Life and Death Issue: Presidential Candidates on Health Care Amid the Bluster, Two Competing Theories

In recent presidential campaigns, the economy and immigration have dominated debates. This election cycle is different.

The COVID-19 pandemic, now entering a third wave as winter approaches, permeates our daily lives, highlighting a vast array of challenges in the country’s health care system. At the same time, President Trump has sought to dismantle the Affordable Care Act, making health care the crucible of the upcoming 2020 election.

The Pew Research Center recently found that nearly seven in 10 registered voters (68%) said health care will be very important to them in deciding who to vote for in the 2020 presidential election. Only the economy, which has been battered by the pandemic, rated higher among 12 top issues.

Though the importance of health care is clear, both candidates’ health policies can be a bit murky at times. Flatland recently asked people on social media what they thought of the candidates’ health care plans and respondents overwhelmingly had no idea what they were. After watching the first debate and dueling town halls, many remain confused. 

The candidates’ websites show a couple of areas of similarity. If one cuts through the debate, accusations and boasting two basic policy approaches appear. Democrats take the approach that the federal government should be more involved in individuals’ health care. Republicans think the states should do the yeoman’s work. 

“They have two different philosophical positions of fairness,” said Ann Marie Marciarille, associate professor of law at the University of Missouri–Kansas City. “Biden has the social insurance theory that we are all in this together… the other side is about having people live with their own actual risk.”

Drug Deals

There are two main areas that Trump and Joe Biden agree need to be changed: drug pricing and surprise insurance billing. These may be popular talking points because, according to Marciarille, these are the areas people tend to cite as the most frustrating about health care in polls. 

Surprise billing occurs when patients visit a provider out of their insurer’s network. The provider then bills the patient for charges not covered by insurance, which can be a sizable amount, particularly for a hospital visit. Both candidates have pledged to end this practice.

On the prescription drug front, both have also said they want to lower costs, but have slightly different ways of doing so. 

It’s important to note that Trump doesn’t have a health care policy, per se. His America First Healthcare Agenda, released in late September, is a recitation of his previous executive orders and a promise that he would continue those, if re-elected. 

Trump said he has, and will, work to manage drug costs by increasing the use of generic drugs, lowering the price of hospital-provided medications for Medicare patients and allowing some lower-cost drugs to be imported from Canada. 

Biden’s plan would allow Medicare to negotiate all drug prices, allow patients to purchase medications outside of the United States and limit price increases of brand-name drugs. He also proposes creating an independent review board that suggests reasonable prices for some new medications introduced to the market (similar to the way Germany prices its pharmaceuticals). 

Both sides have good ideas here, according to Derek Winn, corporate health care strategist with Business Benefits Group. Winn said he is already reimporting medications for some of his larger clients at 50% to 85% of normal cost. (Reimportation is buying excess medications back from other countries that purchased them originally from the United States.) 

Rugged Individualism

The biggest difference between the two candidates’ plans is how they would expand coverage to people who are currently uninsured.

Trump’s plan is multi-faceted. His approach calls for increasing the use of short-term health insurance plans, making available association health plans for small businesses, expanding health reimbursement accounts and giving states waivers to opt out of the Affordable Care Act to implement their own solutions.

His goal is to take the federal government out of the equation when possible, allowing localities and individuals to have responsibility for their health care. 

Faisal Khan, CEO of Samuel U. Rodgers Health, is a proponent of a single-payer federal plan, which neither candidate has proposed. Khan, who treats the indigent and working poor, said through two different administrations, the health of the country is not any better than it was 10 years ago. But given the options, he prefers Biden’s proposals.

“The Democratic party offers better hope in the sense that they talk about things from a humanitarian, scientific perspective and want to invest in rolling out health and social support systems that help people get out of poverty,” he said. 

The less affordable plans on state health exchanges and the short-term plans Trump prefers “aren’t even worth the paper they are written on,” Khan said. In his experience these kinds of plans have high copays and deductibles and little routine and imaging coverage. 

“As a public health professional and provider, I look at those kinds of plans with great skepticism,” he said. “They are a charade at best and just give people the illusion of having their health needs taken care of.” 

Short-term, limited duration plans can help people who are looking for something to fill the gap while they are in transition.

Coni Fries, vice president of government relations at Blue Cross Blue Shield of Kansas City, said limited-duration plans work well for customers who temporarily need assistance because they are changing jobs, graduating from college or transitioning off a parent’s health insurance. 

Blue KC, she said, offers one of these plans that provides broad coverage to beneficiaries. 

