Health care has become increasingly complex, costly and frustrating for many in the U.S., and it’s one of the biggest issues in the 2024 election. Vice President Kamala Harris and former president Donald Trump have both vowed to take this on if they win—and to do so through policies ranging from cutting drug costs to ensuring access to care. But there are drastic differences in how their respective plans would affect the U.S. health care system’s economics—and the people who confront its bureaucracy daily.
Harris says her administration would strengthen the Affordable Care Act (ACA) and expand the Inflation Reduction Act’s (IRA’s) cost-saving provisions. Trump’s presidential record on health care is mixed, riddled with attacks on the ACA and major funding cuts to federal health care insurance programs.
Drug Pricing
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People in the U.S. pay far more for medications than people in most other comparably wealthy nations. Both presidential candidates have prominently stamped lowering drug prices on their agendas, and each has previously made related policy moves during their respective appointments in the White House.
During President Joe Biden’s administration, Harris cast the tiebreaking vote to pass the 2022 IRA—legislation that put new limits on drug price increases. The IRA gave Medicare (the federal insurance program for adults aged 65 and older) the ability to negotiate lower prices for certain medications. The most talked-about in Harris’s campaign is the act’s $35 cap on insulin. It also made Medicare-covered vaccines free and expanded subsidies to help people with the lowest incomes to pay for better coverage. And it will put a $2,000 out-of-pocket annual spending cap on prescription drugs under Medicare starting in 2025. Cancer drugs, for instance, can now cost patients upward of $10,000 a year. But the IRA will drop this to $2,000, explains Stacie B. Dusetzina, a health policy and drug pricing researcher at Vanderbilt University School of Medicine. “This is a huge expansion of the benefit that's coming for seniors,” Dusetzina says.
Ten drugs are already listed for price negotiations, but people won’t start seeing price changes at the pharmacy until January 2026. Harris says that, if elected, she would further strengthen the IRA, lowering costs for more drugs under Medicare—and even expanding coverage to drugs under both private insurance and Medicaid, the federal-state insurance program that covers some people with limited incomes, certain disabilities or preexisting conditions. It’s uncertain what the IRA’s fate would be under a Trump administration.
“One of the reasons that drug price negotiation is such a hot-button issue is that there's concern among the Republican Party that companies don’t have incentives to innovate and produce new drugs” if they can’t reap the possible profits, Dusetzina says. “A lot of Republican members of Congress have pushed to stop the drug price negotiation, and we know that pharmaceutical companies have ... sued the government to stop the negotiations for the products that have been selected.” (Several of these companies have lost their cases, and other cases are ongoing.) If a second Trump administration were to act quickly, it could theoretically try to block or undo the policy before the new prices take effect in 2026, Dusetzina says.
In Trump’s final months in office in 2020, he issued two executive orders to help to lower prescription drug costs. He tried to stop pharmacy benefit managers—third-party companies that negotiate prices and discounts between drugmakers and consumers—from collecting rebate checks on discounted drugs sold to older people with Medicare to ensure these individuals get the full savings from drug manufacturers. He also tried to enforce the “Most Favored Nation” pricing model, which would set certain clinician-prescribed drugs under Medicare at lower average costs, closer to those paid in other developed countries.
Critics have said the Most Favored Nation model would ultimately give other countries more power over drug prices. The Biden administration pulled the plug on the order in 2022. In his campaign, Trump originally supported bringing back the Most Favored Nation model, but he has recently walked back those statements. Dusetzina says there’s bipartisan support for limiting prescription drug patents, which could make it easier for generic drugs to enter the market and thus reduce prices.
Affordable Care
At last month’s presidential debate, Trump falsely claimed he “saved” the Obama-era ACA, which provides health insurance to more than 21 million people. During Trump’s administration, he repeatedly attempted to repeal it. Ultimately, he failed, though he did persuade Congress to rescind the ACA’s individual mandate tax penalty, which incentivized people to enroll in a health insurance program. While Trump was in office, ACA insurance enrollment fell from 12.7 million people to 11.4 million, driving up rates for those remaining.
