Health care is high on the minds of Americans as November approaches. According to a Kaiser Family Foundation poll, 23% of registered voters said health care is the most important issue in determining their vote for president. Only the economy ranked higher, at 25%. Tens of millions of people lost their jobs and health insurance because of the pandemic. The presidential candidates’ stances on health care could hardly be more divergent.

Trump’s priorities

Donald Trump and the Republican party are focused on reducing the federal government’s hand in health care, and dismantling the Affordable Care Act is central to that approach. In late June, the Trump administration submitted a brief to the Supreme Court in support of the claim by a coalition of 18 states that the ACA — widely known as Obamacare — is unconstitutional following Congress’s 2017 move to reduce to zero the tax penalty on Americans who don’t have health insurance. The court will likely hear arguments on the case this fall.

Details are vague on what a replacement for the ACA would look like. In past efforts to repeal the law, Republicans proposed pulling back on tax credits for health plan premiums in the individual marketplace and on Medicaid expansion, which makes all low-income adults in participating states eligible for Medicaid. Instead, more money would be directed to state governments, allowing them to set up their own plans. But Republicans may tread carefully around certain ACA provisions that have proved popular with the public. A Kaiser poll shows that although 79% of Republicans support eliminating the ACA, that figure falls to 45% if overturning the law would mean the loss of protections for those with preexisting conditions.

In a second term, Trump may continue initiatives involving patients’ rights. A court ruling recently upheld a Trump administration requirement that hospitals disclose rates that they currently negotiate in secret with insurers for services. The administration also created rules last spring expanding patients’ access to medical records.

Biden’s plan

Joe Biden wants to build on Obamacare. His proposals include offering a public insurance option, similar to Medicare, that would be available to Americans alongside employer-based coverage and private plans. In states that have not taken on the Medicaid expansion, the public option would be available premium-free to adults who would otherwise qualify for Medicaid.

Biden supports lowering the age of Medicare eligibility from 65 to 60, and he would expand tax subsidies for those buying coverage in the individual marketplace. Currently, families with incomes higher than 400% of the federal poverty level are ineligible for a premium tax credit; Biden would remove that cap and require that policyholders at all income levels spend no more than 8.5% of income on insurance. Subsidies would be calculated based on the cost of a gold-level plan, which provides more-generous coverage than silver ones, the current basis for subsidies.

Biden also hopes to prohibit surprise medical billing, in which patients may receive high bills for health services they were unaware were out of network — such as when you visit an in-network hospital but see a specialist there who is out of network. Biden’s plan includes measures to lower the cost of prescription drugs, and Trump has also shown interest in reducing drug prices.

If Biden is elected and Democrats win majorities in the Senate and House of Representatives, progressives will push for a “Medicare for All” program, a universal government insurance plan. But moderate Democrats, including Biden, are unlikely to go along with it.

Expanded tax subsidies have a stronger chance of becoming reality. Lowering the Medicare minimum age and establishing a public option are in the realm of possibility, too. If Trump wins the presidency or if Republicans maintain control of the Senate, significant reform is unlikely.

(Sandra Block, Lisa Gerstner, Nellie S. Huang and Anne Smith contributed to this story.)