Comparing Trump and Biden's Healthcare plans

Comparing Trump and Biden's Healthcare plans

Video Transcript

RICK NEWMAN: From Yahoo Finance, this is "Electionomics." I'm Rick Newman.

ALEXIS CHRISTOFOROUS: And I'm Alexis Christoforous. Few issues have more sharply divided Republicans and Democrats over the last decade than health care. It is a hot topic once again as we near the election. And this week, we're going to delve into the health care policies of President Trump and Democratic nominee Joe Biden. And to help us do that is Katie Keith. She's a health law professor at Georgetown University and a contributing editor at "Health Affairs."

Katie, great to have you here on "Electionomics." There is plenty to get to, but I want to start with the incumbent. Because when President Trump was candidate Trump, he campaigned on repealing and replacing President Obama's Affordable Care Act. And even with a Republican-controlled Congress, he couldn't do that. So is dismantling the ACA still the centerpiece of the Trump administration's health care policy?

KATIE KEITH: It's a great question, and I think the answer depends partially on what day you ask and who you ask. But in general, we have really seen a movement away from repealing and replacing the Affordable Care Act as sort of a plank. There was an analysis done by "The New York Times" recently of how few times Obamacare was even mentioned during the Republican National Convention. It was one of the centerpieces back in 2016 that not only President Trump, but every Republican presidential candidate had run on repealing and replacing the ACA.

It's a whole different world now. And I think if you look at the-- that shouldn't be that surprising if you look at the midterm elections. So all during 2017, Republicans in charge of Congress and the president did try multiple times and failed to repeal the law, in part because it's at a record-high popularity, believe it or not, about 10 years later. And so in 2018, I think health care was a huge issue in the midterms. It helped Democrats retake the House.

And especially when you look at COVID-19, the idea of talking about repealing and replacing something that's extended, you know, health insurance to about 20 million Americans is, perhaps unsurprisingly, not that popular of an idea. So there really has been a downplaying of the Affordable Care Act. Yeah, it's just not as much of an issue. You don't hear them talking about it as much.

RICK NEWMAN: So Katie, can you talk about that lawsuit that's still out there? I mean, it seems like there's been a lawsuit trying to kill the ACA since the day it went into effect, which actually I think is probably literally true. But there is this one remaining lawsuit that was, I believe, brought by the state of Texas. And the Trump administration is a party to this lawsuit on the side of the plaintiffs, who are still trying to kill the ACA. So could you just explain where that stands and what the timing is on that?

KATIE KEITH: Yeah, that's absolutely right, and you're exactly correct. Within minutes of the Affordable Care Act being signed into law back in 2010, it was challenged in court. And those same fights are still playing out today. And so, you know, this lawsuit stems from the big tax reform bill that the Republican-led Congress adopted in 2017 at the end of the year where they zeroed out the individual mandate penalty of the ACA.

And what they're arguing then in court, led by the attorney general of Texas-- and, you're exactly right, Rick, joined by the Trump administration-- is that the mandate is now unconstitutional. And because it's unconstitutional, you know, it's so essential to the entire rest of the ACA that the whole law should be struck down in court. And so we've seen-- we've been watching this lawsuit. It was filed in February of 2018. It's been winding its way through the courts ever since.

One court has already said the entire law should be thrown out, the entire Affordable Care Act, and now it's pending before the Supreme Court. And so we've-- it's very sort of high stakes. All but four states have weighed in on the case one way or another. You have the Trump administration, the House of Representatives, and California is leading sort of a coalition of Democratic attorneys general to defend the ACA because a Trump administration has declined to.

So we'll see oral argument in that case on November 10, so exactly one week after this year's election, and we'll get a decision on that in 2021. And so you're exactly right. While Republicans aren't necessarily talking about repealing and replacing the ACA, they are very much supporting a lawsuit that would sort of do the same thing, accomplish the same goals through the court system, so almost a judicial repeal of the law.

ALEXIS CHRISTOFOROUS: So we really wouldn't have-- know the fate of the ACA until after the election. But if ACA is not going to be the focal point of a Trump administration health care policy, then can you outline for us, what is? What is at the centerpiece here?

KATIE KEITH: Yeah, so it's a little-- you have to sort of separate what the Trump administration has pledged to do and what their goals are versus what they've actually done. So I think if you focused on what their priorities are, they've done an incredible amount around price transparency, so many different types of rules. This is the idea that everyone should be able to walk into a hospital and know exactly what a service costs. I think that one's actually pretty popular politically and it's something that, who knows, but maybe a Biden administration would continue-- so price transparency.

