Healthcare reform might be a focus in midterms. For Congress, pursuing it will be an uphill climb

STAT News – Monday, February 23, 2026
By John Wilkerson

Lawmakers will likely have a lot to say about health care this year. Paradoxically, they probably won’t accomplish much on the subject.

President Trump has sent conflicting messages about how he wants to handle health care issues. On Feb. 9, he said Republicans had passed all the health care legislation they need for his term and that he was no longer interested in pursuing it.

Ten days later, he traveled to Georgia to talk about the administration’s plans to lower the cost of living, where he put health care back on the agenda. CNN reported the administration is preparing to make health care a central focus ahead of the midterm elections. The reshuffling of senior officials at the Department of Health and Human Services is the first step in those preparations.

The president has another opportunity to talk about his plans for health care affordability when he delivers his State of the Union address Tuesday night.

Some aspects of the administration’s health policy goals, namely efforts to get Americans to eat healthier food, can be accomplished without Congress. But the focus in the upcoming elections will be on the rising cost of living, and most aspects of the president’s agenda that aim to lower drug prices and other health care costs would require legislation.

Unfortunately for Trump, the obvious vehicles for health care legislation have been used up. The tax cut bill that Republicans passed last year included cuts that will raise costs for many people who’ve relied on Medicaid, and Republicans skipped the opportunity to use that bill to renew enhanced tax credits that would have lowered premium payments for people who obtain insurance coverage through the Affordable Care Act marketplaces.

ACA enrollment hasn’t fallen as much as some expected, relieving the pressure on Republican lawmakers to extend the subsidies, though it will take until summer to account for the true impact of higher ACA insurance costs.

Earlier government spending legislation also included a significant health care package, eliminating that as a means for more affordable measures in the near term.

“The natural things that create momentum for legislative action are not there,” said Jonathan Burks, executive vice president of economic and health policy at the Bipartisan Policy Center.

That doesn’t mean Republicans are keeping a low profile on health care reform. They’re keen to counter attacks from Democrats on affordability and will likely echo the administration’s talking points on drug price reductions and on fraud, waste, and abuse in public health care programs.

During his swing through Georgia, Trump complained that insurance companies have gotten rich off of public insurance programs and hinted at an expansion of health savings accounts, though it’s not clear whether he wants to loosen the rules around HSAs that employers offer or convert Affordable Care Act premium tax credits into subsidies for HSA-type accounts that could be used for health care products and services.

“We shouldn’t pay the insurance companies any more,” Trump said. “We should pay the trillions of dollars directly to the people and let the people buy their own health care. Put it in a health care account.”

Some Republicans had pushed for repurposing enhanced ACA tax credits as prefunded savings accounts that ACA enrollees could use for health care costs before hitting deductibles. Those negotiations failed.

It’s long been a Republican desire to make it easier for people to shift more money from employer-sponsored insurance to HSAs, which are an investment instrument and not insurance.

That is a separate matter from discussions over ACA subsidies. Burks said those kinds of HSA reforms would be a natural fit for budget reconciliation, the process that Republicans used to pass tax legislation last summer without support from Democrats. However, with a one-vote margin in the House and major tax cuts already in place, Burks and others doubt there is much chance of Republicans passing another reconciliation bill this year.

Trump has also pressed Congress to take steps to further lower drug prices, an issue he said “every Republican should win on.” Principally, that would mean pursuing legislation that would codify the administration’s “most-favored nation” drug pricing policy into law.

However, Republican lawmakers have shown no interest in doing so. Many have been comfortable with major drugmakers voluntarily lowering certain prices under pressure from the administration, but they oppose any measure that would amount to what they would see as mandatory price setting.

Republicans have been holding hearings on health care affordability issues, and those hearings could lay the groundwork for future legislation. But it’s early going, and Republicans might not retain full control of Congress after the midterms.

Some Republicans are warming to Medicare Advantage reforms. Democrats in Congress have long pressed for an overhaul of the $500 billion program. But the increasing buy-in from Republicans lends bipartisan support to those efforts and represents a major shift in the politics surrounding the program.

Brand drugmakers will likely keep pushing for reforms to the federal hospital drug discount program, called 340B, but it’s a long shot for Congress to do any policymaking this year in this area.

One area for potential reforms centers on the Food and Drug Administration. Lawmakers are negotiating the renewal of user fee programs — programs through which industries help pay for the agency’s review of products. The drug and medical device user fee programs expire at the end of fiscal 2027, but lawmakers aim to finish negotiations over renewing the programs at the end of this year. They comprise just under half of FDA’s annual budget.

The White House is reportedly angling to incorporate aspects of its agenda into the programs. FDA Commissioner Marty Makary has said he’d like to charge smaller user fees for drug-approval submissions that rely on clinical trials run in the U.S.

It’s not clear how health secretary Robert F. Kennedy Jr.’s critical view of user fees might affect the programs. Kennedy has said he thinks user fees create conflicts of interest and that he’d like to heavily restructure them. However, he made those statements before he was health secretary and has since focused his attention elsewhere. Trump’s most recent budget proposal does not call for reductions in user fees for this year.

Senate health committee chair Bill Cassidy (R-La.) recently released a report with suggested legislative and regulatory reforms at the FDA. The proposed reforms include eliminating red tape and increasing predictability in the FDA review process, including for generic drugs and biologics. He also called for new ways to integrate artificial intelligence into the review process and streamline clinical trials.

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