A MARTÍNEZ, HOST:
We’ve been reporting this week on health care as part of our We, The Voters series. And anyone who has had sticker shock at the pharmacy or had to pay high insurance premiums every month or faced an unexpected diagnosis knows this fact – health care in the U.S. is expensive. This is actually a point that President Biden and former President Trump agree on, but their ideas on how to address it could not be more different. NPR’s Selena Simmons-Duffin is here to talk to us about all things health policy and the elections. Selena, where do you want to start?
SELENA SIMMONS-DUFFIN, BYLINE: I want to zero in on something I find really fascinating that I think illustrates the different visions of these two candidates when it comes to health policy, and that is the Affordable Care Act marketplaces, otherwise known as Obamacare.
MARTÍNEZ: Yeah. And under Obamacare, people can buy a health plan on their own.
SIMMONS-DUFFIN: Yeah, exactly. So most people in the U.S. get their health coverage through their job, through Medicare if you’re over 65, or through Medicaid if you’re low-income. But then there are people who don’t get insurance through their job and make too much money to qualify for Medicaid, and that’s what the marketplaces were set up for. So the federal marketplace is at HealthCare.gov, and some states have their own websites.
Cynthia Cox runs the program on the ACA for the health research group KFF, and she says there’s one thing about HealthCare.gov that is vital to its success – making sure people know about it.
CYNTHIA COX: If you have had job-based coverage your whole life and suddenly you lose your job, you might not know where to go. And so that’s where these, like, marketing and outreach efforts are really key.
SIMMONS-DUFFIN: Basically, she says there needs to be tableling at community events and signs on buses and TV ads and all the rest, just to tell people that these marketplaces exist.
MARTÍNEZ: All right. So what does advertising for HealthCare.gov tell us about the two presidential candidates?
SIMMONS-DUFFIN: Well, a lot. So we can start with former President Trump. He talked about Obamacare all the time when he was president. Here he is in June 2017 at the White House, meeting with Senate Republicans about their plan to repeal and replace the whole ACA.
DONALD TRUMP: We have really no choice but to solve the situation. Obamacare is a total disaster. It’s melting down as we speak.
SIMMONS-DUFFIN: So Trump’s repeal and replace efforts failed back then in his first term, but he is still talking about repealing and replacing the ACA.
MARTÍNEZ: So with what, Selena? Because I have looked for a long time to see and find out what that replacement might be.
SIMMONS-DUFFIN: Yeah, he hasn’t laid out a specific plan. That was a challenge for him in his first term. And, like you, I still haven’t seen anything that he would use specifically to replace the ACA in a second term. And the other thing I want to say is this law was passed so long ago. It was passed in 2010, and so much of the things that it did, which are wide and varied, are really baked into the health care system at this point. So it’s really hard to imagine untangling all of that and getting rid of this law, even if there was something fantastic to replace it with.
MARTÍNEZ: All right. So let’s go back to Trump’s first term because even though he was not able to repeal it or replace it, he was able to weaken it somewhat.
SIMMONS-DUFFIN: Yeah, that’s exactly right. And one of the ways he did that was by slashing the budget to advertising and for navigators. So those are people whose job it is to walk people through the process of finding a plan and signing up. Katie Roders Turner is with the Family Healthcare Foundation in Tampa, Fla. She has been a navigator from the beginning, and she remembers what happened when Trump took office.
KATIE RODERS TURNER: When the Federal Administration changed, there was about an 80% decrease in funding.
SIMMONS-DUFFIN: Jeremy Smith is with First Choice Services based in West Virginia. He says it was the same for them. Their federal funding for navigators was slashed.
JEREMY SMITH: During the Trump administration, we went down to a budget of only $100,000 a year in those years. I mean, it was only just a couple of us working on the program, and we didn’t really have hardly any money for advertising or travel or the ability to get out in the community very much at all.
SIMMONS-DUFFIN: Under Trump, enrollment in the marketplaces also went down pretty much every year. Then when President Biden came in in 2021, Smith says the change was dramatic.
SMITH: Our funding increased by more than tenfold. We went from $100,000 a year to over a million dollars a year. So that was just huge. I mean, it was – it just made our heads swim.
SIMMONS-DUFFIN: To start with, he could hire more staff and post people in remote offices in different parts of West Virginia.
SMITH: So we could offer more in-person help for people that wanted to come in. We was able to add bilingual navigators at that point. We was able to actually have a pretty robust travel budget so we could get around the state and do community outreach and promotion.
SIMMONS-DUFFIN: In Florida, Roders Turner says the story was the same.
RODERS TURNER: We actually got 12 times over the budget. We went from a budget that supported two full-time navigators to now we have over 35 navigators in Tampa Bay, mostly of full-time individuals.
SIMMONS-DUFFIN: In addition to way more money for navigators, the Biden administration invested aggressively in advertising, everything from posters and supermarkets to Instagram ads to TV ads in a variety of languages, like Vietnamese.
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UNIDENTIFIED ACTOR: (Speaking Vietnamese) HealthCare.gov (speaking Vietnamese).
SIMMONS-DUFFIN: Another significant change under Biden was an increase in subsidies to make the plans people were shopping for more affordable. Most enrollees can get a plan with a premium of $10 a month or less. Here’s Roders Turner again.
RODERS TURNER: Four years ago, premium prices, that was a big talking point for people – their inability to afford the premium prices. These past few open enrollments, people are really pleased at what they’re seeing as their options.
