Early voting in the 2024 US presidential election is now under way in all 50 states. Although abortion has been a front burner issue in the race between Vice President Kamala Harris, a Democrat, and former President Donald Trump, a Republican, issues such as immigration and the economy have overshadowed other health care topics.
Vice President Kamala Harris | Image: White House photo
Former President Donald Trump | Image: White House photo
But this month, as seniors evaluate changes to Medicare Part D and Medicare Advantage plans, some believe health care may rise on voters’ radar before Election Day November 5, 2024.
What would be Harris’ health care priorities as president? Would Trump pick up where he left off? Both candidates’ platforms and track records offer clues. Here are 5 hot topics in health care heading into Election Day:
Reproductive Health
A recent KFF poll finds that for young women especially, the 2024 election is defined by the abortion issue—specifically, Trump’s 2016 vow to nominate Supreme Court justices who fulfilled his promise to overturn Roe v Wade. In June 2022, Trump’s 3 appointees were part of the majority that supported the Dobbs decision, which turned regulation of abortion over to the states. Before President Joe Biden dropped his re-election bid, Harris had been the administration’s messenger on restoring abortion rights. A former US senator from California who cast many tie-breaking votes as vice president, Harris has said that as president, she would advocate ending the Senate filibuster to restore Roe-era rights.
A recent KFF poll shows that abortion is the most important issue for young women voting in the 2024 presidential election. | Image: Edmond Dantes for Pexels.
During the single presidential debate, Trump claimed, erroneously, that legal scholars “all wanted this issue to be brought back to the states where the people could vote.” According to the Guttmacher Institute, 13 states now have total bans while 4 states ban abortion at 6 weeks, before many women know they are pregnant. Trump has frequently made the false claim that Harris and other Democrats allow abortion up to and after birth.
However, Trump said he won’t sign a national abortion ban, and in the final days of the 2024 campaign, he has tacitly acknowledged that state-level bans have left health care providers confused, even where laws technically allow exceptions to save a mother’s life. At a Fox town hall event airing October 16, 2024, he said some of the state laws are “too tough,” and “those are going to be redone because already there’s a movement in those states.” He has also offered inconsistent statements on banning medication abortion; however, Project 2025, a policy agenda developed by Trump administration alumni, calls for barring distribution of abortion pills by mail under the Comstock Act.
Harris and Trump have also split on issues such as contraception, with the Biden-Harris administration supporting access; Harris’ support for contraception access under the Affordable Care Act (ACA) dates to her time as California Attorney General. As president, Trump issued regulations that restricted funding for contraception; during the 2024 campaign, he first said he was open to state-level limits, but he later backed off the statement. The Trump administration also overturned longstanding rules under the Title X program that supported contraception access for those with low incomes; no funds could be used for contraception if the clinic also provided abortion access.
Future of the ACA
From her time in the US Senate and during her first run for president in 2019, Harris has advocated for expanding the ACA. In the past, she supported progressive ideas such as Medicare for All, alongside private options. As president, she would likely hew more closely to the Biden-Harris record than her earlier positions.
Her priorities include health care affordability, with one of the first big fights in the Congress coming early in 2025: Lawmakers must decide what to do about health care subsidies that were part of the American Rescue Plan of 2021 and were extended another 3 years under the Inflation Reduction Act (IRA).
As president, Trump failed to fully eliminate the ACA, but he did knock out pieces. Notably, he effectively killed the individual mandate; he also cut federal subsidies that caused rising premiums for marketplace plans while allowing “skinny” plans that did not cover all essential benefits required under the ACA. The problem with these plans, critics say, is that they don’t reveal the hidden out-of-pocket costs that await consumers if they get sick. That’s why there was pushback following the vice presidential debate when GOP nominee Sen JD Vance (R, Ohio) claimed that Trump had “salvaged” the ACA.