The president has had a big focus on prescription drugs, trying to bring down the cost of prescription drugs. They have tried a lot of different things. He signed I think four executive orders recently that's focused on prescription drug issues. But the experts that I know on that issue say that none of those have really had an impact. Drug prices continue to stay high. Folks continue to have problems paying their bills. And so there's a big emphasis on some of these issues but very little to show for it, where a lot of the policies that they were pushing, in the first term at least, have not yet come to fruition.

Other things have been kind of alternatives to the ACA, things we call short-term plans, association health plans. And then there's been a big focus on rolling back women's health protections, so things like abortion access, contraceptive-- access to contraceptives, sort of the-- having a religious freedom element of health care. So I think those are some of the big things. Well, the last one I'll mention is sort of tying immigration and health care together. I don't think it's any surprise that this administration has had a big focus on immigration across the board, and so there's been a number of executive orders and things like that to really sort of limit immigration for those who can't pay their health care costs, to discourage immigrants from getting the health care that they need.

RICK NEWMAN: Hey guys, I'm going to read the entire health care platform of the Trump campaign for a second term. And for anybody who feels like, oh no, I couldn't possibly sit through, you know, a 45-minute recitation of some health care policy, no, no, no, I can get through this in less than a minute. This is the entire Trump campaign health care plan.

Cut prescription drug prices. Put patients and doctors back in charge of our health care system. Lower health care insurance premiums. End surprise billing. I'm almost done. Cover all pre-existing conditions. Protect Social Security and Medicare. And last but not least, protect our veterans and provide world-class health care and services.

That's it. That's the whole thing. There are no-- you know, there's no, like, here's how we're going to cut prescription drug prices, here's how we're going to cover pre-existing conditions. It just says they're going to do this. So Katie, I'm not going to ask you to explain their plan or what they mean by any of these things. But when President Trump says his plan for a second term is cut prescription drug prices, that raises the obvious question, why didn't you do that during your first term?

ALEXIS CHRISTOFOROUS: I got to jump in there. Because on that point, Ivanka Trump, his daughter and advisor at the RNC, talked about drug pricing and actually said that her father has told her in private that the big pharma companies are really upset with him, and they wouldn't be upset with him if he was doing-- if he-- you know, he wasn't doing something right in trying to lower those prices. Would you agree with that? I mean, has he done anything to lower the prices?

RICK NEWMAN: Yeah, what do we know about prescription drug prices in the last four years?

KATIE KEITH: Yeah, so I think the thing that they tout the most is that they've had more approvals of generic drugs through the FDA than prior administrations. But the data just doesn't show that prices have gone down. You know, they've rolled out a lot of initiatives on access to insulin and things like that. But the truth is, a lot of their most ambitious proposals have not been finalized or have been tied up in court.

And so we-- you know, maybe they're arguing that their sort of soapbox saying-- you know, shaking their fist at high drug prices is somehow having an influence, but that's not what the data shows. And they don't have any signature achievements to actually point to say, hey, this is what we've done, and here's what you could expect in a second term.

So the evidence just isn't there. A lot of those initiatives have stalled out. They haven't finalized them. They've been challenged successfully in court.

RICK NEWMAN: So there's a big difference between trying-- excuse me-- trying to make changes with executive orders, which is what President Trump has tried to do a lot, and getting legislation passed, which is normally the best and most effective way to make these changes. But I don't think there has been any health care legislation that has passed under the Trump administration, including when Republicans controlled Congress for two years. Did they pass anything on health care?

KATIE KEITH: You could argue that a lot of the COVID relief packages did include certain health protections, right? Things like-- I'm trying to be generous here, I guess, and make sure I'm not missing anything.

RICK NEWMAN: Yeah, no, fair.

KATIE KEITH: You know, COVID testing--

ALEXIS CHRISTOFOROUS: Can I jump in?

KATIE KEITH: Yeah.

ALEXIS CHRISTOFOROUS: Didn't he recently redirect his administration to make it cheaper to import cheaper drugs, I guess from Canada? Is that something? I mean, it's not necessarily legislation, but I guess it was an executive order.

KATIE KEITH: That's an executive order. They've talked about drug reimportation quite a bit. I believe, though, that there was a proposal they first put in place that they haven't finalized yet. And so then this new executive order was kind of recharging that up. Or you know, a cynic would say they're trying to play politics and get credit for something that hasn't been implemented yet.