As president, Trump also proposed budget plans that would have cut $1 trillion to Medicaid if they’d been adopted. The ACA supports a federal funding program that matches 90 percent of costs to states that opt in to Medicaid expansion; this increases the program’s health care coverage eligibility to people at or below 138 percent of the poverty line. States that adopted this expansion saw a 41.7 percent increase in insurance enrollment as of 2020. Ten states have not expanded Medicaid, causing coverage gaps that studies have shown largely affect people of color. People with low-wage jobs may also be ineligible for Medicaid because their income is still too high by individual states’ criteria.
In an attempt to fill these gaps, Trump allowed states to use work requirements—which compel people on Medicaid to prove they work 20 hours a week, participate in community engagement or otherwise qualify for an exemption. But pilot work requirement programs in states without Medicaid expansion, such as Arkansas and Georgia, have seen worse insurance enrollment rates and higher government costs, says Stephen W. Patrick, a pediatrician and chair of Emory University’s Department of Health Policy and Management. Patrick notes that polls suggest the majority of Georgians favor Medicaid expansions. Whereas the Trump administration pushed for such requirements, the Biden administration has moved to reverse them, saying that employment and work shouldn’t be tied to health care access.
Trump’s stance on the ACA has been inconsistent and ambiguous throughout his campaign. He’s implied that he would keep the ACA and make it stronger. In other statements he has promised to replace it with something better. During his September 2024 debate with Harris, Trump said he had “concepts of a plan” but offered no details. Trump’s running mate, Senator J. D. Vance of Ohio, has recently endorsed potentially drastic changes in insurance risk pools that could make coverage cheaper for those with fewer medical needs—and more expensive for those with higher ones. This may undo the ACA protections that prevent insurers from discriminating against people with disabilities or preexisting conditions, including chronic conditions or disabilities, or people who are pregnant.
Trump has tried to tackle medical billing, a byzantine—and sometimes bankrupting—process for many in the U.S. In 2020 Congress passed Trump’s No Surprises Act, an effective transparency law that a survey suggests has prevented millions of unexpected costly medical bills from out-of-network services. It could, however, drive up other costs.
The Biden-Harris administration has actively promoted insurance enrollment and advocated ways to strengthen and protect the ACA, Patrick says. On her campaign trail, Harris has also strongly highlighted a proposal that would use unspent COVID relief funds to waive $7 billion in medical debt from people’s credit reports. “No one should be denied access to economic opportunity simply because they experienced a medical emergency,” Harris said in a June press release.
Pandemic Preparedness
Trump’s administration created the Coronavirus Task Force to oversee public health efforts during the COVID pandemic, and it also pushed Operation Warp Speed to rapidly create the lifesaving mRNA COVID vaccines by the end of 2020. Yet many experts say the country was poorly prepared for the pandemic because of other moves Trump made. At the height of the pandemic, he repeatedly undermined and dismissed advice from public health officials, blocked mask mandates and continued to hold large gatherings during his 2020 presidential campaign. He has since actively fueled anti-vaccine sentiment; multiple experts agree that many COVID deaths among Trump’s own supporters could have been avoided.
Biden’s American Rescue Plan, enacted in 2021, helped to mobilize the public health response to the pandemic. Federal funds provided free COVID vaccinations, tests and treatments. The plan also aimed to reduce racial inequities that emerged during the pandemic. In 2023 Biden signed legislation to help the country to better prepare and plan for future pandemics. It also reestablished a White House pandemic preparedness office, which Trump had shut down in 2018, to monitor emerging biological threats and diseases—such as the H5N1 bird flu, which has recently infected U.S. dairy cows and poultry, as well as some humans. The next administration will have to confront the potential threat of a human H5N1 outbreak.