WASHINGTON — Republicans are set to take control in Washington, giving the party a big opportunity to turn their health care goals into reality.
After years of being sidelined by a Democratic White House and Senate, congressional Republicans and Trump campaign surrogates are brimming with changes they’d like to make to public health agencies and proposals to dismantle infrastructure to respond to pandemics.
The meteoric rise of Robert F. Kennedy Jr. and his crusade to take on chronic disease and rein in vaccines has opened the door to more attacks on the pharmaceutical industry.
STAT reporters assessed how much change is possible on top health care priorities with a Republican Senate and White House. If the House stays under Republican leadership as well, even more transformation could be on the table.
Pharma drug ads
RFK Jr. wants to end television drug advertisements as does Calley Means, who is now part of the MAHA inner circle.
The First Amendment, which guarantees freedom of speech, would make that difficult, said David Hart, assistant attorney-in-charge of opioid litigation and recovery/pharmaceutical fraud at the Oregon Department of Justice. Hart has been involved in several lawsuits over drug promotion and wants direct-to-consumer drug ads banned.
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Former FDA Chief Counsel Dan Troy, now managing director at the law firm BRG, said banning drug ads is “flatly unconstitutional.”
Since the FDA initially allowed drug ads, the U.S. Supreme Court has gotten more protective of commercial speech, Troy said. The high court has upheld commercial speech rights in several cases over the years, many involving pharmaceuticals. The court’s recent ruling weakening federal regulators authority over industries makes the task of reining in drug advertising more difficult.
Trump tried to take on drug ads during his first administration by requiring that drugmakers disclose list prices in ads. Drugmakers sued, and a federal court blocked the rule.
— John Wilkerson
Vaccine approvals and legal immunity
People within the Trump campaign, including transition co-chair Howard Lutnick and Make America Healthy Again leader RFK Jr., have publicly questioned vaccines. If Kennedy is given an important health policy position, he could greatly influence the way vaccines are regulated and distributed.
Kennedy has pushed the disproven idea that vaccines cause autism, and founded a nonprofit to promote theories linking vaccines to other conditions. He’s backed off more inflammatory anti-vaccine rhetoric recently, instead emphasizing his desire for more transparency and data around the products. It’s unclear exactly what data he is seeking.
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“If vaccines are working for somebody, I’m not going to take them away,” he told MSBNC on Wednesday. “People ought to have a choice and that choice ought to be informed by the best information.”
State health officials decide which vaccines to recommend in schools and for the broader population, but they rely upon the FDA and CDC to regulate and recommend vaccines, respectively. While Kennedy may not plan on removing vaccines from the market, experts say he could leverage the agencies to slow approvals, fill advisory committee slots with fellow skeptics, and spread disinformation. The main guardrails against Kennedy going rogue on vaccines are pushback from the public, Congress, the drug industry, and other government employees.
Vaccine makers could lobby lawmakers or potentially sue the FDA if Kennedy pushed it to make unfounded regulatory decisions.
At the CDC, Trump or RFK Jr. could stock the Advisory Committee on Immunization Practices with vaccine skeptics, said Bryant Godfrey, a partner at Foley Hoag and former regulatory lawyer at the FDA.
The simplest thing a Trump-empowered RFK Jr. could do is continue to cast unfounded doubt over the safety and efficacy of vaccines.
“RFK is already having influence in discouraging people from using vaccines, even though he is not part of the government at all right now,” said Leighton Ku, a George Washington University health policy professor.
— Lizzy Lawrence, Timmy Broderick, and Rachel Cohrs Zhang
Fluoride
Another frequent target for RFK Jr. has been water fluoridation.
“I am going to advise the water districts about their legal liability, their legal obligations, their service to their constituents, and I’m going to give them good information on the science and fluoride will disappear,” he told NBC Wednesday.
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Experts questioned how much a Trump presidency could actually change current regulation on fluoridation and the scientific basis for RFK Jr.’s statements.
