As Election Day nears, the pandemic looms large. Amid a surge in new cases, the coronavirus has changed the way we live, work and — perhaps — how some Americans will vote.
As President Trump makes the case that his leadership has saved lives in the pandemic and ushered in record-fast vaccine and therapeutics development, Joe Biden has described Trump's handling of COVID-19 as "totally irresponsible" and points to American's health as the nation's top domestic issue.
Trump's approach to handling the pandemic is clear from his record. His administration has delegated much of the authority for the coronavirus response to states, including testing and contact tracing. He's invested heavily in vaccine development. He signed two coronavirus relief packages and has indicated he'd sign another one after the election.
But what would Biden do? Biden's campaign has a seven-point plan to beat COVID-19 and other proposals for health care and economic recovery that support that vision. NPR asked his advisers for details on his approach, which includes some familiar elements, as well as some less-expected ones.
1. Set consistent, evidence-based guidance to stop outbreaks
If Biden wins the election, "You would see an approach that's driven by science and by scientists," says physician Vivek Murthy, who is a key adviser to the Biden campaign on COVID-19.
And he'd focus on uniting states around some common practices, says Ezekiel Emanuel, a physician and University of Pennsylvania professor who has briefed Biden on health policy but has no formal campaign position. Instead of "different states doing different things, the goal would be to get all the states singing from the same hymnal," Emanuel says.
For instance, Biden's plan says it would direct the CDC to provide specific guidance — based on the degree of viral spread in a community — for when to open or close businesses and schools, when to impose restrictions on gathering sizes or when stay-home orders may be called for.
"Social distancing is not a light switch. It is a dial," the Biden campaign states in its plan. It would create a national "pandemic dashboard" to share this information. This is a strategy recommended by a top group of public health experts, who released a framework for assessing community risk.
And, Biden is calling on every American to wear a mask when they are close to people outside their household. He says he'd work with every governor to make this mandatory in their state. Many states already have mask mandates, but at a time when research suggests that universal masking could save more than 100,000 lives, there's currently no nationwide coordination or requirement.
2. Seriously ramp up testing
The Biden campaign says the goal is to "ensure that all Americans have access to regular, reliable and free testing." It would work to double the number of drive-through testing sites and invest in "next-generation testing" including home tests and instant tests.
"It's not enough to know in seven days or five days or three days whether or not you have COVID," Biden said on CBS' 60 Minutes. If there's a long lag time, a person may spread the disease unwittingly while waiting for results.
There are currently several home test kits that give quick results without being sent to a laboratory in development, but none are yet FDA-approved. While there has been a significant expansion in testing, "we're still encountering shortages," Murthy says. "Testing is still not available and affordable to all people across the country, he says.
3. Establish a U.S. public health jobs corps
The Biden campaign pledges to "mobilize" 100,000 Americans to work with local organizations around the country to perform contact tracing and other services that would help address unmet needs in populations at high risk for COVID-19.
These workers would initially help with contact tracing around the country, and would also shore up local health departments to address other pandemic needs, Murthy says. "We know that people are struggling," he says, and the idea is to empower local communities and local health departments to assist people with challenges such as food insecurity and affordable housing.
"Imagine a public health workforce that was also helping train school officials in how to reopen safely," Murthy says. Or helping run public education campaigns about a vaccine and how to stay safe in the pandemic. "Think about a workforce that was diverse, that looked like the country that we're trying to serve," Murthy says.
This investment would be paid for by increasing taxes on corporations and wealthier Americans.
4. Help people get health insurance
Millions of American have lost health insurance during the pandemic. Biden's coronavirus plan proposes to have the federal government cover 100% of the costs of COBRA coverage for the duration of the crisis. "So when people lose their employer-based health insurance, they can stay on that insurance, given the moment we are in and the pandemic," says Stef Feldman, Biden's national policy director.
In addition, Biden would push to strengthen the Affordable Care Act. "That means expanding coverage," Murthy says, for instance by making more people eligible for premium subsidies. Biden would also push for expansion of Medicaid in states that have still yet to do so, his advisers say, and he has proposed making Medicare coverage available to Americans beginning at age 60 (instead of 65).
During the pandemic, several governors asked the Trump administration to reopen the federal Obamacare marketplace for a special enrollment period.
"One of the most immediate steps Vice President Biden would be able to take is to reopen open enrollment as needed so people who have lost insurance can sign up for new coverage," Feldman says, calling it "a basic step that President Trump has refused to do."
5. Create a caregiving workforce
During the pandemic, Biden says many families are struggling to find affordable care for their children, aging relatives or loved ones with disabilities. "At the same time, professional caregivers have either lost their jobs or continue to work while putting their lives at risk without sufficient pay," his campaign plan notes.
There are thousands of people who would like to receive care in their homes, who are covered by Medicaid, explains Murthy, but are on a waiting list that is as long as five years. "Vice President Biden would work with states to close that gap and make sure that we have Medicaid-funded, home-based care providers to care for our older loved ones," Murthy says.
Biden supports a variety of steps to expand caregiving including ensuring access to preschool for 3- and 4-year-olds and also supporting caregivers through job training and improved benefits and protections. The Biden campaign says these initiatives would cost $775 billion over 10 years and would be paid for, in part, by rolling back tax breaks on high earners.
Expanding opportunities in the female-dominated caregiving workforce would play a dual role in both helping families, and helping improve women's employment outlook, explains Sherry Glied, who is dean of New York University's Robert F. Wagner Graduate School of Public Service, noting that this pandemic-fueled economic crisis has hit women harder.
"This really gives us an opportunity to sort of address two policy objectives with one policy step," Glied says. She is not an adviser to Biden, but has written a perspective in the New England Journal of Medicine on how policies to address the impact of COVID-19 could shift under a new president.
6. Bolster resources for vaccine distribution and PPE production
States will need a lot of money to distribute a vaccine and make sure it gets to everyone who wants it. There are complex logistics that will require planning and resources. For instance, states may need freezers to store their vaccines, and given how many people are hesitant to be vaccinated, they will need public education materials and guidance. Currently state governors are asking for more guidance and financial assistance.
The Biden campaign proposes investing $25 billion in a vaccine manufacturing and distribution plan "that will guarantee it gets to every American, cost-free."
The Biden campaign also wants to solve the PPE shortages that have plagued the U.S. health care system since the pandemic began, stating that it would produce more of these critical supplies, "rather than leave states, cities, tribes, and territories to fend for themselves."
While Trump made limited use of the Defense Production Act to increase ventilator production, Biden says he'd use it to increase production of masks, face shields and other personal protective equipment so that supply exceeds demand.