Health Policy for Older Americans Better Under President Biden than Trump

In the superheated environment of 2024, it is hard to discern actual policy differences amidst a sea of platitudes and claims. That said, for the first time in over a hundred years, Americans have two major party candidates for president who have already held the office before. Presidents Trump and Biden have records that demonstrate the priority their administrations have placed on health policy, including health care for older Americans.

How the nation’s leaders care for older residents is important because it provides insight into what they think about all health policy. Older residents represent a large and growing percent of the U.S. population. These Americans have a disproportionately high need for care. And, reflecting the contributions to society made by people age 65 and older across their lifespans, the federal government pays for a greater share of this age group’s health care costs than of others’ costs.

This snapshot examines documented, concrete changes in health policy for older Americans during two periods of time: from 2017 to 2020 (the Trump presidency) and 2021 to 2024 (the Biden presidency). It neither reviews presidential proposals that were not enacted nor includes results of laws that were implemented beyond these time frames, in the interest of pinpointing what was done for older people during equal four-year terms. While some of these results reflect Congressional priorities, presidents can—and have—vetoed legislation, so they get credit for affirming such priorities. The five areas of focus are:

• the health of Medicare,
• affordability of prescription drugs,
• investment in long-term services and supports,
• coverage of older people not yet eligible for Medicare, and
• protection against public health threats.

While these represent a subset of domains and metrics, they better reflect policy than other effects (such as changes in the economy) and provide insight into these presidents’ attention to the health of older Americans—and all of health policy—during their terms.

Table 1. Results Related to the Health Policy Affecting Older Americans: 2017 to 2024

Health of Medicare

Medicare, which covers people age 65 and older and certain individuals with disabilities, is the most popular health program in the country. Its Hospital Insurance Program is financed primarily by payroll taxes. When its funding runs out, without action, payment for hospital care for Medicare beneficiaries will end. The life expectancy of the Medicare Trust Fund was reduced by two years under the Trump presidency (from predicted insolvency in 2028 to 2026) while it was extended by ten years by the end of the Biden presidency’s first term (from predicted insolvency in 2026 to 2036), giving confidence that the program will be there when needed. (See Figure 1.)

As background, President Trump signed into law a reduction of tax revenue used to support Medicare and repealed the Independent Medicare Advisory Board, both of which shortened the life of the Trust Fund.

President Biden implemented policies that cut down on excessive Medicare Advantage payments that both improves Trust Fund solvency and reduces the cost of Medicare Part B which pays for physician and outpatient services.

Affordability of Prescriptions

Prescription drugs matter now more than ever, and even more for older than younger people. A recent survey found that 60 percent of Americans age 50 and older are concerned about being able to afford medication that they or someone in their family might need. The boost in Medicare prescription drug coverage during the Biden presidency saved beneficiaries over five times as much as during the Trump presidency ($5.3 billion in net federal spending increase versus $1.1 billion in net federal savings; see Figure 2). The extra Medicare coverage makes it easier for people to afford the cost of living.

President Trump implemented a $35-per-month cap on medication spending for Medicare beneficiaries, but it was time limited, for a subset of drugs, and was voluntary for private prescription drug plans, only half of which participated. President Trump signed into law the Bipartisan Budget Act of 2018 that accelerated the closure of the Affordable Care Act’s policy to close the Part D coverage gap which provided savings for Medicare beneficiaries in 2019 and 2022 (and ongoing). Both laws took actions to reduce how much Medicare pays for drugs (separate from what beneficiaries pay out of pocket).

The Inflation Reduction Act of 2022 signed into law by President Biden includes some of the most substantial changes to the Medicare Part D drug benefit in years. In 2023, it capped the out-of-pocket cost for insulin for Medicare beneficiaries at $35 per month, saving an estimated 1.5 million beneficiaries an average of $500 each. In 2024, it lowered beneficiary spending in its Low Income Subsidy (Extra Help) program and the out-of-pocket cap on spending for all Part D enrollees. And, the law enables Medicare to negotiate for the price of prescription drugs starting with ten drugs in 2025. Also starting in 2025, it lowers the out-of-pocket cost sharing limit to $2,000 for Medicare Part D drug benefit expected to benefit 1.5 to 5 million beneficiaries.

Investment in Long-Term Services and Supports

Older people also disproportionately use long-term services and supports—a system hard hit by the COVID-19 pandemic. The American Rescue Plan Act (ARPA) signed by President Biden directed $37 billion in time-limited federal and state Medicaid funding for home- and community-based care, including investment in the direct care workforce. No new investments or major policy changes related to long-term services and supports occurred from 2017 through 2020, the duration of the Trump presidency. (See Figure 3.)