Expanding Access

Biden’s plan is to maintain the Affordable Care Act and build on it in two ways – by lowering the age of eligibility for Medicare and implementing the oft-maligned public option. 

Winn said lowering the Medicare age to 60 is an interesting option. If Biden can figure out how to pay for it, Winn said it makes good business sense by allowing people to retire early without fear of health costs and reducing employers’ costs as well. 

Group health plans foot the bill for a large portion of the health care expenses in this country. The highest-cost claimants tend to be older and need a lot of care. Allowing people from 60 to 65 onto Medicare would enhance the risk pool of employer-sponsored plans, reducing the plans’ costs. 

Though the details are somewhat fuzzy on Biden’s public option, Scott Behrens, director of government relations at Lockton Cos., said it would likely be a new plan on the exchanges and look like the options already there. 

Aside from that, it is uncertain who would qualify – it could include people with low incomes not covered by Medicaid, all people on the exchanges or even people currently covered by employer-sponsored plans. 

That is one major concern with the public option, Behrens said. Some think that allowing people on their employer’s plans to qualify for the public option could be a ramp to a single-payer system. There’s also uncertainty as to how robust the benefits would be on a public-option plan. And health care providers worry their reimbursements could be lower under these plans, Behrens said. 

One other tier of the Biden plan that Khan likes is his intention to increase funding to federally qualified health centers such as Samuel Rodgers. The government provides about one-third of the funding coming into those health centers each year, which typically do not make a profit, Khan said. Increasing funding would allow organizations like his to hire community health workers that could link patients from his organization to places like domestic violence shelters or groups that provide food and housing. 

“It would strengthen our system to have community health workers working out of local neighborhoods,” he said. “And give us the ability to focus beyond trying to make our next two to three pay periods.”

What Women Want

One major area of difference between the candidates is women’s health. Where Biden includes a few points in his plans, Trump offers none. And what candidates neglect to say can speak volumes. 

Biden offers to ensure women’s right to choose, increase availability of contraception and restore funding to Planned Parenthood.

These are broad plans, but Rachel Sweet, regional director of public policy and organizing for Planned Parenthood in Kansas and Missouri, said Biden is taking on what some people call the defunding of the organization.

Planned Parenthood does not have a budget line for state or federal governments. One major funding source for the organization is known as Title X. Health care providers use this national grant program to pay for contraception for low-income Americans.

Last year, the Trump administration passed regulations saying any provider who provides or refers patients to abortion services except in cases of rape, incest or a medical emergency, can no longer take part in Title X. Planned Parenthood chose to opt out of the program, which allowed it to use funds to treat 1.6 million patients a year nationwide and 36,000 in Missouri, Sweet said. Biden has pledged to repeal those rules.

The Affordable Care Act also has given millions of women access to free and low-cost contraception. Biden is clearly a champion of that law and Trump an opponent. Sweet said one doesn’t have to look too deeply into Trump’s record to determine where he stands on other issues pertinent to women’s health. 

“The Trump administration has done everything they can to undermine women’s reproductive rights over the past four years,” she said. “He has bragged about opposing safe, legal abortions and said publicly he will only consider [Supreme Court] justices that want to take down Roe versus Wade.”

Devilish Details

Winn said part of the challenge in discerning which health care plan might be most effective is that few politicians ever really reduce health care costs in a significant way. Americans, he said, are held hostage by “big health care” – pharmaceutical giants, hospitals and insurance companies. 

Here’s how he interprets the two candidates’ competing approaches for ending the holdup. 

 “Trump says, ‘We don’t negotiate with terrorists and we also don’t have a rescue plan,’ ” Winn said. “Biden says, ‘We just need to pay more ransom.’ ”

Under Biden, people are likely to see a more cohesive, national health policy, including the way that COVID-19 is managed. Under Trump, things will likely remain much like they are currently. Trump’s strategy is to provide flexibility to states, insurance companies and individuals to determine their own routes.

Marciarille said Biden has a more solid plan, but the devil is in the details. For example, neither candidate has given much information about how COVID-19 and people with its lasting effects will be managed.

Trump’s move to curb hospital charges is a bold idea, she said. But his positions are inconsistent – he says he wants to protect patients with pre-existing conditions from insurance exclusions while his Department of Justice is arguing the Affordable Care Act (which does exactly that) is unconstitutional. Meanwhile, Biden’s public option could be a good idea – but lacks the hows and whys of management.

“I see admirable things on both sides and not enough details on either,” she said.

Tammy Worth is a freelance journalist based in Blue Springs, Missouri.