They've been working with states like Florida to try to get drug reimportation going. Nothing has happened yet, though, right? And so it's-- there are these ideas out there. That's one that even actually has some popularity on the left too, right? Bernie Sanders is in favor of drug reimportation and so-- but nothing-- there's really not anything to show for it besides a lot of maybe press releases, executive orders, things like that.

RICK NEWMAN: So I have a question about drug reimportation. Correct me if I'm wrong here, Katie, but I think the idea is because other countries basically set price controls on prescription drugs and we don't, for the most part, that's why they're cheaper overseas. And the idea is that we could import them from overseas at those lower prices.

But there's one caveat here, which is if those countries agree to it-- and I've heard some commentary from Canada of people saying, you know, so if you-- if the United States just starts importing Canadian drugs because we have price controls in Canada and you don't, well, our prices are-- we're just going to have scarcities or, you know, we're going to have problems like that. So doesn't the reimporting country have to agree?

KATIE KEITH: I think that's part of it, and Canada has said exactly that of, you know-- well, I don't know what it would do to their prices, but they're worried about shortages, right? Even just making those drugs available. So it could be one of those situations too where if you-- you could build drug reimportation, but you might not actually have the supply to support it when it comes down to it.

There's also-- I've heard concerns raised about safety. Who's going to check the quality of drugs coming in? You know, counterfeit drugs are a big issue, those types of things. So it is one of-- it sounds somewhat simple, right? Oversimplified, to just, well, they pay less. Why don't we just report it from there? There's-- the devil's in the details, as it is with most things as we talk about health care.

RICK NEWMAN: So we're having trouble coming up with any actual, real Republican health care plan here. But let's give him another chance. So to go back to this Trump campaign--

KATIE KEITH: The bulleted list.

RICK NEWMAN: Yeah, the bullet points. I just want to hit on this other one, cover all pre-existing conditions. Now, pre-existing conditions, that has already been taken away because of the ACA, correct? So can you explain where we stand on pre-existing conditions and what would change if that lawsuit were to succeed?

KATIE KEITH: Yeah, great question. So as of now, I think this is one of the-- you know, if you know nothing else about the ACA, you know it protects people with pre-existing conditions, right? This has been sort of drilled into folks' minds over the past 10 years that the law has been in place. This is one of those-- and the way that this works, there's no sort of one single way to protect people with pre-existing conditions. You have to look at all factors of health insurance to make sure that, you know, I can't-- I don't have to pay more, my benefits will be covered, and I can't be denied coverage by my insurance company. I'm sort of a multifaceted issue.

It's very easy to say we're going to protect people with pre-existing conditions. But the truth is, all during 2017, when we watched Republicans in Congress try to repeal the law, this was a sticking point. Every one of their alternative proposals would either leave folks with pre-existing conditions unprotected, paying more, facing benefit gaps, or it would result in significant coverage losses where you have millions, if not tens of millions of people, losing coverage.

And so when you-- you know, I'm just somewhat skeptical when I hear the president say or some Republicans in Congress say, we're going to absolutely protect people with pre-existing conditions. There is no evidence that we've seen that shows that they have a proposal that would do that. It's something very easy to say, much harder-- you know, harder-- easier said than done. Let's put it that way. And so that's something I'm very much watching out for.

I do think it's going to take a lot of sort of fact-checking by news organizations and things like that to make sure that folks really do understand who would be protected or not. And to your point, this lawsuit that is working its way through the system, that the Trump administration very much supports, would-- the goal would definitely be to get rid of those protections for people with pre-existing conditions.

RICK NEWMAN: So I guess the idea is if a court-- if the-- well, it's really just the Supreme Court at this point because Congress isn't going to do it. If the Supreme Court were to kill the ACA, the idea is I think it would not happen, like, the next day, right? It would-- there would be some kind of implementation period because people would still have insurance they had purchased through the ACA or through the exchanges and that Congress would have time to pass a new law that said, OK, all the ACA is dead, but we're going to just pass this one standalone thing that says insurance companies have to take people with pre-existing conditions. You can't charge them more. You're saying that's just really oversimplified and not the way it works in the real world?

KATIE KEITH: Yeah, I think it's wishful thinking is probably the way I would put it of-- you know, if the court-- I would expect this decision, it'll be kind of a blockbuster Supreme Court decision. It will come down in June of 2021, as most of those blockbusters come down. You're exactly right. Folks would be in the middle of their coverage here.

If they-- I don't know that we'll get sort of an off ramp, right? That we'll have a bunch of months for Congress to get its stuff together and actually, you know, protect people and correct whatever fault the court finds. So it's going to be something really, really important to watch. What I will say is that, you know, everything we're fighting about is about zeroing out of the individual mandate penalty. And so there are folks-- we call it save, sever, or sink.

