An Easy Guide to Healthcare in the 2020 Election

Blake Madden
11 min readFeb 28, 2020


It’s official. Healthcare is the top issue heading into the 2020 Election.

But our healthcare system is so complex. How can I possibly even begin to understand the issues?

Don’t worry — that’s what this handy guide is for. I’ll be breaking down the major stuff that you need to know. Here’s the layout of the guide:

  • Healthcare vocabulary you need to know
  • The 3 main healthcare issues to know in the 2020 election
  • What each candidate wants to do about the 3 main issues (costs, drug pricing, and surprise billing)
  • Helpful resources to learn more

For anyone interested in learning more about a particular topic, I’ll be linking plenty of helpful resources throughout. You can also learn more about healthcare here.

One quick caveat: this guide doesn’t cover any of the costs associated with each of the plans. (It’s pretty difficult to estimate costs, anyway.)

Let’s get started!

Vocabulary Lesson: Healthcare Election Lingo to Know

So I actually hate healthcare jargon. The phrases and buzzwords that the industry comes up with make me want to gag. But, alas, you’re going to hear these words — a lot:

Affordable Care Act / The ACA / Obamacare

These are all the same thing. The ACA was the most recent broad healthcare reform, enacted by Barack Obama in 2010. It gave individuals greater access to health insurance by expanding government funding for Medicaid. Obamacare allows people to buy health insurance plans from the government, and low-income individuals can qualify for reduced, subsidized rates.

  • Read more about specific ACA policies and more in-depth analysis here.

Medicare for All

A Democratic health policy that would remove the current private medical health insurance model and put everyone on a government-run health insurance plan. It’s funded by higher taxes but would replace your employer's health insurance plans, including all deductibles, co-pays, and out of pocket costs.

  • Read more about it here.

Single Payer

The entirety of healthcare is covered under one payer, whether that payer is Medicare or managed by a private company. Note that Medicare for All is a TYPE of a single-payer system.

Public Option

Think of it as an employer health insurance plan run by the government that anyone can buy into.

  • Read more about it here.

Medicare vs. Medicare Advantage

Medicare is an entitlement program — a federally run health insurance plan — that everyone pays taxes for. Once individuals reach the age of 65, they qualify for Medicare.

  • Medicare Advantage is a type of Medicare plan run by private insurers. Individuals can opt into these plans to get expanded benefits not included in just ‘original’ Medicare. Medicare Advantage plans are growing like crazy with the Baby Boomer influx.


  • Medicaid is a social welfare program that was expanded by Obamacare in 2010. It’s a federal and state program that provides health coverage for certain people with limited income and assets.

Pre-Existing Conditions

If you have diabetes or had a stroke or whatever the condition may be, then you have a “pre-existing condition.” Prior to Obamacare in 2010, people with pre-existing conditions had to pay more for health insurance coverage. When Obamacare was instituted, health plans could no longer charge higher premiums to those with pre-existing conditions.

  • Nowadays, it’s extreme political taboo and very unpopular to discuss taking away the protections given to those with pre-existing conditions.

Repeal and Replace

  • Back in 2017, Trump and Republican Congressional representatives attempted to repeal Obamacare in an effort to replace it with a conservative healthcare plan. It didn’t gain enough traction. However, the ideas within the proposal are still popular with Trump and Republicans to form a new healthcare reform plan.

Medicaid Work Requirements

  • Another proposal where proof of work must be given in order to be covered under Medicaid.

Surprise Medical Billing, or just Surprise Billing

Surprise Billing occurs when a patient receives a much larger-than-expected medical bill from services and treatments received while at the ER.

  • The most important thing to remember when it comes to surprise billing is that a hospital can be in-network on a patient’s insurance plan, but the physician might not necessarily be covered.

If the physician practice is out of network with the patient’s insurance, they can bill much higher out-of-network rates that the patient is completely responsible for.

This unfortunate fact happens because hospitals generally contract with physician groups, who then contract SEPARATELY with insurance plans. That’s why patients generally receive two bills whenever they go to the ER. Physicians can opt-out of any insurance plan if they don’t like the negotiated rate that the insurance plan is offering.

  • Patients grow confused — “Wait,” they thought. “I thought my insurance covered an emergency room visit?” Well, yes, Karen — your insurance might cover the facility (hospital) portion of the bill, but the emergency physician treating you (who is separately contracted and probably works in an emergency physician practice) might not be covered at all. Which would put YOU on the hook for 100% of that out of network bill. Yikes.

So, in summary, patients receive 2 bills for an ER visit — one from the hospital, called the “facility” bill. Then, one from the physician, called the “professional” bill. The physician bill can be out-of-network, even though your insurance covers the hospital bill.

