Medicare. Drug costs. The fate of the Affordable Care Act.

Health care — and who would handle it best — has continued to be contested turf in the final weeks of the presidential campaign. Polls show that Americans have ranked health care costs high on the agenda for national leaders.

It's little surprise, then, that both Vice President Kamala Harris and former President Trump have pledged to bring down the cost of prescription drugs and protect Medicare.

But in a campaign season that has been light on detailed proposals on health policy — which has often taken a back seat to other issues — "you have to look more at their records," said Larry Levitt, executive vice president for health policy at KFF, an independent health policy research and news organization.

"And if you look at their records, Harris and Trump are polar opposites," starkly split on the role that government should play in health care and the trade-offs surrounding its spending, he said. Trump has focused on cutting government spending, he said, while Harris has emphasized expanding coverage and affordability.

The debate is playing out as the Affordable Care Act, the landmark law passed nearly a decade and a half ago to reshape health coverage, has swelled in public popularity. Harris has taken Trump to task for his repeated attempts to roll back the law, arguing that its protections are at risk if he wins a second term. Trump said he would replace it only if there is a better alternative, but provided little detail about a plan.

In the aftermath of Roe vs. Wade being overturned, Harris has also focused heavily on abortion rights — see another Times guide for more on where the candidates stand on the issue. Trump, in turn, has targeted Harris over expressions of support for gender-affirming care and vowed to stop "COVID mandates," issues that reverberate on the political right.

Here's a breakdown of where the candidates stand on key issues.

The Affordable Care Act

When she sought the Democratic nomination for president five years ago, Harris promoted a "Medicare for All" plan. This time around, Harris has promised to protect and strengthen the Affordable Care Act.

For instance, she wants to permanently extend an enhanced set of premium subsidies for people buying health insurance through Affordable Care Act marketplaces. Those subsidies, which reduced premium costs for recipients, are now due to expire at the end of 2025.

Trump sought to repeal the Affordable Care Act as president. His administration eliminated a financial penalty for individuals who fail to maintain health insurance coverage, a significant provision in the federal law.

As Trump campaigns for another term, he has said he would replace the Affordable Care Act if a better plan is devised, but would "run it as good as it can be run" until then. As of the September debate, Trump had not provided a detailed plan on what he would implement in its place.

His running mate, JD Vance, has said their plan would "allow people with similar health situations to be in the same risk pools." Risk pooling means sharing medical costs to calculate insurance premiums. Such a plan could lower insurance costs for the young and healthy but risks driving up rates for older people, especially those with chronic conditions, said Mark A. Peterson, a professor at the UCLA Luskin School of Public Affairs.

The Trump campaign has also raised concerns about the premium subsidies that Harris wants to make permanent, telling the Washington Post that they "benefit big insurance companies and brokers more than American patients."

Cost of drugs and health care

Levitt described bringing down the costs of prescription drugs as "the one area in health care where they seem to agree, but how that would translate into specific policies is somewhat unclear."

The Trump administration paved the way for states to import prescription drugs from Canada. As president, Trump also tried to tie Medicare reimbursement for certain drugs to the prices paid by other countries, although that effort was blocked in court and ultimately rescinded during the Biden administration. A Trump campaign spokesperson said he would pursue that plan again.

Trump also issued an executive order on price transparency, which led to hospitals having to reveal information online about their standard charges. (The Biden administration followed up with rules meant to bolster its enforcement.) And as president, Trump created a demonstration program that limited insulin copays to $35 monthly for some Medicare beneficiaries.

Many of the efforts to bring down health costs touted by the Biden administration came under the Inflation Reduction Act, for which Harris cast the tie-breaking vote. For instance, that law extended a $35 monthly limit on insulin copays to all Medicare beneficiaries. It also put a $2,000 cap on out-of-pocket drug spending for Medicare drug coverage.

The Inflation Reduction Act also required the government to negotiate prices for some drugs under Medicare: In August, the federal government announced it had negotiated lower prices for 10 medications to treat conditions such as heart disease and diabetes.

