Medicare for All

Achieving universal access to health care services is a national objective reflected in the 2010 passage of the ACA. The Trump administration, however, is actively working to strip access to care for millions through lax implementation and refusals to defend the ACA's core foundations. With many Americans facing potential denials of basic coverage, all the leading Democratic candidates are rallying around universal health care. Popularized by Sanders in his 2016 run and central to his current campaign, Medicare for All proposals purport a single-payor, tax-funded system in which the federal government acts as the sole intermediary between patients and providers. Following President Trump's criticism of Sanders' plan as “extreme,” Biden and Harris endorse proposals maintaining private insurance to an extent.^{Reference Harris3} O'Rourke, Gillibrand, and Buttigieg are pushing for a hybrid system allowing Americans to opt for Medicare-based or private plans. Hickenlooper and Klobuchar reject Medicare for All outright. Despite high voter support for universal health coverage, future passage is daunting amidst a divided Congress.^{Reference Schor, Woodall and Jaffe4}

Climate Change

Climate invariably impacts human health and stability.⁵ In January 2019, the U.S. Department of Defense confirmed “effects of a changing climate are a national security issue,”⁶ yet the Trump administration has rolled back environmental regulations, pulled out of the Paris climate agreement,⁷ and manipulated publicly-reported climate science data.^{Reference Davenport and Landler8} Every Democratic candidate champions more robust climate change policies. Eight candidates support global mitigation efforts by promising to rejoin 195 countries in the Paris accord.⁹ Domestic policy proposals revolve around the Green New Deal. Inslee and Bennet offer detailed plans emphasizing carbon emission reduction while increasing clean energy jobs. Gabbard and Delaney propose to transition to 100% clean energy by 2035 and 2050 respectively. Sanders, Buttigieg, and Moulton make similar pledges, but lack a definitive timeline. Warren seeks to achieve net-zero carbon emissions by 2030 on non-combat military bases, the single largest government energy consumer. Gillibrand and O'Rourke prioritize investments in clean energy through broad legislation, building on Congress' unfulfilled promises to pass a federal infrastructure package.

Reproductive Rights

Through adverse policies, executive orders, and judicial appointments, President Trump's administration has underscored a myriad of reproductive rights challenges. As highly restrictive abortion legislation passes in select states (e.g., AL, AR, GA, ID, KY, LA, MO, ND, OH, SC),^{Reference Hutzler10} Democratic candidates are responding. All candidates support women's constitutional and civil rights to make their own bodily and reproductive decisions. Seven candidates promise to appoint federal judges who respect Roe v. Wade ¹¹ as precedent and reconsider the Hyde Amendment,¹² limiting federal funding to abortion providers. To expand access to contraception and safe abortions, Sanders proposes to fully fund Planned Parenthood.^{Reference Burke13} Yang advocates for universal basic income as a tool to improve access to reproductive health care and support pregnant women at risk financially. Harris' reproductive rights plan mandates that states with a history of unconstitutionally restricting abortion rights must obtain federal preclearance before enacting laws impacting reproductive rights.^{Reference Stevens14} O'Rourke is explicitly pro-choice concerning late-term abortions.¹⁵

Mental Health Protections and Coverage

The ACA requires insurers to cover mental health and substance abuse services as part of essential health benefits (EHBs).¹⁶ However, the Trump administration has chipped away at these protections, allowing states some discretion to disregard EHBs.¹⁷ Many Democratic candidates, like Moulton^{Reference Thompson18} and Klobu-char,^{Reference Vitali and Koenig19} advocate for greater access to mental health services through specific policy proposals. Others seek to address related stigmatization.²⁰ Sanders and Gabbard view aforementioned Medicare for All proposals as the path to fill ACA gaps in assuring mental health services for all Americans. Concerning increasing suicide rates among military members, Booker, Buttigieg, and Moulton push for expanding mental health resources for active and retired military personnel. Swalwell and Warren pledge to reduce suicide rates through initiatives addressing gun violence and opioid abuse. Advocating for criminal justice reform, Gabbard views America's prison system as the epicenter of the mental health crisis. Biden emphasizes children's access to mental health care in schools.²¹

Affordable Care Act

Since its passage, the ACA has polarized the U.S. political environment while achieving substantial reforms. ACA implementation, including Medicaid expansion, individual/employer mandates, and health insurance exchanges, has helped lower the numbers of uninsured Americans from 44 million to < 27 million from 2013-2016.²² After dozens of failed attempts to legislatively repeal the ACA,²³ Congress eliminated individual mandate penalties via the Tax Cuts and Jobs Act^{Reference Eibner and Nowak24} in 2017. Subsequently, Texas and multiple other states have judicially challenged the entire ACA. With a pending decision of the Fifth Circuit Court of Appeals in Texas v. United States, ²⁵ Democratic support for President Obama's signature legislative achievement is building. Biden, Bullock, Castro, Harris, Hickenlooper, Klobuchar, and O'Rourke defend the ACA or its specific components. Klobuchar, for example, advocates for the ACA's pre-existing conditions protections.²⁶ Hickenlooper supports building on the ACA to reach universal coverage.²⁷ Thirteen candidates in all favor provisions exceeding the ACA to allow Americans to access insurance through a public option or aforementioned Medicare for All proposals.^{Reference Brownstein28}

