Donald Trump and Kamala Harris stand far apart on most issues, and health care is no exception. The November election carries major implications for Californians’ access to health care and the cost they pay for it.

While neither candidate has put forth a comprehensive health care agenda, both have track records from their respective time in the White House or previous posts that offer a glimpse on where they might stand on key health issues.

The cost of health care is a top concern for Californians and voters across the nation, millions of whom are saddled with medical debt or take less medication than prescribed because of the cost. While both candidates have acknowledged that health costs are a major burden to Americans, the difference will be in how they go about providing relief.

How the next president goes about strengthening — or chipping away — at the Affordable Care Act and abortion rights will also directly affect voters’ lives. Below are examples of both candidates’ records on key health issues and what they’ve promised to voters so far.

The future of the Affordable Care Act

TRUMP. Trump as president tried and failed to repeal the Affordable Care Act, the signature legislative achievement of his predecessor, Barack Obama. As recently as last year, Trump vowed to try again if he’s reelected.

The idea of overhauling the health law would be a much harder sell today than in Trump’s presidency, some experts say, because the law is generally more popular. Some Republicans who opposed the law in the past have come to accept that it is here to stay or have moved on to other issues.

Nowadays Trump says he wants to “improve” the the Affordable Care Act and make it “less expensive.” He hasn’t offered any details as to what that would entail, but experts say any changes would likely come in the form of chipping away at certain provisions of the law.

Trump as president made one major change to the Affordable Care Act: He signed a tax cut law that also eliminated a penalty levied on people without health insurance. The idea behind this provision of the Affordable Care Act was that a penalty, charged when people filed their income taxes, would encourage people to sign up for health insurance. And getting more people insured, especially the young and healthy, drives down the cost of coverage for everyone. Today, uninsured Californians still pay a penalty of up to $850 per adult because Gov. Gavin Newsom enacted a state version of this mandate.

HARRIS. During her 2019 presidential campaign, Harris promoted a version of Medicare for All, a government-run single-payer system. Today, health policy experts expect Harris to continue the current administration’s efforts to promote and build on the Affordable Care Act rather than move the country toward a new system.

Some California lawmakers are still interested in exploring a single-payer-like health care system. Last year, Newsom signed a law that directs the state to map out next steps in creating a “unified financing” system that would cover all Californians. Getting anywhere near this goal will require federal permission and resources, which are more likely to happen under a Harris administration, experts involved in these discussions say.

“A Harris presidency, I think, is going to view a waiver application from the state of California favorably,” said Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research, who has served as a consultant to a state commission exploring this issue. “It’s not to say that it will sail through…getting a waiver to pool federal and state funding is still going to be a challenge, but I think her administration is going to find a way to work with California to make it happen.”

More people than ever, 21 million, signed up for health insurance under Affordable Care Act exchanges in 2024. Marketplace officials across the country say that’s in part because of the increased premium subsidies made available under the COVID-19 relief laws known as the American Rescue Plan and later the Inflation Reduction Act. That enhanced financial aid is currently set to expire at the end of 2025. About 90% of enrollees in Covered California receive financial assistance. The odds of continuing that enhanced aid are better under a Harris administration, experts say.

The cost of health care

HARRIS. As attorney general of California, Harris went after large health companies by moving to restrict mergers and investigate anti-competitive behaviors that research shows can drive up the cost of care.

She launched an investigation into several California health systems, examining their market power and their influence on prices. That investigation led her successor, Attorney General Xavier Becerra, to file a lawsuit against Sutter Health, a nonprofit hospital and clinic system in Northern California. In the lawsuit, Becerra accused Sutter of using its market power to drive up prices in Northern California. In 2019 Sutter settled the case for $575 million, although it did not admit wrongdoing.

Harris has also taken a leading role in the current administration’s efforts to address the medical debt that burdens millions of families. In June, she proposed rules to remove medical debt from credit reports. California lawmakers have a similar proposal currently sitting on Newsom’s desk. About 4 in 10 Californians report having some type of medical debt, according to the California Health Care Foundation.

Among Harris’ campaign promises: “Work with states to cancel medical debt for millions of Americans.” While she hasn’t said how exactly she plans to do this, her work with North Carolina Gov. Roy Cooper may offer a preview: Starting next year, North Carolina will roll out a program that incentivizes hospitals to forgive patients’ medical debt in exchange for additional Medicaid dollars.

TRUMP. Perhaps some of Trump’s most significant contributions to reigning in health care costs came in the form of price transparency rules. He signed an executive order that led to requirements for hospitals to disclose prices for common services on their websites. And in 2020 Trump signed the No Surprises Act, a law designed to protect consumers against surprise medical bills when receiving care from out-of-network providers. This often happens when people receive emergency care and are not in a position to choose their providers. Surprise medical bills tend to rank among the public’s top concerns.

