Click here for the Monthly‘s Presidential Accomplishment Index and more essays comparing Trump and Biden’s achievements in office.

Health care reveals the chasm between the two major presidential candidates as much if not more than any other issue. As president, Joe Biden has successfully advanced the Democratic Party’s 75-year-long campaign to use government to ensure that everyone has health insurance. During his four years in the White House, Donald Trump led a traditional GOP effort to roll back such coverage—and failed. Trump’s response to the coronavirus pandemic was shambolic and disastrous, except for his vaccine development efforts. Biden’s was orderly and successful, though it may have erred in not recommending an end to school lockdowns sooner. Biden signed legislation that, for the first time, negotiates some drug prices and caps most senior citizens’ out-of-pocket prescription drug costs. Trump rhetorically supported similar efforts but accomplished little. Trump appointed Supreme Court justices who overturned Roe v. Wade, and in so doing created new risks to the reproductive health of American women. Biden is working to minimize those risks while maximizing the chance that GOP politicians, including Trump, pay a price. Reviewing Biden’s and Trump’s accomplishments and failures while in office leaves little doubt where either man will take the country over the next four years when it comes to health.

Insurance coverage

Trump came into office vowing to repeal Barack Obama’s Affordable Care Act (ACA), which had lowered the uninsured rate from 17 percent to 9 percent—the biggest insurance expansion since the creation of Medicare and Medicaid in 1965. Trump promised to replace Obamacare with “something terrific.” His never came up with the promised replacement plan. And his hopes for repeal were dashed with a thumbs-down vote by a dying Senator John McCain in July 2018, which prevented passage of a bill that would have gutted the law.

That failure didn’t stop Trump from making it harder for people to sign up for ACA plans, which are heavily subsidized for low-to-moderate-income families and individuals. His Health and Human Services Department (HHS) cut advertising and funding for Obamacare exchange navigators during the enrollment period; it cut the enrollment period in half; it cut subsidies for insurance companies that experienced large losses on their plan offerings; and it expanded access to short-term and employer association plans that did not meet ACA coverage requirements like guaranteed issue, allowing kids to stay on plans until age 26, and mandatory coverage of preventive health care. He also signed a 2017 tax bill that repealed the individual mandate that required people to buy health insurance or face a tax penalty. 

Those actions halted the program’s momentum, at least for a while. Signups on the exchanges fell steadily during his first three years in office, and the uninsured rate rose. But when the pandemic hit, some eligible people finally saw the wisdom in finding coverage either on the Obamacare exchanges or through Medicaid. By the time Trump left the White House, the uninsured and ACA participation rates were back to where they had been before he entered it. 

When Biden took over, he and congressional Democrats reversed most of those Trump-era policies, although it never restored the individual mandate. The American Rescue Plan and Inflation Reduction Act authorized major enhancements to government subsidies for low-and-moderate-income people signing up for plans, which sharply reduced their out-of-pocket costs and provided a powerful incentive for signing up. Biden refunded the navigator program and resumed nationwide advertising.

Finally, in an unheralded but somewhat successful program, his Centers for Medicare and Medicaid Services (CMS), led by Chiquita Brooks-LaSure, worked closely with state Medicaid agencies, including in Republican-run states, to switch people losing Medicaid coverage onto exchange-based plans. The end of the COVID emergency reinstated the requirement that everyone on Medicaid be recertified annually to ensure that they still quality for the program.

The Biden administration’s efforts galvanized the individual market. An estimated 21 million people signed up for Obamacare plans during the recently concluded enrollment period—a 30 percent increase over 2023, which held the previous record for signups. The biggest surges came in Texas and Florida, which never expanded Medicaid. 

What happens during the next administration will depend on which party controls Congress. If Trump wins the White House and Republicans win back the Senate while maintain a majority in the House, they will likely succeed at their second attempt to repeal Obamacare. The uninsured rate will soar back to levels not seen since the early 2010s. Even if Democrats control Congress, it won’t prevent Trump from taking the same types of administrative actions that resulted in a gradual rise in the uninsured rate and a deterioration in the quality of coverage for millions of Americans. 

