁰ Additionally, the Trump Administration approved Medicaid work requirements in some states, which were subsequently withdrawn by the Biden Administration.²¹ During COVID-19, Trump signed legislation that required Medicaid programs to keep beneficiaries enrolled for the duration of the public health emergency in exchange for increased funding.²²

Conclusion

With the election currently a dead heat, the issues considered most important to voters on Election Day, and the candidates’ stance on those issues, may be what wins the presidency. A May 2024 poll found that 48% of Republicans and 65% of Democrats believe that the affordability of healthcare is a very big problem in the U.S.; notably, this “concern tops illegal immigration, the federal budget deficit, gun violence, and drug addiction.”²³ As of September 2024, 67% of adults believed that healthcare is not receiving enough attention thus far during the 2024 presidential campaign, and only 27% believe it’s receiving the right amount of attention.²⁴ The same poll found that a “candidate’s position on protecting Medicare and Social Security is either the single most important or among the most important healthcare-related issues in determining nearly two-thirds of Americans’ votes in the upcoming election.”²⁵ Also top of voters’ minds is reducing the cost of healthcare (57% ranked it as the single most important/among the most important healthcare issue), lowering drug costs (47%), and policies related to mental health access (43%).²⁶