As with so many issues, there is a major gulf between President Trump and former Vice President Joe Biden when it comes to issues that directly affect older adults. Biden has proposed a long list of specific proposals. Trump has said remarkably little about what he’d do in a second term, and that silence extends to programs that affect seniors. But over the past four years he has described several initiatives that he could address starting next year.
Here is a quick rundown of where each candidate stands on Medicare, Social Security, long-term care, and health insurance for older working adults.
Medicare. Biden would allow working-age people enroll in an optional public health insurance plan. While this often is described as letting younger people buy into Medicare, Biden insists the program would be run separately from the current Medicare program.
The former vice president wants government to negotiate drug prices directly with manufacturers. He would reduce Medicare costs for specialty drugs by benchmarking their prices to those paid by other countries. He’d impose a tax penalty on drug manufacturers that raise prices of current branded, biotech, or “abusively priced” generics by more than the rate of inflation.
While Trump has been largely silent about Medicare in his campaign, his most recent budget provides some important clues about his second-term agenda. In that budget, he proposed reducing projected Medicare payments to teaching hospitals and hospitals with large numbers of low-income patients. He also proposed reducing future payments for outpatient services that take place in a hospital.
Trump also proposed changing out-of-pocket costs for Medicare drugs: He’d cap payments for those with very high drug costs but increase cost-sharing somewhat for those with lower drug expenses. The president also signed an executive order that he says would lower Medicare drug costs by tying them to average prices paid in other developed countries. That order has not been implemented and its effects remain unclear.
Finally, Trump promised to give ever senior a debit card for $200 in Medicare prescription drugs. Those discount cards have not been delivered, however.
Social Security. Biden would raise Social Security payroll taxes for those making $400,000 or more. Currently, earnings in excess of $137,700 are exempt from the Social Security tax (though they are subject to the Medicare tax). He’d also increase some benefits, especially for very old and very poor beneficiaries and surviving spouses. Combined, his initiatives would reduce but not eliminate Social Security’s long-term fiscal imbalance. For a more detailed analysis of Biden’s Social Security plan, here is a recent report from several of my Urban Institute colleagues.
Trump’s Social Security agenda is unclear. He has, at times, vowed to “terminate” the Social Security payroll tax (which would leave the program insolvent almost immediately). At other times, aides insisted he backed only a temporary reduction in the payroll tax to assist workers during the covid-19 pandemic.
Long-term care. Biden says he’d spend $450 billion over 10 years to reduce state waiting lists for Medicaid home and community-based services (HCBS). He also supports a $5,000 tax credit for family caregivers, increased tax subsidies for purchasing long-term care insurance, and paid leave for family caregivers, including those assisting aging parents. Biden would give those who stay home to care for loved ones credit towards their own Social Security benefits. He’d also raise wages and benefits for direct care workers such as home care aides.
Trump has largely been silent on the issue of long-term care. While the White House has backed family leave, it appears to support paid time-off only for those caring for new borns and adoptees, but not those assisting older adults. Last year, Trump backed a bill to provide leave for federal workers that applies to new parents only.
In contrast to Biden’s plan to expand Medicaid long-term care, Trump would cap the overall federal contribution to Medicaid in exchange for increasing state flexibility. Such a step would likely reduce resources available for Medicaid supports and services for older adults and young people with disabilities.
Health insurance. Biden would strengthen the Affordable Care Act by allowing people without affordable private insurance to buy into a public program.
Trump has called on the Supreme Court to overturn the Affordable Care Act, which he frequently describes as “a disaster.” Eliminating the ACA, with its protections for those with pre-existing conditions, would be especially challenging for people in their 50s and early 60s who are not yet eligible for Medicare. Many currently have pre-existing conditions, which would make private insurance unavailable or unaffordable. The ACA also caps the ability of insurance companies to price policies based on age. Trump repeatedly has promised to replace the ACA with anew health plan, but has yet to do so.
As with many other issues, Trump and Biden have fundamentally different approaches to government’s role in assisting older adults and their families.
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