  • Surprise billing is so contentious because patients in a medical emergency can’t exactly choose which hospital they can go to. Obviously, they’re going to go to the closest one. And if the ER physicians at that hospital are out of network with your insurance? Well, you’re SOL.

Surprise Billing: Benchmarking vs. Arbitration

Who wants what in surprise billing? what are the proposed solutions? Each of the candidates has varying solutions. All of the solutions boil down to one of two proposals centered around benchmarking and arbitration, while some are a hybrid of the two approaches.

  • Arbitration would settle payment disputes for out of network emergency bills by asking a third party to decide what payment a provider should receive. Arbitration would allow providers to negotiate for favorable rates and argue their side.
  • Unsurprisingly, in direct contrast to providers, health insurers want Congress to cap surprise billing payments at some agreed-upon rate — this is called “Benchmarking.”

Social Determinants of Health

Could we have picked a stuffier term for this? Essentially, what this means is that there are other ‘social’ aspects to your livelihood that ‘determine’ how healthy you are — diet/access to nutrition, neighborhood, income, etc.

  • Learn more about them here.

Prescription Drug Importation

Since other developed countries like Canada pay less for drugs, the thought here is that the U.S. would allow patients or drug distributors to purchase prescription drugs from other pre-approved countries (that meet the right safety requirements) and import them into the U.S. for much cheaper than what they would pay for them in the U.S itself.

Direct Drug Price Negotiation

Democrats, in particular, want the government to be able to directly negotiate with drug companies on how much they can charge for their drugs.

The government, through the Department of Health and Human Services (HHS), would negotiate on behalf of both public (Medicare, Medicaid) and private (your employer-based health insurance plans) to determine prices that drug companies can charge for your prescriptions AND how much drug companies can raise prices in the future.

Generally speaking, Democrats want to tie drug pricing inflation to the standard U.S. inflation rate — which is pretty low right now.

Read more:

Interoperability — It’s a horrible way to say that you want all electronic health records systems to be able to play nice with each other.

  • For instance, if your primary care physician is on one electronic health records system, but your gastroenterologist is on another, the two systems can’t communicate with each other to transfer your data.
  • Many current policy proposals — on both the right and left — want ALL electronic health records systems to be able to send data to each other. It’s a major-minor issue in healthcare right now.

On to the Issues: The 3 Main Healthcare Issues.

#1. Healthcare spending reform.

  • The U.S. spends much more than other developed countries on its healthcare system. In fact, healthcare costs are one of the top reasons for bankruptcy for Americans. Many officials want to change that.
  • Learn more about the healthcare cost issue here.

#2. Prescription drug pricing.

  • Lowering prescription out of pocket costs has been an extremely popular topic lately. In Congress, getting to the finish line on a bill has been…pretty difficult.
  • Learn more about the drug pricing issue here.

#3. Surprise medical billing.

  • As previously mentioned, patients who visit the ER or hospital will sometimes receive high-cost medical bills from providers who were out of their insurance plan’s network. Multiple bill proposals are floating around Congress, and all of the candidates have plans surrounding the issue.
  • Learn more about the surprise billing issue here.

General Healthcare Plans, by Candidate

Now that we’ve covered the main issues and policy lingo, let’s get into what each candidate wants from the U.S. healthcare system. Here’s what each candidate generally wants at a high level. You’ll find that most of the more moderate candidates (Bloomberg, Buttigieg, Biden) tend to share similar healthcare policies.

We’ll start with the incumbent:

Donald Trump

  • Repeal and replace Obamacare (details currently fuzzy). Provide more oversight for Medicaid state programs. Give states more healthcare spending flexibility in the form of Medicaid block grants. Increase price transparency for patients and what they’re spending for healthcare procedures.

Bernie Sanders

  • Fully-fledged Medicare for All. Completely replace the private health insurance system that predominantly runs through employer-sponsored benefit programs. Increase taxes, but no copays, deductibles, or any other insurance network problems. Expand coverage to include vision, dental, and others.

Pete Buttigieg

  • Medicare for All who want it, meaning instituting a Public Option. Expand the ACA. End surprise billing and cap out of network bill totals. Make mental health coverage easier. Reduce healthcare admin costs and create an all-payer claims database to create better data-driven health outcomes. Put more regulatory scrutiny on healthcare mergers.

Mike Bloomberg

  • Institute a public option along with expanding the ACA. Only allow one patent per drug to reduce costs. Increase rural healthcare funding and make rural hospitals more financially viable. Cap surprise medical bills and eliminate anything being ‘out of network.’ Use CMS to directly negotiate with drug companies on pricing.

Joe Biden

  • Institute a public option along with expanding the ACA. Provide a middle-class premium tax credit. End surprise billing. Keep healthcare providers from consolidating market power. Use CMS to directly negotiate with drug companies on pricing. Implement a wide variety of other drug regulation to combat rising costs.

