Health care was going to be the defining issue of the 2020 election before a pandemic and economic upheaval eclipsed pretty much everything else. But of course, the pandemic has highlighted many health policy issues.

With a highly contagious virus spreading around the world, "you might be thinking more about the importance of health insurance, or you may be worried about losing your job, which is where you get your health insurance," says Sabrina Corlette, co-director of the at Georgetown University. "The COVID pandemic and health policy are intertwined."

Meanwhile, the choice between the two major presidential candidates on health policy could not be more stark. Drawing from President Trump's record on health care and former Vice President Joe Biden's policy proposals, here's a guide to where they stand.

The Affordable Care Act

The candidates' visions differ radically on the Affordable Care Act, President Barack Obama's signature health care law, which was enacted in 2010.

"President Trump has — from Day 1 — pushed for repealing or overturning the ACA, and Joe Biden is pushing to build and expand on it," says Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation.

The Supreme Court is slated to hear arguments on the latest challenge to the ACA on Nov. 10. If the court does overturn the law, the president and Congress will have to work quickly to address the possibility of tens of millions becoming uninsured.

One of the ACA's most popular provisions is protection for people with preexisting conditions from being denied coverage or charged higher premiums. Trump has promised to keep this part of the law but hasn't offered specifics on how, and policy experts warn it's harder than it sounds.

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Medicare and Medicaid

When it comes to Medicare and Medicaid, the federal health programs that together provide coverage to 115 million people, Trump has promoted the private market and given states control, while Biden wants to expand eligibility to both programs.

Trump has sought to bring drug costs down and provide more private plan options for beneficiaries in Medicare — the federal program for people over 65 — while supporting spending caps and work requirements for Medicaid — the state-run program for low-income adults, children, pregnant women and people with disabilities.

Biden would allow people to enroll in Medicare at age 60 and would also try to create a new federal health program similar to Medicare, which he calls a public option.

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COVID-19 pandemic

Biden has remarked often that he would "listen to science" in handling the pandemic, drawing a contrast with Trump, who has repeatedly contradicted his top health officials.

Biden's proposals emphasize the role of the federal government leading the response, while Trump has delegated much to the states, says Douglas Holtz-Eakin, president of the American Action Forum, a conservative think tank. "Trump's very clearly relying on governors and mayors to pick policies that they think are appropriate for their geography," he says.

Early in the pandemic, Trump supported and signed a series of big congressional relief packages, but talks over a new one have stalled. "His position has shifted back and forth about the importance of another COVID relief package," says Allison Orris, counsel for Manatt Health, a legal and consulting firm.

If Biden were elected, she says, he "would really focus on injecting money" into these efforts, especially since many of the plans the Democrat outlines are expensive.

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Drug and health care costs

This is the area where the candidates are most closely aligned. Both want to end surprise billing and bring down prescription drug prices, and they even agree on some ideas about how to do so.

Trump has pushed hard on Congress to deal with surprise billing, and lawmakers got close in December but ultimately failed to agree on legislation. The president has used his executive authority to try to bring down drug prices — another Trump term might mean some of these efforts will go into effect.

Trump has made some big moves on price transparency, issuing rules that would require hospitals and insurance companies to disclose negotiated prices to consumers, so they can shop around. This effort has "kind of flown under the radar, but could actually have quite far-reaching effects," the Kaiser Family Foundation's Levitt says.

For either candidate, fixing many of these thorny problems with health care costs needs to be done through new laws rather than executive action, Holtz-Eakin says. "If you're in the White House, you have to learn how to get something through Congress," he says.

Because lawmakers have such a key role, it won't be until after the election "that we'll have some clues into how likely is legislative action" on these measures, Orris says. The need to deal with the pandemic and the economic downturn could also slow these efforts down, she says.

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Other key health issues

With so much attention on the pandemic, the public may have missed how different the candidates' views are on reproductive health, Levitt says.

"Reproductive health is also the area where President Trump has probably had the biggest and most tangible effect in health care," he adds. "And Joe Biden's platform on reproductive health can almost be summed up by just: 'Do everything the opposite and undo everything that President Trump has done.' "

Many other key health issues have been made worse by the pandemic; addressing mental health issues, opioid use disorder and racial health disparities are all the more urgent and daunting because of how they intersect with COVID-19.

Copyright 2021 NPR. To see more, visit https://www.npr.org.

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