Gun Violence Prevention

In 2018, nearly 40,000 Americans died from gun violence, including multiple, sensationalized mass shootings.^{Reference Mervosh29} Frustrated by government inaction,³⁰ gun violence prevention is a priority for many Democrats. Sixteen candidates advocate for universal background checks, banning assault weapons, and closing gun exchange loopholes. Others go even further. Booker promotes a national gun licensing program, requiring potential purchasers to submit fingerprints, pass a background check, complete gun safety courses, and be limited to one handgun purchase per month.^{Reference Epstein31} Promising executive action, Harris calls for mandatory background checks for customers of firearm dealers selling more than five guns per year. She also seeks an immediate reversal of President Trump's 2017 decision allowing fugitives to purchase guns.^{Reference Levitz32} Swalwell makes preventing gun violence the cornerstone of his campaign, proposing a mandatory buyback program of all assault weapons.³³ Hickenlooper seeks to reverse long-standing federal prohibitions to allocate funds to the Centers for Disease Control and Prevention to research gun violence prevention. Sanders and Yang advocate for new technologies such as fingerprint locked guns.

Opioid Epidemic

Nearly two years after the Trump administration declared the opioid crisis a national public health emergency, 130 Americans on average still die of overdoses each day.³⁴ Consequently, 16 Democratic candidates seek greater federal efforts to curb the epidemic. They espouse a comprehensive approach coupled with substantial funding. Some of the candidates' proposed solutions stem from their broader objectives to promote universal health care coverage, provide enhanced mental health and substance abuse services, and hold pharmaceutical companies liable. Yang would levy fines against drug companies' improper marketing tactics and allocate the proceeds to quell the epidemic. Buttigieg calls for expanded use of medication-assisted treatment and drug courts as alternatives to criminalization. Harris wants to end the administration's practice of promoting former drug company executives to high level government positions.³⁵ Booker is “fully in favor”^{Reference Oprysko36} of evidenced-based practices including supervised injection sites despite contrary interpretations of their legality by the U.S. Department of Justice (DOJ).^{Reference Gostin, Hodge and Gulinson37}

Cannabis Regulation

Marijuana policy nationally is changing rapidly as DOJ continues to waffle over whether to enforce federal prohibitions of cannabis use against individuals in legalizing states.^{Reference Lopez38} Fifteen candidates view cannabis regulation as a health and criminal justice issue. Booker seeks to legalize cannabis nationally, expunge criminal records for cannabis offenders, and divert funds directly to communities that have been unjustly targeted through marijuana criminalization.^{Reference Dickinson39} Several others (Inslee, Gabbard, Gillibrand, Harris, Buttigieg, Sanders, Warren, and Yang) support federal legalization of cannabis. Klobuchar, Hickenlooper, and Biden only favor federal decriminalization, relegating to states and tribes the authority to legalize or not. Motivated by his service in the U.S. Marine Corps, Moulton pledges to make cannabis a more accessible treatment option for veterans.^{Reference Frazin40}

LGBTQ Rights and Equality

Discrimination against LGBTQ persons leads to denials of health services and increased risks of mental illness and substance abuse.⁴¹ The current administration has demonstrated hostility to the health of LGBTQ Americans, contravening protections established during President Obama's tenure. ACA anti-discrimination regulations have been negated through new rules allowing health providers to openly refuse care to LGBTQ individuals. Democratic candidates are pushing back. Fifteen support same-sex marriage, endorse the Equality Act (which explicitly bans LGBTQ discrimination), and condemn current federal policies, including the transgender military ban.^{Reference Fitzsimons42} Sanders and Harris support LGBTQ Americans' access to comprehensive health insurance. They also seek reversal of discrimination allowances among federally-supported health providers (although Harris is reluctant to support government funding for sex reassignment surgery^{Reference Bush and Desjardins43}). Delaney proposes to ban sex discrimination of LGBTQ students.⁴⁴ Yang advocates for direct funding of public education programs on LGBTQ issues.⁴⁵

Prescription Drug Pricing

One of President Trump's undelivered campaign promises is to reduce rising prescription drug costs^{Reference Kesselheim, Avorn and Sarpatwari46} that require millions of Americans to choose between meeting basic needs and accessing medications. Democratic candidates recognize the relatively high cost of prescription drugs as a contributing factor to the larger health care crisis. Through Medicare for All proposals, Sanders, Harris, and Gabbard would allow the federal government to negotiate with pharmaceutical companies to lower prices. Swalwell and Sanders want to import low-cost drugs from Canada where its national government already negotiates prices with manufacturers. Booker emphasizes reducing prescription drug prices as a major policy goal but does not provide an actionable path. Klobuchar and Messam champion specific cost containing measures^{Reference Bluth47} in response to escalating prices of insulin, which doubled from 2012-16,^{Reference Respaut and Terhune48} impacting millions of diabetics.

Our snapshot of Democratic candidates' diverse views on health law and policy topics underscores Americans' interests in improving health care and public health nationally. Which candidates and specific health positions will dominate Presidential politics in the months ahead is indeterminable. Additional critical health issues outside our assessment (e.g., immigration, vaccinations, nicotine devices, obesity, health disparities, and veterans' health) may take prominence. What is clear, however, is that Americans' votes may ultimately hinge on core health issues in 2020, just as they did in 2016.