Elizabeth Warren

  • Medicare for All, but a slower transition to it. First, implement a public option. Use the government to manufacture drugs where there are shortages. Use CMS to directly negotiate with drug companies on pricing. Increased funding for rural healthcare providers. Prioritize mental health.

Broad Healthcare Reform Plans

Many believe that healthcare costs in the U.S. are getting out of hand, approaching 20% of GDP.

Most Democratic candidates think that adding more government health insurance options will help ease the healthcare cost burden for both patients and employers.

Here’s what each candidate wants to implement:

Donald Trump

  • Repeal and Replace Obamacare.

Bernie Sanders

  • Medicare for All that fully replaces private insurance.

Pete Buttigieg

  • Public Option that competes with private insurance plans.

Mike Bloomberg

  • Public Option that competes with private insurance plans.

Joe Biden

  • Public Option that competes with private insurance plans.

Elizabeth Warren

  • Medicare for All that fully replaces private insurance, but implement a public option first.

Drug Pricing Proposals

What each candidate is thinking on rising prescription drug prices.

Donald Trump

  • Have the U.S. pay similarly to what other developed countries pay for drugs (“International Drug Pricing Index”).
  • Import drugs from other countries (hello, Canada). Speed up FDA approval of generic drugs to increase supply. Increase drug pricing transparency.

Bernie Sanders

  • Use Medicare to directly negotiate with drug companies. Allow drug importation from lower-cost countries like Canada.
  • Use an International Drug Pricing index comprised of other developed countries to determine how much Medicare for All should pay for drugs.
  • Cap patient drug spending at $200 per year.

Pete Buttigieg

  • Limit drug out of pocket spending to max $250/month.
  • Cap Medicare part D monthly drug costs at $200/month. Make generic drugs free for Medicare, Medicaid, and the Public Option.
  • Allow the federal government to directly negotiate with drug companies on how much they should pay.
  • Cap drug price inflation. Penalize non-compliant drug companies.

Mike Bloomberg

  • Allow the federal government to directly negotiate with drug companies on how much they should pay.
  • Cap Medicare part D costs at $2,000/year. Only allow one patent per drug, no exceptions.
  • Eliminate all drug company payments to pharmacy benefit managers.
  • Have the federal government charge royalty payments for drugs developed by public tax dollars.

Joe Biden

  • Allow the federal government to directly negotiate with drug companies on how much they should pay.
  • Limit launch prices for drugs that face no competition and peg prices to an international drug pricing model.
  • Cap drug price inflation to the standard U.S. inflation rate.
  • Allow drug importation.
  • Improve the supply of generic drugs.

Elizabeth Warren

  • Allow the federal government to directly negotiate with drug companies on how much they should pay.
  • Use HHS to address generic drug shortages and high drug prices by manufacturing drugs.
  • Introduce tighter patent regulation.
  • Allow drug importation from other countries.

Fixing Surprise Medical Billing

The last major policy issue we’re going to cover.

Donald Trump

  • Whatever gets through Congress, I’ll probably sign.

Bernie Sanders

  • Under Medicare for All, everything is in network. Therefore, no surprise medical bills.
  • To go one step further — eliminate all medical debt, estimated at $81 billion. Remove medical debt from bankruptcy court.

Pete Buttigieg

  • If a facility is in network under your healthcare plan, then require all of the services provided in that facility to be served at in-network rates as well.
  • Put a cap on what out of network providers can charge patients.

Mike Bloomberg

  • Ban surprise medical bills by capping all out of network services at 200% of Medicare’s typical payment.
  • Require providers and insurance companies to arbitrate out of network payment amounts, leaving the patient out of it.

Joe Biden

  • Prevent providers from charging out-of-network rates for true emergencies, when a patient has no choice over which provider cares for them.

Elizabeth Warren

  • Under Medicare for All, everything is in-network. Therefore, no surprise medical bills.
  • But before Medicare for All, cap out of network healthcare services received at the lower cost of A) the median in-network payment rate for that procedure in that region, or 2) 125% of Medicare’s payment rate.

More helpful healthcare election resources.

I really want to encourage you to stay in the conversation, especially as the election approaches (and even beyond the election — crazy, I know). Here are some additional great resources for you to look through.

Candidate Healthcare plans:

Other Resources:

Sign up for my newsletter

Finally, I wanted to let you know that I cover all of the top healthcare stories — election news, policy, business, digital health, and more — in one weekly e-mail newsletter.

Thanks for reading! Good luck out there voting.

  • Blake

This post first appeared on February 26, 2020 at



Blake Madden

I write about healthcare. Policy, business, digital health, & more. Written in plain English. Here to connect, learn, and continue the healthcare convo.