So Congress could actually fix this issue very easily. They could save the mandate by taking it from zero dollars to maybe a $5 mandate. That would make it magically constitutional again, and then everything would be fine. They could sever it. They could go in and add a severability clause to the ACA and make it much easier, or they could sink it and just strike that provision and all of the cross references.

And so I think when we're talking about this case, there is this idea of, you know, Congress would have to reenact the entire Affordable Care Act, which would be extremely challenging. It almost didn't happen the first time around in 2010. But really, we're just talking about this one provision. And so I think there would be some fighting over that in Congress and, you know, lots of negotiations that would take place.

The truth is, if you had a president to sign it, d you know, if there's a new-- I think that's a question right now. Even if Congress could get it together in a bipartisan way to sort of fix whatever problem the court finds with it, would you have a president to sign that bill? And that-- a lot of that-- you know, if we're just sort of leaving that with President Trump, I don't know what the answer to that would be. It's just another reason that I think the next administration is going to have a huge impact on the future of the Affordable Care Act.

RICK NEWMAN: Katie, I follow your--

ALEXIS CHRISTOFOROUS: We've been talking about--

RICK NEWMAN: Go ahead, Alexis.

ALEXIS CHRISTOFOROUS: Sorry. We've been talking about health care and haven't talked about COVID-19 yet. And Trump's job approval rating since the pandemic we know hit a new low. So where do Republicans go next on COVID-19, Katie? Because we saw the Democrats, you know, light into the response from the White House, saying that there was no federally-mandated response, like everybody has to wear a mask. Biden has pointed to that. Where do Republicans go from here, and could this really be the thing that trips up a Trump re-election?

KATIE KEITH: I mean, at this point-- and you could sort of see it from watching the Democratic National Convention too, I think keeping the focus on the virus and the lack of a federal response here, whether-- you know, whether it's on-- it was access to PPE and having states fight against each other, whether it's a lack of a national testing strategy, whether it-- you know, sort of maybe mismanagement perhaps of the PPP program. You know, you name it, there have been all kinds of issues with the federal response here.

You know, I don't know where Congress goes next. And so you kind of-- there was hope-- I'm based here in DC. There was hope that you would have this COVID package. The Senate-- the House has passed multiple bills on this issue. They've sort of gone nowhere in the Senate. And so you sort of have an effort being led by Majority Leader Mitch McConnell. And the negotiations are ongoing, and they've totally fallen apart, right?

So folks left town without really getting anything going. Right now, the packages don't seem to be that focused on health care at all, which in this kind of crisis, I think is so frustrating to watch people losing their jobs, which means losing their health insurance. The testing-- you know, testing, from delays to access, seems woefully outdated. We just need a lot more help there, looking at the public health system. There's just so many issues.

And instead, I think the debate has been around liability for businesses, definitely schools, the Postal Service. And you know, the last package I looked at before they left town, it had some public health funding, primarily for testing and contact tracing. But it doesn't feel like on health care, in my opinion, Congress is really rising to meet the moment that we find ourselves in a global pandemic on the health care side. There's been an incredible amount of assistance that's gone out. I wish we were focused a little bit more on health care.

RICK NEWMAN: This is a good segue to what Joe Biden might do, but I do want to just go one more question on the ACA because I guess I'm obsessed with this. But this is such a big deal. I followed your analysis on this, Katie, at your blog on health affairs. And it seems to have gone from legal experts thinking this Texas lawsuit had very little chance in the courts and then the courts seemed to validate in surprising ways, I guess at the appellate level. And now there seems to be a more serious concern that the Supreme Court could actually kill the ACA. I mean, that could happen, right?

KATIE KEITH: It could definitely happen. I don't know how likely it is with this court, you know, the nine justices that are on the court now. The five justices who voted to uphold the ACA the first time around in NFIB, the big 2012 Supreme Court decision. They're all still on the bench.

RICK NEWMAN: And John Roberts, the chief justice, was the--

KATIE KEITH: Wrote that--

RICK NEWMAN: --swing vote in that case, right?

KATIE KEITH: Right, and he wrote that decision. That's right. What I don't know is if you have a different court, for example. If those nine justices-- if that makeup changes, I think the ACA could be in a lot more trouble. I also think even a-- I'm going to use air quotes-- a narrow ruling of, you know, just the mandate goes and then the protections for people with pre-existing conditions go, that would also create an incredible amount of chaos. So even if the-- my point there is even if the court didn't strike the entire law, striking down, you know, bits and pieces here and there could open up all kinds of problems for patients, for the health care system, for all of that.