Trump has long promised to offer an alternative to the ACA; during his own debate with Harris, he said he that he had a “concepts” of a health plan. His 2020 budget proposal called for repealing both Medicaid expansion and ACA premium subsidies; instead, states would get block grants. However, these steps would be more challenging today than in 2017. Since Trump left office, 5 states have expanded Medicaid, bringing the total to 41.
Amid the uncertainty over Trump’s plans, 1500 physicians who are part of the Committee to Protect Health Care PAC, which has endorsed Harris, called on Trump to release his health plan, The Hill reported on October 16.
Reducing Prescription Drug Costs
When it comes to holding down drug costs, Harris doesn’t offer much that drug companies like. Trump, meanwhile, just doesn’t offer much, period.
Harris and Trump have taken different approaches over the years to reining in prescription drug costs. | Image: Pixabay photo
The centerpiece of the Biden-Harris agenda on drug costs was contained in the IRA of 2022, for which Harris famously cast the tie-breaking vote in the Senate. The IRA created headline grabbers such as $35-a-month insulin for seniors—something Harris wants to expand to commercial plans—alongside vast new powers for HHS to negotiate Medicare drug costs and collect rebates if certain drug prices rise too quickly. These more labyrinthine elements, which have fueled cottage industries to determine which drugs will be targeted and manage Medicare’s process, have drawn ire from pharma companies that say they are stifling innovation, delaying product launches, and triggering other unforeseen effects.
Through its trade association, PhRMA, the industry formally supports the other IRA bumper sticker—the $2000 out-of-pocket cap for Medicare Part D, which starts in January 2025. But PhRMA released an analysis that says this benefit could be undermined by the IRA provisions for drug pricing negotiations.
As a candidate for president in 2019, Harris supported “march-in” rights, which allow the government to claim patents for drugs developed with federal research funds, thus making them more affordable. The Biden administration has not exercised march-in rights, and it has not been a focus in the current campaign.
Trump has complained that the $35-per-month insulin was his idea and Biden and Harris have “nothing to do with it.” It’s true that Trump’s HHS created a voluntary model for Medicare plans to offer at least one formulation of the cheaper insulin, but the IRA made it the law for 3.4 million insulin users on Medicare.
Meanwhile, Trump has wavered on whether he will revive an idea seriously pursued during his term as president: use of a Most Favored Nation pricing model, meaning that high-cost, physician-administered Medicare Part B drugs would be available for the lowest price charged in other similar countries. A proposed rule sparked 4 industry lawsuits and was pulled after Biden took office.
Trump also pushed for importing drugs from outside the US. He hasn’t said whether he would continue IRA pricing talks; Harris has pointed out that Trump promised to introduce his own price negotiations but never did.
His remaining policy ideas are listed in a section of the campaign website, Agenda 47. The tone of the policy is negative toward the drug industry, stating that the rise of chronic illness among children must be “investigated” and connections to the pharmaceutical industry pursued: “Too often, our public health establishment is too close to Big Pharma—they make a lot of money, Big Pharma—big corporations, and other special interests, and does not want to ask the tough questions about what is happening to our children’s health.”
Consistent with his overall trade policy, Trump pledges to address drug shortages with a combination of tariffs, import restrictions, and domestic incentives to promote onshore drug manufacturing. His policy document lambasts “the extreme national vulnerability caused by the lack of an adequate domestic manufacturing capability for critical pharmaceuticals.” To a degree, Trump’s goal aligns with Democrats who reached the same conclusion in a 2023 report produced by the Senate Homeland Security and Governmental Affairs Committee.
Health Care Consolidation, Costs, and Consumers
Two decades of mergers, first in the hospital sector and then among pharmacy benefit managers (PBMs) and health plans, are now considered a factor in driving up health care costs generally and drug costs in particular. The power of PBMs is now a bipartisan concern in the Congress, and action to bring more transparency may come during the lame duck session.
Under Biden-Harris, the Federal Trade Commission (FTC) has worked aggressively to block mergers and investigate PBM abuses; it recently sued the “Big 3” PBMs that control 85% of the market. At the same time, hospitals and physicians have complained that CMS could do more to enforce Medicare Advantage (MA) contracts that abuse prior authorization to limit access to services and drugs.
