What Trump or Harris would mean for health care access and affordability

Health care has become increasingly complex, costly and frustrating for many in the US and is one of the biggest issues in the 2024 election. Vice President Kamala Harris and former President Donald Trump have both vowed to take on this challenge if they win – and to achieve this through measures ranging from reducing medication costs to ensuring access to medical care. But there are drastic differences in how their respective plans would affect the economy of the U.S. health care system — and the people who deal with its bureaucracy every day.

Harris says her administration would strengthen the Affordable Care Act (ACA) and expand the cost-saving provisions of the Inflation Reduction Act (IRA). Trump’s presidential record on health care is mixed, peppered with attacks on the ACA and significant funding cuts to federal health insurance programs.

Drug prices

To support science journalism

If you like this article, please consider supporting our award-winning journalism Subscribe. By purchasing a subscription, you are helping to ensure the future of impactful stories about the discoveries and ideas that shape our world today.

People in the United States pay far more for medications than people in most other comparably wealthy countries. Both presidential candidates have placed lowering drug prices prominently on their agendas, and both have already taken similar policy steps during their respective White House appointments.

During President Joe Biden’s administration, Harris voted crucially in passing the IRA 2022 – a law that sets new limits on drug price increases. The IRA gave Medicare (the federal insurance program for adults age 65 and older) the ability to negotiate lower prices for certain drugs. The most debated issue in Harris’ campaign is the $35 cap on insulin. It also made vaccinations covered by Medicare free and expanded subsidies to help people with the lowest incomes pay for better coverage. And starting in 2025, Medicare will impose a $2,000 annual spending cap on prescription drugs. Cancer drugs, for example, can now cost patients more than $10,000 a year. But the IRA will reduce that amount to $2,000, explains Stacie B. Dusetzina, a health policy and drug pricing researcher at Vanderbilt University School of Medicine. “This is a huge expansion of the benefits available to seniors,” says Dusetzina.

Ten drugs are already listed for price negotiations, but people won’t see price changes in the pharmacy until January 2026. Harris says that if elected, she would further strengthen the IRA and reduce the cost of more drugs under Medicare and even expand drug coverage under both private insurance and Medicaid, the federal insurance program that provides certain people with limited income, certain disabilities or pre-existing conditions. It is uncertain what the fate of the IRA would be under a Trump administration.

“One of the reasons that drug price negotiations are such a sensitive issue is that the Republican Party fears that companies will not be incentivized to innovate and produce new drugs” if they cannot reap the potential profits, Dusetzina says . “Many Republican members of Congress have pushed to stop negotiations over drug prices, and we know that pharmaceutical companies… have sued the government to stop negotiations over the selected products.” (Several of these companies have lost their cases, and other cases are ongoing.) If a second Trump administration were to act quickly, it could theoretically try to block or reverse the policy before the new prices take effect in 2026, Dusetzina says.

In Trump’s final months in office in 2020, he issued two executive orders to reduce prescription drug costs. He sought to stop pharmacy benefit managers — third-party companies that negotiate prices and discounts between drugmakers and consumers — from collecting rebate checks for discounted drugs sold to the elderly through Medicare to ensure those people receive the drugmakers’ full savings receive. He also sought to impose the “Most Favored Nation” pricing model, which would price certain doctor-prescribed drugs under Medicare at lower average costs, closer to those paid in other developed countries.

Critics said the MFN model would ultimately give other countries more power over drug prices. The Biden administration pulled the plug on the order in 2022. During his campaign, Trump initially supported the return of the MFN model, but has recently walked back those statements. Dusetzina said there is bipartisan support for limiting patents on prescription drugs, which could make it easier for generics to enter the market and thus lower prices.

Affordable care

At last month’s presidential debate, Trump falsely claimed he had “saved” the Obama-era ACA, which provides health insurance to more than 21 million people. During Trump’s time in office, he repeatedly tried to repeal it. He ultimately failed, although he was able to convince Congress to repeal the ACA’s individual tax penalty that encouraged people to enroll in a health insurance program. While Trump was in office, the number of ACA enrollees fell from 12.7 million to 11.4 million, driving up rates for those who remained.