President Trump’s record includes COVID-19 guidance targeted to nursing facilities and his own health accomplishments document mentions long-term services and supports in reference to flexibility given to private Medicare Advantage plans for in-home supports and services.

The Biden administration has focused on Medicaid generally and direct care workers specifically in its COVID-19 response as well as its waivers, regulations, and the American Rescue Plan Act implementation. As demonstrated in state plans to spend the $37 billion in ARPA funding, this investment has catalyzed training, supports, and other expansions of the direct care workforce that serve older people in all settings.

Health Coverage for Pre-Medicare Older Americans

Health coverage matters for people age 55 and older who do not yet qualify for Medicare. This does not just reflect that age is correlated with health need: it is also because as older people retire and take part-time jobs, they may lose access to job-based health coverage. As shown in Figure 4, the number of uninsured Americans ages 55 to 64 increased during the Trump administration by 764,000 while it decreased by 641,000 during the first two years of the Biden administration (the most recent data from the Census Bureau).¹ This potentially understates the gains in health coverage for older people since the continuous coverage provision in Medicaid continued through part of 2023 and the premium tax credit expansion in the Inflation Reduction Act continues through 2024.

President Trump aimed to repeal the Medicaid expansion and the Health Insurance Marketplace—the private insurance system and premium tax credits included in the Affordable Care Act. While this effort failed, he unilaterally cut funding for outreach conducted by Marketplace navigators by over 80 percent and stopped funding subsidies for low-income Marketplace enrollees’ cost sharing (which health insurers instead funded through higher premiums and tax credits). He also signed into law the Families First Coronavirus Response Act, which provided states with higher federal Medicaid matching rates in return for not disenrolling people during the pandemic.

President Biden restored and increased Marketplace navigator funding and signed the American Rescue Plan Act and the Inflation Reduction Act that expanded and increased premium tax credits for Marketplace coverage from 2021 through 2025. In 2023, the nation’s uninsured rate hit a record low and, in 2024, Marketplace and Medicaid expansion enrollment hit a record high.

Public Health Protections

Public health supports and protects health at the community level, including communities disproportionately affected by disease—as was the case with older people and COVID-19. From 2020 to September 2023, over 75 percent of all deaths related to COVID-19 occurred in Americans aged 65 and older. The span of the pandemic across the Trump and Biden administrations complicates comparisons of actions, since different ones were warranted at different times. That said, leadership mattered, since protection against COVID-19 relied on encouraging people to take precautions, get vaccinated, and accept effective treatment.

As such, a proxy for leadership is how people who voted in 2020 for Trump versus Biden followed public health advice. The disparity is stark. Death rates from COVID-19 from January 2021 to May 2022 in counties where 60 percent or more voted for Trump averaged 381 per 100,000, compared to 259 per 100,000 in counties in which 60 percent or more voted for Biden. In other words, as shown in Figure 5, deaths rates were 27 percent higher than the national average in the Trump-voting counties and 13 percent lower in the Biden-voting counties. A similar disparity emerged in COVID-19 vaccination rates (52 percent in Trump-voting counties versus 65 percent in Biden-voting counties). Research has found a correlation between vaccine attitudes, rates, and deaths from COVID-19.

President Trump’s Operation Warp Speed successfully accelerated the development and approval of effective vaccines against COVID-19. He also signed laws to improve response and sustain the economy during its initial period. President Trump’s record shows that he believed that states rather than the federal government should lead the response and, in 2020, criticized public health officials and guidance to prevent its spread and did little to promote vaccination once it became available in late 2020 and early 2021.

President Biden on his first day in office announced the creation of the position of COVID-19 Response Coordinator and a unified national approach to the pandemic that included paying for vaccines, testing, and personal protective equipment throughout the public health emergency. His administration focused on nursing facilities given the disproportionate impact of the disease on their residents and promoted (and in some cases) required vaccination.

Similarities and Differences

There are areas where both presidents made inroads into health policy for older Americans. For example, they both improved coverage in Medicare for behavioral health service and access to telehealth. Both struggled with the impact of the pandemic on workforce, the economy, and inflation. Both supported policies that could potentially help older Americans such as drug importation, price transparency, and limits on surprise billing.

That said, the policy results for their past terms suggest that President Biden placed a higher premium on the health of older Americans.

1. The uninsured rates changed similarly over this period of time, suggesting that this is not the result of demographic shifts.

Tags: medicare, health coverage