Health care is a defining issue in the 2024 election – Democratic presidential nominee Kamala Harris and Republican contender Donald Trump have starkly different records on the issue. Rather than focusing on what they promise to do, let’s examine what their past actions reveal about their approaches to Medicare, the Affordable Care Act, public health infrastructure, drug policy and child abuse and domestic violence prevention.

As a specialist in public health history and policy, I have carefully examined both candidates’ records on American health care. With years of experience in the health care field and being a cystic fibrosis patient myself, I have developed a deep understanding of our health care system and the political dynamics that shape it.

For me, as for many other Americans, health care is more than just a political issue; it is a deeply personal one.

Medicare

During Harris’ time in the Senate, she co-sponsored the Medicare for All Act, which aimed to expand Medicare to all Americans, effectively eliminating private insurance.

At the presidential debate on Sept. 10, 2024, Harris clarified her former support of “Medicare for All” by emphasizing her prior legislative efforts to preserve and expand protections for patients’ rights and access to affordable health care.

Harris’s legislative efforts, primarily around the 2017-2020 period, reflect a commitment to broadening access to Medicare and reducing costs for seniors. During that time, Harris advocated for the Medicare program to negotiate drug prices directly with pharmaceutical companies.

Later, as vice president, Harris cast a tie-breaking vote on the 2022 Inflation Reduction Act, allowing the government to negotiate drug prices for Medicare with pharmaceutical companies.

In contrast, during Trump’s presidency, he made several attempts, some of which were successful, to cut funding for Medicare. The 2020 budget proposed by his administration included cuts to Medicare totaling more than US$800 billion over 10 years, primarily by reducing payments to providers and slowing the growth of the program.

The proposed cuts did not take effect because they required Congressional approval, which was not granted. The plan faced significant opposition due to concerns about potential negative impacts on beneficiaries.

Affordable Care Act

Harris has been a staunch defender of the Affordable Care Act, also known as the ACA or “Obamacare.” As a senator, Harris consistently voted against any efforts to repeal the ACA. She advocated for expanding its provisions, including supporting legislation that aimed to strengthen protections for people with preexisting conditions and increase funding for Medicaid expansion.

Harris’ record shows a clear commitment to ensuring broader health coverage under the ACA. And, in the recent debate, Harris noted this record and reasserted her commitment to the act.

During his presidency, Trump led multiple efforts to repeal the ACA, including the 2017 American Health Care Act, which would have significantly reduced the scope of Medicaid expansion and removed individual mandates.

Although these efforts ultimately failed in the Senate, Trump succeeded in weakening the ACA by eliminating the individual mandate penalty through the 2017 Tax Cuts and Jobs Act. In the debate against Harris, Trump reiterated his position that the Affordable Care Act “was lousy health care,” though he did not ultimately offer a replacement plan, stating only that he has “concepts of a plan.”

Public health infrastructure

Harris’ tenure in the Senate, from January 2017 to January 2021, shows a consistent pattern of supporting public health infrastructure. She co-sponsored several bills aimed at increasing funding for community health centers and expanding access to preventive care.

Harris also advocated for more federal funding to address public health emergencies, such as the opioid epidemic and the COVID-19 pandemic.

During Trump’s presidency, however, he made significant cuts to public health programs. The Trump administration proposed budget cuts to the Centers for Disease Control and Prevention and other public health agencies, arguing that they were necessary for fiscal responsibility. These proposals drew criticism for potentially undermining the nation’s ability to respond to public health emergencies, a concern that was underscored by the CDC’s struggles during the early days of the COVID-19 pandemic. Trump frequently has responded to these criticisms by asserting he “cut bureaucratic red tape” rather than essential services.

Drug pricing policy

Harris has also supported legislation to lower drug prices and increase transparency in the pharmaceutical industry. She co-sponsored the Drug Price Relief Act, which aimed to allow the federal government to negotiate drug prices for Medicare directly. She also supported efforts to import cheaper prescription drugs from Canada. Her record reflects a focus on reducing costs for consumers and increasing access to affordable medications.

Trump’s record on drug policy is mixed. While Trump took credit for some decreases in prescription drug prices during his presidency, his administration’s most significant regulatory changes favored pharmaceutical companies. The administration’s attempts to implement a rule allowing the importation of cheaper drugs from Canada faced significant hurdles and did not lead to immediate changes.

Trump also ended a rule that would have required pharmaceutical companies to disclose drug prices in television ads, citing concerns over its legality.

Child abuse and domestic violence

Harris has a strong record of advocating for the prevention of child abuse and domestic violence. During her time as California’s attorney general and as a senator, Harris pushed for legislation that increased funding for domestic violence prevention programs and expanded legal protections for survivors. She has consistently supported measures to enhance child welfare services and improve coordination among agencies to protect children.

Trump’s record on these issues is less defined, but his administration did sign into law the Family First Prevention Services Act, which aimed to keep more children safely at home and out of foster care by providing new resources to families. However, critics argue that the Trump administration’s broader cuts to social services and health programs could indirectly undermine efforts to combat child abuse and domestic violence. In addition, some experts suggest that Trump’s family separation policies on the southern border contributed to an increase in child trauma during his administration.

Zachary W. Schulz does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.