So I think it's a very real risk and not something to be underestimated at all. And you know, the fact that the Trump administration has kind of put its thumb on the scale in favor of Texas and the other states arguing against the ACA in its entirety-- it's very unusual for them to take a position like that and I think shows kind of the ideology behind opposing the Affordable Care Act. I can't-- I don't have any other explanation except for ideology for them to take that position.

RICK NEWMAN: So that's one side of the equation, the Republican plans or lack of plans. So what do you think could be the priorities and might actually change if Joe Biden wins? And I think it's important to say, for Biden to really get anything done on health care, he would probably have to have Democrats take control of the Senate. So do you have a feel for what the, you know, top one or two health care priorities would be if that were the scenario?

KATIE KEITH: Yeah, I think at this point-- I might have said something different, you know, six months ago, as many of us might have said, but I think that there will be a very strong COVID response. And I'm not quite sure what the Biden administration is thinking on that point. I think that is shifting all the time. But you could look to the bills that have been passed by Democrats in the House to get an example of that-- much bigger spending bills, better protections for the uninsured, you know, all kinds of major changes there.

I mean, what's in his campaign plan is definitely building on the ACA, so making the subsidies for folks in the individual market much more generous, allowing more folks to enroll, creating sort of a work-around for the 12 states that have expanded their Medicaid program. So that would expand coverage to another 4 million people who fall in that gap right now. Many of these things I think are things that the Democrats in the House have already worked on or have pending bills.

So in some ways, I think folks could be pretty quick. It will absolutely, though, depend on the makeup of the Senate and whether the filibuster is going to stick around, right? If you only need 51 votes to make some major changes as opposed to 60, I think you'd see a lot more sort of core Democratic priorities get passed through. If you still need 60 votes, I think we might still be in a lot of gridlock, to be perfectly honest with you, especially around health care.

I had been someone who was hopeful that after the repeal efforts over the ACA failed in 2017 that maybe we would have a moment of just moving on on the ACA politics of, you know, the Democrats can't improve it but the Republicans can't repeal it. Maybe we can just get over it. And then you had this lawsuit that we've been talking about get filed, and it has just really maintained the law of saliency as a political issue. And so now you will have kind of ACA politics hanging over everything that a new Congress might want to do, even if they would want to move on and do things like surprise medical bill protections and, again, more COVID response, actual prescription drug changes, that kind of thing.

So there's a lot of Biden priorities. I don't know if it'd be helpful to drill down. And I don't know what-- how they would put them on the bullet point list or what order they would put them in, but I'd be happy to dig in further. And then-- well, I should say, I think there's things that Biden administration could do on its own aside from Congress, sort of an executive-level strategy. So there's probably two things going on there.

ALEXIS CHRISTOFOROUS: Katie, I think we need another podcast. I think we need another health care podcast to dig into all of that. Before we wrap up though, I don't think mental health gets enough attention in anybody's health care policy. And I want to talk about that in relation to the pandemic because a recent poll showed 53% of adults in this country reported that their mental health has been negatively impacted because of worry and stress about the virus. Do either one of these candidates have a real mental health policy plan?

KATIE KEITH: This is not my area of expertise. I do know the Biden administration has put forward proposals-- like, I know they talk about mental health. I know this is a big priority for them. I could not tell you exactly what their policies are. I'm sure the Trump administration would say the same, but I also can't think of much that they've done in this arena.

Plus, I think it's a focus-- the other thing that I would add that I haven't mentioned is I think given the COVID-19 response, given the disparities that we all knew about but that are getting un-earthed in health care of, like, who is, you know, having communities of color be dramatically more affected by COVID-19, I do think that the Biden administration is also looking at this from a disparities angle too and that you'd see a lot more attention on things like maternal health, especially for Black women, addressing some of the-- like, the death rates and differences in mortality rates, things like that. So I think there's even a-- going to be a doubling down of emphasis on who is most impacted and who is most at risk.

ALEXIS CHRISTOFOROUS: All right, Katie Keith, health law professor at Georgetown, contributing editor at "Health Affairs." Thanks for being with us. Be sure to rate and review what you just heard and saw, and you can follow me @AlexisTVNews.

RICK NEWMAN: And me @RickJNewman. And you all know, my Twitter feed is just a stream of love.

ALEXIS CHRISTOFOROUS: Thanks, everybody. We'll see you next time.

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