• Fresh Perspectives

    Decision 2020: Where Do the Candidates Stand on Health Care?

    The 2020 election is upon us, and it is an especially contentious and charged presidential election. Oftentimes, the real issues are pushed aside for soundbites or political points. It is often difficult to actually understand a candidate’s position on issues such as health care. We are in the midst of the worst global pandemic of the past 100 years, so it seems reasonable to want answers about COVID-19, the economy and health care.

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    A conversation regarding health care reform cannot occur without a brief conversation about health care economics and the economic impact of reform. The United States spends more than 17% of its gross domestic product on health care; overall, it is the largest percentage of U.S. government spending (23%), about the same as education and defense spending combined. The next-highest-spending countries? Switzerland, Germany and France at 11-12%.

    We should be worried about the current economic impact of our health care system, and we look to our presidential candidates for answers.

    It isn’t enough to hope President Trump or Vice President Biden will outline their specific plans for health care in the post-COVID era during a debate or rally. Instead, there is some benefit in looking at what each candidate has actually done during their tenures at the White House to reform health care and build on that by reviewing the health care platforms they have provided on the Trump and Biden campaign websites and in interviews and other public statements.

    Before diving into the presidential candidates’ health care platforms, let’s review the AAFP’s stance on health care reform. After all, a virtual AAFP Congress of Delegates just concluded on Oct. 13, and there were many questions and discussions about the future of health care reform.

    The AAFP stance on health care reform is succinctly described in the Academy’s Health Care for All Primer. The primer is built on two foundational principles — health care is a basic human right, and individuals should have universal access to timely, acceptable and affordable health care of appropriate quality. These principles were developed by AAFP membership through the Congress of Delegates, and they help shape the Academy’s policies on health reform.

    The primer details the AAFP’s recent history, stance and thought process on achieving health care for all that is based in foundational primary care. It is well worth a read. But to save time and summarize the 38-page document, the AAFP concludes that there is a plurality of ways to achieve universal health coverage, and it is best done through either a Bismarck model, a public option or a single-payer system.

    To be clear, this is a conversation on how to ensure every patient has health insurance that is equitable and accessible, not how we pay or employ physicians. Below is a brief description of each of those models so we can better understand where each presidential candidate’s health care platform falls within the context of the AAFP’s primer on health care for all.

    The Bismarck model, originating in Germany and named after Chancellor Otto von Bismarck, is a form of social health insurance that covers all citizens. Employees and employers pay into sickness funds through mandatory payroll reductions (taxes), and everyone taps into these funds to obtain health insurance. The actual insurance is administered by many private not-for-profit insurance companies, which offer essentially the same benefits to everyone in a system that is highly regulated by the government. Many people look at the German, Belgian or Japanese health care systems as examples.

    A public option can be many things, but it essentially is adding another insurance plan to our current health system, which could increase competition and drive down the prices of private insurance plans. As the name implies, this insurance coverage would be a government-run health insurance plan. The flexibility of a public option is that it could be implemented at a state, regional or national level. It could be a public/private partnership, work as a Medicaid buy-in, work within Medicare or become its own publicly administered insurance plan. The public option is unique to the United States, although some countries have mixed models that incorporate both public and private insurance coverage.

    A single-payer system, technically known as a national health insurance model, is publicly financed and administered, meaning the government acts as the insurance company. It covers all citizens with the same health insurance and the same benefits. Some countries using this model allow for supplemental private health insurance. The idea behind this model is decreased costs through increased bargaining power with pharmaceutical and medical device companies, along with the decreased administrative burden of having uniform insurance coverage and benefits. Two examples of countries using this model are Canada and South Korea.

    Health care in the United States does not currently fit any of the models outlined by the AAFP’s Health Care for All Primer. We have multiple publicly financed insurance systems, such as Medicare, Medicaid and the Children’s Health Insurance Program. We have private insurance coverage, which is often tied to employment status (employer-sponsored insurance). We have publicly subsidized private insurance in the form of health exchanges under the Patient Protection and Affordable Care Act. Lastly, we still have millions of Americans who are without health insurance and must pay out of pocket.

    Although it is difficult to compare and contrast Trump’s and Biden’s health care platforms on major issues, we can compare their vision for U.S. health care and their differing views on how to achieve better health care.

    Public Option

    Biden: One of the centerpieces of Biden’s health care platform is the aim to develop a national public option. The Biden-Sanders Unity Task Force Recommendations, a 110-page document that outlines a Democratic platform for many national issues, describes the public option as publicly financed and administered through Medicare. The public option would cover all primary care costs without copay and provide the essential benefits described in the ACA. The public option would offer at least one plan on the health exchanges and would automatically enroll Americans eligible for Medicaid in states that have not expanded eligibility under the ACA, as well as those who have low incomes and are caught between Medicaid eligibility and 200% of the federal poverty level.

    Trump: Trump has come out against the public option and has no plans to use this in his health care platform.

    The ACA and Health Insurance Exchanges

    Trump: The Trump administration has worked to increase the affordability of plans in the insurance exchanges by expanding the availability of health care plans that do not comply with the ACA, such as short-term plans and health reimbursement arrangements. The administration has allowed states to use ACA waivers to expand these more affordable but less comprehensive plans. In 2017, Trump signed into law tax legislation that eliminated the individual mandate, thus weakening one of the pillars of the ACA and leading to a Supreme Court challenge to the ACA that is still pending. In addition, the administration has decreased funding for enrollment programs and shortened the enrollment window.

    Biden: The Biden campaign has repeatedly emphasized a plan to “improve and expand” on the ACA. This would be accomplished primarily through increasing eligibility for federal subsidies and capping the cost of premiums at 8.5% of income. Additionally, Biden has outlined a plan to further bolster the ACA by rolling back the Trump administration’s cuts to the enrollment period and funding for enrollment programs. Biden plans to finance the public option and ACA expansion by eliminating the 20% flat tax on capital gains for those with incomes of more than $1 million and having them instead pay the top tax rate of 39.6% on capital gains.


    Biden: The Biden campaign has discussed providing incentives to states to expand Medicaid under the ACA. To date, 38 states and Washington, D.C., have expanded Medicaid.

    Trump: CMS under the Trump administration has approved waivers in 10 states to allow the addition of work requirements to Medicaid eligibility. In addition, the administration has repeatedly discussed the idea of block grants, a per capita set amount of money for states to spend on their Medicaid populations, as opposed to the current pay-for-services model.


    Trump: In 2019, Trump expanded Medicare Advantage supplemental benefits, including telehealth.

    Biden: As outlined in the Biden-Sanders Unity Task Force Recommendations, Biden plans to decrease the enrollment age for Medicare to 60; allow Medicare to negotiate drug prices with pharmaceutical companies; and increase Medicare coverage of dental, vision and hearing services.

    Ultimately, Trump has promised to extend protections for preexisting conditions while dismantling the ACA, transferring regulatory control to states and the free market. His platform on health care does not include a comprehensive reform plan to achieve health care for all as outlined by the AAFP. Biden’s health care platform builds on his work under the Obama administration by expanding the ACA and adding a public option, which is one of the avenues put forward for achieving universal coverage laid out by the AAFP.

    Kyle Leggott, M.D., is an assistant professor of family medicine at the University of Colorado, where he recently completed a fellowship in health policy and politics. You can follow him on Twitter @KyleLeggott.


    The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.