If Biden wins, coverage will continue to expand, but only through the end of 2025, when the enhanced subsidies in the Inflation Control Act expire. It’s unlikely even a Democratic Congress will be able to overcome a Republican filibuster in the Senate of legislation renewing those subsidies. During the final three years of Biden’s second term, the onus will be on his HHS team to come up with creative solutions for maintaining existing levels of coverage.

Coping with COVID

Trump’s mismanagement of the pandemic’s first year was so egregious that it may have cost him the 2020 election. He initially downplayed the virus’s risks; refused to roll out a national testing program; failed to coordinate a national response; contradicted the advice of public health professionals; promoted the use of unproven drugs; and allowed profiteering and hoarding of personal protective equipment, ventilators, and other scarce supplies.

His idea of setting an example was to refuse wearing a mask in public for the first six months of the pandemic. This behavior was rewarded one month before the 2020 election when he came down with COVID, which landed him in Walter Reed National Military Center for a three-night stay.

His one victory was Operation Warp Speed, a federal effort to speed up the development of COVID vaccines. Launched in May 2020, the program led to the first of several vaccines receiving emergency authorization from the FDA in December, less than a year after its genetic code had been identified. He left office, however, without having set up a system for mass distribution of vaccines.

That job fell to the Biden administration, which promised to administer 100 million doses in its first 100 days. Mission accomplished within 58 days, in part because officials quickly jettisoned its early reliance on mass vaccination sites in favor of using retail pharmacies, which were more accessible. By fall, almost half the population was fully vaccinated (that is, had received at least two doses), which the Commonwealth Fund estimated saved a million lives and 10 million hospitalizations. By the end of 2021, 62 percent of the U.S. population was fully vaccinated, with 73 percent having been administered at least one shot. The administration also took steps to facilitate global distribution of the vaccine, although some public health advocates argue that it didn’t go far enough. Still, what some call the biggest international public health campaign in human history resulted in nearly 2 billion people receiving at least one shot within eight months, which researchers say saved 2.4 million lives in 141 countries. 

The Biden administration also successfully rolled out a national testing program and strongly encouraged masking, social distancing, and economic and school lockdowns—thus rejecting the herd immunity strategy being pushed by some scientists, many of whom were aligned with conservative think tanks. These latter policies remain controversial, especially when it comes to schools, where in the eyes of many the learning setbacks affecting millions of children was too high a price to pay to prevent the deaths of the 1,289 children 19 and under who died from COVID during the pandemic.

Prescription drug prices

During his 2016 campaign for president, Trump promised to negotiate prices directly with drug companies—a position that put him in the same camp with Bernie Sanders, who was then challenging Hillary Clinton in the Democratic primaries. In his Time magazine Person of the Year interview shortly after getting elected, he said, “I’m going to bring down drug prices. I don’t like what has happened with drug prices.”

But given the lack of interest among the Republican majority on Capitol Hill, nothing moved on the legislative front. His appointment of Alex Azar, a former Eli Lilly executive, to run HHS closed off new initiatives through regulation, especially after PhRMA, the industry’s trade association, launched a successful public relations and lobbying campaign to shift blame for high prices onto pharmacy benefit managers.

After Democrats won control of the House and introduced legislation in 2019 allowing Medicare to negotiate prices on 250 drugs, Trump signaled his opposition (and echoed Big Pharma’s line) in a tweet: “FEWER cures! FEWER treatments!” During the 2020 election year, he administratively took action on a few high-profile issues, like capping Medicare beneficiaries’ out-of-pocket monthly costs for insulin at $35 and requiring all pharmacy discounts on insulin and epinephrine pens be passed along to low-income consumers.

Late in his term, the CMS finalized rules that allowed states to import drugs from Canada (in January, Florida became the first state to receive FDA approval to do so). It also proposed a rule weeks before the insurrection that would set prices Medicare paid for 250 drugs at the lowest level paid by a handful of other advanced industrial economies—arguably the most radical price control measure ever issued by Medicare. The Biotechnology Innovation Organization immediately filed suit and won an injunction.