The Trump administration pushed through rules that require transparency in billing by hospitals. | Image: Pixabay
In his term as president, Trump pushed for loosening regulations to give providers more options for business flexibility, which would presumably put less pressure on practices to consolidate into hospital systems. Starting around 2010, oncology practices began creating on-site pharmacies to dispense increasingly complex therapies, and about a third of practices had pharmacies by the end of Trump’s term. But as the pandemic lifted, Biden’s CMS team reinterpreted the Stark Law, which bars self-referrals; practices were told that caregivers could no longer pick up prescriptions for patients, and practices must stop putting drugs in the mail to spare cancer patients a trip. This sent oncologists to Congress for legislation to undo CMS’ action.
Overall, both candidates have staked out consumer protection turf. As president, Harris would draw on her history as California Attorney General, when she battled hospitals, drug distributors, and insurers over antitrust issues. Amid the many mergers that occurred during that era, one didn’t happen: Harris, representing the largest state, joined 11 others and the Department of Justice to stop a $48.6 billion merger of Anthem and Cigna. A lawsuit she started against Sutter Health to show that health system consolidation caused higher prices eventually led to a $575 million settlement for California. She also battled drug companies that tried to hold up introduction of low-cost generics.
As president, Trump adopted rules on hospital pricing transparency, which the Biden administration continued. And, under HHS Secretary Alex Azar, Trump pushed through rules to give patients access their own health data—along with a requirement that it be downloadable to their phones. Patients’ use of personal health data jumped 50% between 2020 and 2022, according to the Office of the National Coordinator of Health IT.
More recently, Harris has focused on the challenge of medical debt, announcing new rules to ban medical debt from credit reports. Trump’s lack of specifics and past actions to allow low premium, high out-of-pocket health plans concerned a consumer advocate who spoke with NPR.
“People will face a wave of medical debt from paying premiums and prescription drug prices,” Anthony Wright, executive director of Families USA, told the outlet. “Patients and the public should be concerned.”
A Medicare Home Health Benefit
On October 8, 2024, Harris proposed what would be the first new major expansion of Medicare in a generation—a home health benefit to help what the vice president called the “sandwich generation” of adults taking care of both children and aging parents.
Harris, who unveiled the proposal on the daytime program “The View,” drew on her own experience caring for her mother, who died of cancer in 2009. “There are so many people who are right in the middle,” she said.
So far, Harris pegs the annual price at $40 billion, to be paid for largely with the drug savings achieved under the IRA. KFF notes that amount doesn’t factor in reduced spending at hospitals and nursing homes, where many seniors now end up when home health care is not an option.
Right now, traditional Medicare only pays for home care that involves other care, such as physical therapy for a homebound senior. Medicaid will cover home care for elderly and disabled Americans who qualify, but beneficiaries must spend down all their savings first—and as the Harris campaign notes on its website, some states then seize the family home to repay Medicaid after a person dies. Harris wants to end this as well.
Not all analysts who have weighed in on Harris’ plan think her cost estimate will hold up, and some say it shouldn’t be offered through a universal benefit program such as Medicare.
Details of the program are not complete. “Medicare will design a plan that provides coverage for those of modest incomes with a sliding scale for cost-sharing for seniors with higher incomes,” a campaign statement said.
Following Harris’ announcement, the Trump campaign pointed to language in the 2024 GOP platform that includes a sentence, “President Trump will prioritize home care benefits by shifting resources back to at-home senior care, overturning disincentives that lead to care worker shortages, and supporting unpaid family caregivers through tax credits and reduced red tape.” There are no financing details.
The Trump campaign claimed that Medicare Part B premiums have seen their largest increase ever under Biden, and that Trump will do more to strengthen Medicare solvency. The Harris campaign warns this could mean Trump will revive earlier plans to push the retirement age to 70, as some Republicans support. But Trump’s campaign insists he no longer supports this change.