Major-party presidential candidates Trump and Biden have dramatically different visions for the future on health care issues—an important topic for seniors. 

Overturning Obamacare

Trump has been relentless in his determination to undo his predecessor’s health care plan. Failing to legislatively turn around the Affordable Care Act (ACA) in Congress, Trump has turned to other tools to undermine the sweeping health care law also known as Obamacare. He’s repeatedly tried to gut the law and eliminate parts of it both through executive actions and the courts. 

Trump’s Justice Department is backing a lawsuit brought by several Republican-led states seeking to overturn the entire ACA law, which the U.S. Supreme Court is expected to hear either later this year or in 2021. If Trump is successful in persuading the court to overturn Obamacare, it’s unclear what, if any, protection an executive order would offer in its place.

Trump’s Republican Congress passed the 2017 tax bill eliminating the ACA’s individual mandate, which required most people to either maintain insurance or face a penalty. To date, this is the administration’s single biggest achievement on health care policy, though it resulted in increased premiums. 

Trump has used his executive power to boost “skinny” short-term plans. These are exempt from the ACA’s requirement to cover essential benefits (like prescription drugs) and do not guarantee coverage for people with preexisting conditions. While Trump touts the affordability of the health plans, Democrats deride them as “junk” plans because they don’t provide the same level of benefits or protections. 

Preexisting medical conditions directly affect about 64 million seniors. Recently, Biden suggested that people exposed to COVID-19 might develop long-term illnesses that insurance companies could label as preexisting conditions, increasing insurance rates.

A public option

Unlike many of his Democratic rivals for the presidential nomination, Biden never endorsed Medicare for All. Rather, he vowed to strengthen Obamacare. 

Biden’s plan calls for a Medicare-like public option to compete alongside private insurance markets for working-age Americans, while also increasing premium subsidies that many working-class and middle-class workers use already under the ACA. The public option would be available for small businesses and individuals who do not have, cannot afford or do not like their employer-based coverage. That positions Biden between Trump—who wants to scrap the 2010 law altogether—and more progressive Democrats who want a single-payer system to replace private insurance. 

Biden sees his approach as the next step toward universal coverage. His plan would open up the ACA to millions of people who are uninsured because they live in one of the 13 states that have refused to expand Medicaid.

Biden proposed lowering the age to opt into Medicare from 65 to 60, a move that would extend it to some 20 million more Americans. Medicare would be free to negotiate prices with drug companies, and makers of Medicare-covered drugs wouldn’t be allowed to raise prices by more than inflation. He also recommended expanding the subsidies available on the ACA marketplaces. To pay for this $750 billion plan over 10 years, Biden suggested increasing taxes on the wealthy.

In contrast, Trump has proposed several budgets that would cut both Medicare and Medicaid spending. Medicare reductions wouldn’t affect benefits directly, but they would change how doctors and medical providers get paid. The Trump administration has also supported imposing work requirements and other limitations on Medicaid and installing caps on Medicaid spending growth. He has also supported converting Medicaid to block grants, which would result in fewer people covered. 

What neither Biden nor Trump has adequately addressed is the impending insolvency of the Medicare Trust Fund, which was projected to run out of money in 2026.

Caregivers

Senior care—an important topic often overlooked on the campaign trail—is back in the spotlight due to Biden’s plan. The former vice president is focused on supporting the professional, long-term care workforce serving seniors in nursing homes, assisted living facilities and in their own homes, as well as family caregivers.

Biden’s plan also calls for improving the pay and benefits of home health care aides and personal care assistance. It advocates for a national minimum wage of $15 an hour for caregivers as well as 12 weeks of federally paid medical and family leave. Plus, about 40 million unpaid family caregivers would get help with an annual tax credit of up to $5,000. The plan would additionally help seniors buy long-term care insurance with tax breaks. 

As a part of his economic agenda, Biden calls for a 10-year $775 billion overhaul of the nation’s caregiving infrastructure. He wants to expand alternatives to institutional care for all older Americans while helping veterans by filling vacancies at Veterans Affairs facilities. He’s also pledging to train and hire 150,000 new community health workers in underserved communities and creating a public health job corps.

However, Biden’s plan falls short by not adequately addressing universal long-term care coverage. It doesn’t include much to benefit middle-income recipients of long-term care and their families who are not poor enough for Medicaid but don’t have enough to purchase assistance on their own. 

Drug prices

Drug prices have been a big focus of President Trump’s rhetoric. 

In August, Trump signed executive orders aimed at lowering drug prices. His orders would allow states to develop plans to import cheaper drugs from Canada, eliminate a system of rebates in a bid to simplify the system, and seek to make EpiPens and insulin more affordable for some patients. He also announced a more sweeping order seeking to slash the price that Medicare pays for drugs to be in line with prices paid in other countries.

These are ideas Trump had previously floated but not succeeded getting in to law. His effort to base the price of some Medicare drugs on the costs in foreign countries, where drugs tend to be cheaper, stalled and died in 2019. 

Biden supports a bill approved by the Democratic-led House of Representatives last year that would allow Medicare to negotiate drug prices the way private insurers do. Allowing this would enable the federal government to save billions of dollars and lower drug prices. Republicans and the pharmaceutical industry argue this would force drug makers to spend less money on research and development. The Trump administration vowed to veto the House bill if it ever got Senate approval, which is unlikely.

There’s one area where both Trump and Biden agree: both favor some form of importing prescription drugs from foreign countries to lower costs. However, safety concerns, questions about counterfeit drugs and the powerful drug lobby’s objections have stopped this proposal in both Democratic and Republican administrations for more than 25 years.