The Trump administration greenlit some major health care mergers, but it did so with certain conditions signaling some caution in approving such deals. One example — CVS Health’s $69 billion acquisition of insurance giant Aetna, one of the biggest health mergers of all time. Aetna and CVS Health were competitors in the sale of Medicare drug plans. As a condition to approve the merger, Trump’s Department of Justice required that Aetna sell part of its Medicare drug business to another company as a way to preserve competition.

“That one was really contentious, and it took a long time, but we definitely didn’t see a rubber stamp,” said Rachel Nuzum, senior vice president of policy at The Commonwealth Fund. . “There was an acknowledgement that the size and scope of these mergers could be problematic for consumers.”

Abortion in the 2024 election

Pro-abortion rights supporters marched in protest of a Supreme Court ruling that overturned Roe vs. Wade, in Sacramento on June 25, 2022. Photo by Miguel Gutierrez Jr., CalMatters

TRUMP. No other health issue has received as much attention this election cycle than abortion and reproductive health. In California, Democrats have tried to cement abortion rights into state law, and this is often the first issue they use to go after Trump. That’s because the Supreme Court justices he appointed made the difference in overturning the 1973 ruling that had protected abortion rights, Roe v. Wade.

Trump has given inconsistent messages about abortion rights. Earlier this year, Trump made headlines for suggesting that if he were re-elected he’d support a national ban on abortion at 15 weeks of pregnancy. A few weeks later he changed his tune, saying abortion should be left up to the states. He has indicated that he would not ban mail delivery of medication abortion pills, and has said he wants insurance to cover the cost of in vitro fertilization treatment, or IVF, “because we want more babies.”

HARRIS. Harris has leaned heavily into abortion and reproductive rights, an issue she has remained consistent on throughout her career. She is often the voice and face for reproductive health in Biden’s administration, and has expressed support for restoring abortion access through federal law.

As vice president she launched a nationwide tour to promote reproductive rights with events across the country. It included a visit to a Planned Parenthood clinic, reportedly the first ever such visit by a sitting VP or president.

As attorney general in California, Harris sponsored state law that aimed to regulate crisis pregnancy centers. These are often religiously affiliated and known for trying to prevent women from getting abortions. The law required these centers to display a notice, letting people know that comprehensive family planning services including contraception and abortion were available through state programs. The U.S Supreme Court eventually overturned that law.

How they’d curb prescription drug prices

Shelves full of prescription medication at La Clinic pharmacy in Oakland on Sept. 26, 2019. Photo by Anne Wernikoff for CalMatters

TRUMP. Trump often takes credit for lowering the price of insulin for millions of Americans — but that’s not totally accurate. What his administration did was establish a temporary program known as the Part D Senior Savings Model. This program reduced copayments for insulin to $35 a month for about 800,000 seniors on certain Medicare plans. It lasted two years, expiring at the end of 2023. The Biden administration went further in the Inflation Reduction Act, which included a provision that capped insulin copay prices at $35 a month for about 3.3 million Medicare beneficiaries.

Trump also took the first steps to allow states to import prescription drugs from Canada, as a way to increase competition and lower drug prices. This move was heavily opposed by the pharmaceutical industry and the Canadian government. This idea came to fruition earlier this year when the FDA approved Florida’s plan to import prescription drugs to treat HIV/AIDS, mental illness and prostate cancer. Florida Gov. Ron DeSantis said that importing medications from Canada will save the state about $180 million in year one.

HARRIS. For the first time, the Biden administration empowered the In addition to expanding insulin copay caps to more seniors, Biden-Harris’ Inflation Reduction Act also directed its Health and Human Services agency to negotiate drug prices with manufacturers for certain high-cost drugs covered under Medicare. The 10 drugs in the first round of negotiations included medications to treat diabetes, heart failure, blood clots and rheumatoid arthritis. The negotiations resulted in discounts between 38% to 79%. The new negotiated prices are set to go into effect in 2026.

The Inflation Reduction Act — for which Harris likes to remind voters she casted the tie-breaking vote — also caps the total annual out-of-pocket drug spending for people on Medicare. This means that starting in 2025, seniors will pay no more than $2,000 a year for all their medications. About 3.2 million Medicare beneficiaries are expected to reach this limit in 2025, including 271,000 in California, according to recent estimates from the AARP.

Harris has said she wants to expand these cost-saving efforts to everyone, not just seniors. She has also pledged to go after drug companies and pharmaceutical middlemen that thwart competition and drive up costs.

###

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

CalMatters.org is a nonprofit, nonpartisan media venture explaining California policies and politics.