As president, Trump also proposed budget plans that would have cut Medicaid by $1 trillion if passed. The ACA supports a federal funding program that covers 90 percent of the costs for states that choose to expand Medicaid; This increases the program’s eligibility for health insurance coverage for people who are at or below 138 percent of the poverty level. States that adopted this expansion saw a 41.7 percent increase in insurance enrollment from 2020. Ten states have not expanded Medicaid, leading to coverage gaps that studies have shown primarily affect people of color. People with low-wage jobs also may not be eligible for Medicaid because their income is still too high based on individual state criteria.

In an attempt to close these loopholes, Trump allowed states to apply work requirements – forcing people on Medicaid to prove they work 20 hours a week, participate in civic engagement or otherwise qualify for an exemption question come. But in states without Medicaid expansion, such as Arkansas and Georgia, work requirement pilot programs have resulted in worse insurance enrollment rates and higher state costs, says Stephen W. Patrick, a pediatrician and chair of the department of health policy and management at Emory University. Patrick points out that polls suggest the majority of Georgians support expanding Medicaid. While the Trump administration pushed for such requirements, the Biden administration has sought to roll them back, saying employment and work should not be tied to access to health care.

Trump’s stance on the ACA was inconsistent and ambiguous throughout his campaign. He has indicated that he would keep the ACA and strengthen it. In other statements he has promised to replace it with something better. During his debate with Harris in September 2024, Trump said he had “concepts of a plan” but gave no details. Trump’s vice presidential nominee, Sen. JD Vance of Ohio, recently advocated potentially drastic changes to insurance risk pools that could make coverage cheaper for those with lower medical needs — and more expensive for those with higher medical needs. This could eliminate ACA protections that prevent insurers from discriminating against people with disabilities or pre-existing conditions, including chronic illnesses or disabilities, or people who are pregnant.

Trump has tried to tackle medical billing, a byzantine — and sometimes bankrupt — process for many in the United States. In 2020, Congress passed Trump’s No Surprises Act, an effective transparency law that a survey found prevented millions from unexpectedly costly medical bills. However, it could drive up other costs.

The Biden-Harris administration has actively promoted insurance enrollment and advocated for ways to strengthen and protect the ACA, Patrick says. In her campaign, Harris has also strongly highlighted a proposal that would use unspent COVID relief funds to cancel $7 billion in medical debt from people’s credit reports. “No one should be denied access to economic opportunity simply because they have experienced a medical emergency,” Harris said in a June press release.

Pandemic preparedness

Trump’s administration created the Coronavirus Task Force to oversee public health efforts during the COVID pandemic, and it also advanced Operation Warp Speed ​​to quickly deliver the life-saving mRNA COVID vaccines by the end of 2020 develop. Still, many experts say the country was ill-prepared for the pandemic because of other steps Trump took. At the height of the pandemic, he repeatedly undermined and rejected advice from health officials during his 2020 presidential campaign, blocked mask mandates and continued to hold large gatherings. Since then, he has actively fueled anti-vaccination sentiment; Several experts agree that many COVID deaths among Trump’s own supporters could have been avoided.

Biden’s American Rescue Plan, which took effect in 2021, helped mobilize the public health response to the pandemic. Federal funding provided free COVID vaccinations, testing and treatment. The plan also aimed to reduce racial inequalities that emerged during the pandemic. In 2023, Biden signed legislation intended to help the country better prepare and plan for future pandemics. It also reestablished a White House Office of Pandemic Preparedness, which Trump closed in 2018, to monitor emerging biological threats and diseases — such as the H5N1 avian flu, which recently infected U.S. dairy cows and poultry, as well as some people. The next government must address the potential threat of an H5N1 outbreak in humans.