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Health Care in the 2020 Presidential Election: Health Insurance Coverage and Affordability

Health Care in the 2020 Presidential Election: Coverage
  • Both presidential candidates say they aim to lower health care costs but take vastly different approaches

  • Trump wants to replace the Affordable Care Act with market-driven options; Biden would build on the ACA by enhancing marketplace subsidies and expanding Medicaid eligibility

The Issue

  • The number of uninsured people has increased since 2016, rising from 29 million, following the reforms of the Affordable Care Act (ACA), to 35.7 million by the end of 2019. The economic recession has left an estimated 3 million more people uninsured this year.
  • Racial inequities in coverage narrowed after the ACA, but uninsured rates among people of color exceed those of white people.
  • Many insured people pay premiums that consume an increasingly large share of their income.
  • An estimated 40 million people with insurance are effectively underinsured because of deductibles and cost-sharing.
  • An estimated 133 million people under age 65 have preexisting health conditions; COVID-19 has already increased that number by an estimated 3.4 million nonelderly adults (20–59) as of October 7.

The Candidates’ Approaches

President Donald Trump

Overall approach: Repeal the ACA and replace it with market-driven coverage options aimed at lowering premiums and increasing choice of plans tailored to individual preferences; give states more flexibility in designing coverage options; require more accountability for people with low incomes enrolled in public programs; protect preexisting conditions.

Medicaid: Repeal the ACA Medicaid expansion for adults; provide block grants to states to design their own programs; increase accountability through work requirements.

Individual market and marketplaces: Has promoted weaker regulations on plans that don’t comply with the ACA’s preexisting condition protections and other requirements; elimination of advertising and enrollment assistance during open enrollment; elimination of payments to insurers to offer lower-deductible plans.

Employer coverage: Has promoted weaker regulations on association health plans that don’t comply with the ACA and allowed employers to fund accounts for employees to buy health plans on their own, including products that don’t comply with the ACA.

Vice President Joe Biden

Overall approach: Protect insurance for people with preexisting conditions by supporting and building on the ACA; expand insurance coverage and reduce consumers’ health care costs by enhancing the ACA’s marketplace subsidies, covering people currently eligible for Medicaid in nonexpansion states, and giving more people in employer plans the option to enroll in marketplace plans with subsidies.

Medicaid: Expand enrollment by allowing eligible people in 12 states without Medicaid expansion to enroll in a public plan through the marketplaces with no premiums; make enrollment easier with autoenrollment.

Individual market and marketplaces: Expand enrollment through enhanced subsidies, greater advertising and enrollment assistance: no one pays more than 8.5 percent of income on marketplace coverage; change the benchmark plan from silver to gold to reduce deductibles and cost-sharing.

Employer coverage: Allows anyone with employer coverage to enroll in a public plan through the marketplaces and be eligible for subsidies.

Medicare: Would allow people ages 60 to 65 to enroll in a Medicare-like heath plan.

Implications of the Candidates’ Approaches

I don’t have health insurance. Will the approaches provide me with new options?

Trump: The number of people without health insurance has increased under the president’s watch in part because of policies that have eliminated the promotion and advertising of marketplace open-enrollment periods, enrollment restrictions in Medicaid, and immigration policies that have had a chilling effect on enrollment of legal immigrants and their children. Trump supports a lawsuit now before the Supreme Court that argues for repeal of the ACA, which would eliminate coverage for as many as 20 million people. Says he will come up with a replacement but has yet to do so.

Biden: Has introduced proposals to build on the ACA by covering people in the 12 states that haven’t expanded Medicaid and enhance subsidies for marketplace plans. This would provide new options for people who are currently uninsured and increase coverage over time.

I have a preexisting health condition. Will the approach guarantee that I can always get covered?

Trump: The ACA currently provides this protection. Trump supports the lawsuit before the Supreme Court that argues for repeal of the ACA and its preexisting conditions provision. Trump issued an executive order that said preexisting conditions are protected, but without the ACA or new legislation the order has no effect and is purely symbolic.

Biden: The vice president pledges to support and build on the ACA, retaining its preexisting condition protections.

My premiums and deductibles are becoming less affordable; will the candidates’ approaches lower them?

Trump: The president eliminated payments to insurers to reimburse them for offering lower-deductible plans in the ACA marketplaces to people with lower incomes, as required by the law. This had the effect of increasing premiums for people not eligible for subsidies. He has promoted the sale of non-ACA-compliant health plans, like short-term plans. These plans have lower premiums for healthy people but screen for preexisting conditions and often provide little cost protection if someone becomes sick. He has loosened regulations for association health plans, although that was turned back under legal challenge. The repeal of the ACA would mean the loss of marketplace subsidies and preexisting-condition protections, making coverage unavailable or unaffordable for people with low and moderate incomes and those with health problems.

Biden: The vice president’s proposal to enhance marketplace subsidies will cap the amount of premiums people pay at 8.5 percent of income, including people in employer plans who would have the option to enroll in the marketplaces. By linking subsidies to gold plans, deductibles would also fall for those who choose those plans.

I am worried about racial inequity in health care. Will the approach make health coverage more equitable?

Trump: Uninsured rates among Hispanic people have risen under the president’s watch. Repealing the ACA would further eliminate coverage gains made by Hispanics, as well as Black people and Asian Americans, widening racial disparities in coverage and access.

Biden: The vice president’s proposals to expand coverage under the ACA will particularly benefit people of color. This is because people living in the 12 states that have not yet expanded Medicaid are disproportionately Black and Hispanic.

Publication Details



Sara R. Collins, Vice President, Health Care Coverage and Access, The Commonwealth Fund

[email protected]


Sara R. Collins and Gabriella N. Aboulafia, “Health Care in the 2020 Presidential Election: Health Insurance Coverage and Affordability,” To the Point (blog), Commonwealth Fund, Oct. 8, 2020.