Requiring Medicare plans to be more generous in drug benefits, however, has raised concerns that they could significantly increase premiums. The Biden administration avoided that for next year, on average, with the help of subsidies for insurers, but the Trump campaign has criticized the Inflation Reduction Act over that and other issues.

Harris has promised to expand the $2,000 cap on out-of-pocket spending and the $35 monthly cap on insulin copays to cover everyone, not just seniors. She has also vowed to speed up negotiations to lower Medicare drug prices.

Harris has also made eliminating medical debt a focus: As vice president, she worked on removing medical debt from credit reports and promoted the use of American Rescue Plan funds by state and local governments to buy up and forgive debts. Harris said that as president she would expand such efforts.

Medicare and Medicaid

Both candidates have vowed to protect Medicare, but that hasn't stopped it from being a campaign issue.

The Republican Party platform under Trump pledges to protect Medicare, the federal insurance program that covers Americans ages 65 and older, "with no cuts." Trump has at points made remarks that seemed to suggest he was open to cutting entitlements, but then said he was taken out of context.

Harris, who has vowed to protect Medicare, argues that Trump and his allies pose a threat to the program, repeatedly pointing to Project 2025, a conservative playbook for a second Trump term. Project 2025 says that Medicare Advantage, the private offering under Medicare, should become its default option for enrollees.

Trump has repeatedly sought to distance himself from the Project 2025 plan. Trump campaign senior advisor Danielle Alvarez said Harris was "fear-mongering" and that the former president has only endorsed the Republican platform and his own "core promises," but didn't say whether he supported making Medicare Advantage the default option.

Then there's Medicaid, which covers Americans who are low-income. The Trump administration approved work requirements in some states as a condition for being eligible for Medicaid. He also proposed major changes in how Medicaid is financed that could have capped its federal funding.

The Biden administration withdrew approval for work requirements in state Medicaid programs and encouraged states to expand coverage. As vice president, Harris urged states to extend postpartum coverage under Medicaid from two months to a year, promoting it as a way to combat maternal mortality.

Gender-affirming care

Trump has decried the use of puberty blockers and other forms of gender-affirming care for transgender youth, saying that he would seek to terminate any hospital that "participates in the chemical or physical mutilation of minor youth" from Medicaid and Medicare. The Republican Party platform also includes banning taxpayer funding for gender transition surgeries.

During her Democratic primary run five years ago, Harris told the ACLU she supported policies ensuring prisoners, who rely on the state for their care, can access "medically necessary care for gender transition." Courts have since weighed in on that issue, and a Harris-Walz campaign communications director recently told Fox News that that is "not what she is proposing" now.

Harris has said she supports the Equality Act, a bill prohibiting discrimination based on sexual orientation or gender identity in public accommodations, as a way to protect LGBTQ+ patients from discrimination in health care.

During her vice presidency, the Biden administration rolled out federal regulations that provide broad protection against discrimination based on gender identity by federally funded health care entities. The rules prohibit them from denying gender-affirming care if the same kind of care is provided for other medical purposes, but provisions related to gender identity are now on hold after a legal challenge.

Public health

Trump helped accelerate the development of a COVID-19 vaccine through Operation Warp Speed. Despite touting that accomplishment, Trump has at times expressed skepticism about vaccines.

He said he would "stop all COVID mandates" and cut federal funding from schools with vaccine or mask mandates. His campaign said he was referring specifically to COVID vaccination requirements, although Trump has repeatedly made the statement without specifying that.

He has also pledged to create a commission to investigate a rise in chronic illnesses among children. That echoes concerns raised by former presidential candidate Robert F. Kennedy Jr., who has spread debunked claims about vaccines and endorsed Trump after dropping his bid.

Harris called vaccination "the single-best defense against COVID-19." Earlier in the pandemic, the Biden administration rolled out broad rules requiring COVID vaccination for federal employees and contractors, which have since been phased out.

The Biden administration also launched a new office at the White House focused on pandemic preparedness and response. Trump has said he "probably would" disband that office.

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