Where Trump failed, Biden succeeded. In August 2022, he signed the Inflation Reduction Act (IRA), which gives Medicare the right to negotiate the price of its 10 most costly drugs beginning in 2026, growing to 40 by 2028 and another 20 more in succeeding years. The Congressional Budget Office (CBO) estimates that negotiations will save taxpayers almost $100 billion over the next decade. This effort, too, faces court challenges by the pharmaceutical industry, but thus far the Biden administration has succeeded in blocking injunctions—or, as happened in a federal district court in Texas in February, had a case dismissed. 

The other major victory for pharmaceutical consumers in the IRA capped out-of-pocket spending on Medicare prescription drug plans at $3,250 this year and $2,000 next year. The bill also slapped a limit on future price increases on existing drugs. Drug companies will have to pay rebates to Medicare if their prices rise faster than inflation. This one provision alone will save the federal government $62 billion over the next decade, according to the CBO.

Abortion rights & reproductive health

On October 19, 2016, during the third and final debate between Trump and Hillary Clinton, the Republican nominee vowed to appoint Supreme Court justices who would overturn Roe v. Wade, the landmark 1973 decision that legalized abortion throughout the U.S. He did. Then they did, despite having pledged fealty to stare decisis during their confirmation hearings.

Since the June 2022 Dobbs v. Jackson Women’s Health Organization decision overturned Roe, nearly two dozen states have imposed abortion restrictions. They range from a total ban on the procedure (including in cases of rape or incest) to setting time limits that are long before fetal viability (23 or 24 weeks) or, in some cases, even before a woman knows she is pregnant. Republican-run states and courts have also attempted to give fetal rights to frozen embryos, ban the importation of morning-after drugs, restrict women’s health clinics, and make criminals of medical professionals and their patients who include abortion as part of their reproductive health care. The U.S. has joined Malta and Poland as the only countries in the 38-member OECD that ban abortion within their borders. 

While these victories have solidified Trump’s hold over the nation’s anti-abortion vote, his party has paid a political price. Every time abortion has been on a statewide ballot, protecting abortion rights has won. Most analysts agree it was the reason why Republicans won only a bare majority in the House in the 2022 midterms, when the opposition party usually makes major gains.

Yet in this election cycle, Trump is doubling down with a proposal that would impose restrictions on abortion access in every state in the union. In February, The New York Times reported that the presumptive Republican candidate now backs a national ban on abortions after 16 weeks with exceptions for rape, incest, and to protect the life of the mother. If Republicans win control of Congress, he will be able to impose that limit on the 30 states that still allow abortions after 16 weeks. It would also open the door to further national restrictions. 

Biden, on the other hand, has promised to sign legislation that protects abortion rights. If he faces a Republican Congress, he says he will veto any legislation that includes a national ban. Though his single nominee to the Supreme Court, Justice Ketanji Brown Jackson, arrived after the Dobbs decision, she has already penned a dissent in a Missouri case where the high court reversed a lower court decision that said a minor had the right to seek an abortion without parental consent.

With abortion rights in blue states at stake and the likelihood that there will be at least one and possibly more openings on the high court over the next four years, abortion access will be the number one health care issue on the November ballot—including at the top, where voters have a precise picture of where both presidential candidates stand based on their records.

There are a few areas where the Biden and Trump administrations have been on the same page when it comes to health care. Both have been more rigorous than previous administrations in enforcing antitrust laws. Both mounted challenges to hospital and insurance company mergers. Both supported the bipartisan No Surprises Act, which put an end to patients receiving bills from out-of-network providers working at in-network facilities. That law also required hospital and insurance company price transparency. Trump signed the law a few months before leaving office, and the Biden administration has raised compliance each year it’s been in effect. However, compliance remains incomplete, the data is hard to access, and many of the posted prices are not user friendly.

However, the areas where they disagree are wide and unbridgeable. Health care policy, whose future direction is very much on the ballot this November, will remain one of the major causes of the deep divisions within this country for the foreseeable future.

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