SIMMONS-DUFFIN: One of those happy customers is Sidney Clifton. He’s 53 and lives in Pasco County, Fla., about 30 miles west of Tampa. He had been on his wife’s insurance, but then he got divorced.
SIDNEY CLIFTON: I’m in the car business, and I sold a lady a car that recommended Lynnette that could help me.
SIMMONS-DUFFIN: Lynnette Lacy is a navigator who works with Roders Turner at the Family Healthcare Foundation.
CLIFTON: So I called Lynnette, and she gave me all the breakdowns on how it worked, and based on the income, this and the other.
SIMMONS-DUFFIN: Clifton says he has health issues, including diabetes, so he needed a comprehensive plan, and Lynnette Lacy helped him find one.
CLIFTON: It was like 975 a month, and then I got the government assistance with the rebate, the 300 bucks, or something like that. So at 675, I could afford it ’cause I was paying – with my ex-wife, I was paying, like, 740 a month. So it’s really the best decision I ever made. I love it.
SIMMONS-DUFFIN: He says all his providers are in network. The copays are manageable. He says he would be happy to keep the plan for as long as he can. But he doesn’t love that it’s Obamacare, and it won’t change his plan to vote for Trump.
CLIFTON: I’m not selfish like most people. What’s the best for America’s best for America. And if that’s taking this stuff away, it’s taking this stuff away.
SIMMONS-DUFFIN: So, A, he told me if Trump gets elected and he loses his health plan, he’ll figure something else out, even if that means going without insurance or getting a job with health benefits or even getting remarried.
MARTÍNEZ: Wow, love for health coverage. It sounds like a saucy reality show, Selena. It just does. I’ll do the reunion show, by the way. OK. Now, you mentioned under Trump, when HealthCare.gov wasn’t really advertised and didn’t have the lower premiums, enrollment went down. What’s been happening since Biden took office?
SIMMONS-DUFFIN: Enrollment has hit record highs nationally. There are now more than 21 million people enrolled, and enrollment has grown the most in red states, according to a recent report from KFF. For example, in Florida, where Clifton lives, and in West Virginia, enrollment has more than doubled. And the biggest growth was actually in Texas, where enrollment tripled between 2020 and 2024. Another factor I want to mention is that Medicaid grew substantially during the pandemic because of rules that allowed people to keep coverage uninterrupted. Those rules expired last year, and experts were really worried that a lot of people would lose Medicaid and become uninsured. But Cynthia Cox of KFF says what happened was this.
COX: What we’ve seen is that millions of people did make that transition onto ACA marketplace plans, which has helped keep the uninsured rate very low.
SIMMONS-DUFFIN: The uninsured rate in 2023 was 7.7%, according to the Federal Health Department, which is lower than it has ever been.
MARTÍNEZ: All right. So one clear difference between the candidates is their approach to HealthCare.gov. What are some other health policy differences?
SIMMONS-DUFFIN: Well, Biden has managed to get some significant health policy laws through, including the Inflation Reduction Act, which allowed Medicare to negotiate the price of several very expensive prescription drugs for the first time. He also capped out-of-pocket costs for people on Medicare and fixed something called the family glitch. He’s done a lot with nursing home staffing and mental health access. But one challenge for him is that some of the new laws take a while to take effect and be noticed by voters. For instance, the cap for seniors won’t take effect until 2025. When it comes to Trump, Cox says there aren’t a lot of details on the policies he’ll push for. So it’s instructive to see what he did as president.
COX: What he tried to do is to deregulate health insurance, to try to make it cost less for the federal government.
SIMMONS-DUFFIN: So if Trump is elected, she expects more of that deregulatory approach to health insurance.
MARTÍNEZ: So there are some areas, though, of health policy where Trump is interested in regulating, and that’s in two other areas that you cover – abortion and trans health.
SIMMONS-DUFFIN: Yeah. I think this is a really important point. So since Roe v. Wade was overturned by the Supreme Court in 2022, the Biden administration has been battling with states that have enacted abortion bans in the courts, and Biden instructed federal agencies to protect access to abortion where possible. The same is true for states passing laws about trans health policy. There are now 25 states with laws banning gender-affirming care for minors.
The Biden administration has opposed those bans in courts and through agency actions. Trump has said he would take executive actions to limit access to gender transition at any age, not just for minors. And with abortion, he’s spoken proudly about how he’s responsible for overturning Roe v. Wade with his appointments to the Supreme Court. He would certainly reverse the current federal position that access to abortion is a right. So this is a really strong distinction between the candidates when it comes to health policy.
MARTÍNEZ: Are there any areas of agreement here, anything that you might see continue regardless of who gets elected?
SIMMONS-DUFFIN: Yeah. There are a few. Both have talked a lot about the high cost of prescription drugs. Biden has made moves to curb those prices with the co-pay caps in Medicare drug negotiation we talked about. Trump talked a lot about drug importation from countries like Canada with cheaper drugs when he was president. There was a law passed under Trump called the No Surprises Act to protect patients from exorbitant ER bills, and Biden has implemented that law.
And price transparency is another area of some agreement. This is the idea that you, the patient, if you can see the price of services from your hospital or insurance company, you can shop around to find the best price. So it’s not clear how well that’s working, but it’s something that has bipartisan support. But I think these areas of agreement are the exception, not the rule. These two candidates have extremely different ideas when it comes to the federal government’s role in health policy.
MARTÍNEZ: That’s NPR’s Selena Simmons-Duffin. Thanks a lot.
SIMMONS-DUFFIN: Thank you.
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