Donald Trump returns to the presidency with big ambitions to shake up health care

STAT News – Wednesday, November 6, 2024
By Sarah Owermohle

WASHINGTON — Republican Donald Trump has won the presidency, marking a new era for federal health agencies and the industries they oversee.

The president-elect campaigned on promises to shake up public health institutions, reshape federal health programs, and slash high costs across the system. Trump has said he’s ready for campaign lieutenants like Robert F. Kennedy Jr. to “go wild” on health, medicine, and food policy.

Trump repeated that promise in his victory speech. “We can add a few names like Robert F. Kennedy Jr.,” Trump told his supporters. “And he’s going to help make America healthy again… He’s a great guy and he really means that he wants to do some things, and we’re going to let him go to it.”

While health care took a back seat in Trump’s campaign rhetoric to stoking the economy and cracking down on illegal immigration, his Democratic opponent Kamala Harris made it a central part of her pitch. Both promised to strengthen the Medicare program that covers millions of seniors, and to bring down high health care costs. But they diverged on the details. While Harris painted health care, including reproductive rights, as basic freedoms, Trump’s position has continued to evolve during the campaign.

Polling published by the Associated Press showed that health care was dwarfed by the economy and immigration in voters’ minds. Abortion was the top issue for 11% of voters surveyed, and health care for 8%, compared with 39% who chose the economy and 20% who chose immigration.

Trump has said he would not sign a law restricting abortion nationwide, but he’s promised other policies that would shape who receives health care and who can deny it. The president-elect has said he will bar federal funding for gender-affirming care and ban it entirely for minors. He’s also promised to protect religious freedoms, which in his first presidency included allowing certain employers to decline to cover birth control based on their religious beliefs.

Trump has signaled he doesn’t want to revisit one of the defining fights of his first term in office — the failed effort to repeal the Affordable Care Act. Instead, Trump and Congressional Republicans have said they want to bring down costs within the ACA and possibly let the current enhanced tax credits expire.

Trump will have a Republican Senate to help implement his agenda and confirm his nominees, as the GOP picked up the required seats to take back the Senate majority. The Associated Press has not yet called which party will control the House of Representatives.

A number of unfinished Biden administration priorities hang in the balance. President Biden and Vice President Harris sought to tackle Americans’ medical debt, broaden behavioral health care access, and speed up Medicare negotiation for high-cost drugs.

With Trump set to take office in January, a new set of priorities is on the table.

Vaccines and public health

Trump has pledged to form a presidential commission to probe the “stunning” rise in chronic illnesses, examining food policy, environmental factors, federal health care agencies, and possibly the pharmaceutical industry itself.

While the president-elect has leaned heavily into the “Make America Healthy Again” call for public health reforms, he has previously avoided the idea — pushed by MAHA leaders such as RFK Jr. — that vaccines play a role in chronic disease. However campaign surrogates have signaled in recent weeks that a second administration is increasingly open to unproven theories about vaccine risks.

Trump transition co-chair Howard Lutnick told CNN days before the election that while RFK Jr. would not be tapped to lead the Health and Human Services Department, he could oversee efforts to whittle down the number of vaccines on the recommended schedule. Lutnick and others have also talked about reassessing liability protections for the pharmaceutical companies that develop the shots.

GOP lawmakers have already discussed massive restructurings of two public health agencies, the Centers for Disease Control and Prevention, and the National Institutes of Health. For the CDC, that includes separating the agency into two entities, one tasked with infectious disease response and the other with chronic disease prevention. The latter has been a growing focus of Trump’s campaign.

For both the CDC and the Food and Drug Administration, potential reforms may also focus on overhauling food and nutrition policy, efforts that have found more bipartisan support.

Reproductive rights

Trump has distanced himself from some conservatives’ calls for national abortion restrictions, and committed during a presidential debate to vetoing such a ban if it got to his desk.

However abortion rights advocates say there are myriad other ways that abortion access and reproductive care could be narrowed in Trump’s presidency, such as via insurance coverage exemptions for religiously affiliated employers.

The FDA under Trump could also revise guidance that allows the abortion pill mifepristone to be sent to patients in the mail. Mifepristone is used in a majority of abortions.

Threats to mail-order mifepristone are also swiftly coming from the courts. Attorneys general from three states have joined a case on mifepristone regulations that the Supreme Court sent back to a Texas district court; their arguments center around the legality of mailing abortion pills under an obscure law that has not been enforced for decades. Trump’s Justice Department could find itself defending the FDA in this case in the coming years.

Separately, Trump has vowed to protect access to in vitro fertilization and to mandate insurance coverage of the procedure.

Reshaping health insurance

GOP lawmakers and policy experts have floated a number of potential ways to reform the ACA and signaled an appetite for major overhauls. Many Republicans are opposed to the enhanced tax credits that keep ACA premiums low, which are expiring after next year.

Vice President-elect JD Vance has suggested that the administration would let insurers divide enrollees into different risk pools and offer different plans based on those health risks. While that could lead to lower-cost plans for healthier, younger Americans, policy experts warn that older people and those with chronic health issues could see their premiums balloon.

A second Trump administration could also revive his earlier efforts to offer more short-term health plans. Those insurance options — extended during the first Trump term then narrowed by Biden — don’t have to cover everything required under ACA plans. A 2018 KFF survey found that 71 percent did not cover prescription drugs, for instance.

Trump did not discuss Medicaid specifically during his campaign, and notably left it out of pledges that he would not cut spending for Medicare and Social Security programs.

But Medicaid went through a number of significant changes in Trump’s first administration, such as an effort to allow states to implement work requirements for some beneficiaries. Officials issued guidance for how states could implement work requirements for coverage, and approved 13 waivers to roll them out.

The program also in 2020 rolled out an option for states to convert part of their Medicaid funding into block grants.

Barring gender-affirming care

Trump has repeatedly pledged to bar federal funding for reassignment surgeries. His website promises that on his first day in office, he will issue an executive order “instructing every federal agency to cease all programs that promote the concept of sex and gender transition, at any age.”

The legality of gender-affirming care bans, at least under state law, will be before the Supreme Court soon. The court will hear arguments on Tennessee’s ban on Dec. 4, but likely will issue a decision when Trump is in office.

Caring for aging seniors

Trump proposed in the final days of the campaign to introduce tax credits that would support long-term caregivers. While he hasn’t provided details on who would be eligible or the plan’s potential cost, at least 53 million Americans say they are caregivers for sick family members. That number is expected to surge in the coming years, as the Baby Boomer generation ages.

The proposal also parallels a number of other tax relief plans unveiled by Trump, and his broader promises to “strengthen” Medicare and bring down costs.

Some GOP policy experts have suggested that these costs can be managed by incentivizing more seniors to choose privately-managed Medicare Advantage plans. Separately, others have floated changing the law to let seniors contribute to health savings accounts while they are enrolled in Medicare.

Slashing drug prices

Trump has long lamented the high costs that Americans pay for prescription drugs and the “freeloading” by other developed nations paying much lower prices. But he’s abandoned his signature most-favored nations proposal to lower costs, and it is unclear how he will work within the framework of Biden’s Inflation Reduction Act, which allows Medicare to directly negotiate certain drug prices.

His campaign has promised to push for more transparency around prices, which echoes his first administration efforts to require hospitals post their prices. GOP leaders have also called for more transparency in the negotiations between Medicare officials and pharmaceutical companies under the IRA process.

Trump also made cracking down on pharmacy benefit managers a top priority in his first administration. Several of those efforts, such as a rule to eliminate rebates drugmakers pay to PBMs, failed or were reversed by Biden.

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