The power to regulate fluoridation falls to the states, and the president “has no power to ban fluoridation of water supplies,” said Lawrence Gostin, the director of the O’Neill Institute for National and Global Health Law. The Trump administration, he says, could pressure states to ban fluoride and encourage local opposition to fluoridation. “ RFK Jr. could also put out false or misleading information about the effects of fluoride in the water supply, which would scare the public and do harm.”
In many areas, water naturally has some level of fluoride in it. At certain dosages, it is helpful at strengthening teeth and rebuilding enamel — the outer layer of teeth that can be worn down from sugary foods.
At higher dosages, concerns have been raised about hampering brain development in children and even making teeth weaker.
The Centers for Disease Control and Prevention, the American Medical Association, American Academy of Pediatrics, and the American Dental Association all recommend community fluoridation programs.
“There are hundreds of studies on fluoride that show the benefits outweigh the risk. Tooth decay is at an all-time low because people are using fluoridated water,” said Marc Scheineson, former FDA associate commissioner.
Researchers have found negative implications for childrens’ dental health when cities like Calgary, Canada and Juneau, Alaska stopped adding fluoride to their water. The CDC estimates that every dollar spent on fluoridation saves $20 in the long term by preventing the need for dental treatments.
— Anil Oza
Public health and science agency overhauls
RFK Jr. has said Trump promised him “control of the public health agencies,” including the National Institutes of Health and the Centers for Disease Control and Prevention. He’s talked about cleaning up “corruption” at those agencies and reorienting them towards a chronic disease focus (in a page on his MAHA website that has since been scrubbed).
GOP lawmakers are also eager for public health reform. House Republicans this year recommended restructuring NIH and retooling its funding; appropriators also sought to slash CDC funds and eliminate 23 “duplicative” programs. Several GOP lawmakers want to bar controversial “gain-of-function” research on infectious pathogens.
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If Republicans take control of both the House and Senate, the pathway opens up for several of these reforms to make their way into the budget process and quickly get to Trump’s desk.
The administration itself could take a number of steps. In the waning days of Trump’s first presidency, for instance, health officials raced to enact term limits and periodic job reviews for agency center directors — a rule that appeared aimed at career scientists such as Anthony Fauci.
“I think you need to not get carried away,” said Robert Bradner, a partner at Holland and Knight focused on health policy and funding. “It is Congress that has imposed numerous programs and mandates on the CDC; it is Congress that created many if not all of the institutes and centers at the NIH. It’s a little unfair to point the finger at these agencies.”
However, there are legitimate reasons to call for changes in federal health agencies, said Ziyad Al-Aly, senior clinical epidemiologist at Washington University in St. Louis, and a long Covid researcher. If the pandemic was a stress test, “the readout is that we failed. Our institutions massively failed.” Whether it was a CDC too bogged down by bureaucracy to jump into action, or the RECOVER trial’s slow start, the need for reform became apparent, Al-Aly said.
However, some proposals — particularly those espoused by the “Make America Healthy Again” cadre — go much further, like arguments to gut infectious disease research in the name of chronic disease investigations. Such sweeping statements will need to turn into specific, practical policies, and that’s where future advisers will be crucially important, Al-Aly said. “The debate or discussion is going to be: How do we fix this course?”
— Sarah Owermohle and Isabella Cueto
Reproductive care
Trump has said he would veto a national abortion ban. But he hasn’t weighed in on other ways abortion access could be restricted, some of which are the subject of court fights.
The Biden administration has pushed to ensure that women can receive abortions in emergency situations, pointing to a federal law known as EMTALA. A lawsuit against Idaho over its total abortion ban reached the Supreme Court, and was kicked back to the lower court. It’s unclear how or whether the Trump administration may continue to pursue the case or the broader issue of access to abortions in medical emergencies.
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Another potential battleground is regulations for the abortion pill mifepristone. While Trump and running mate JD Vance said they would not push for the medication to be taken off the market, neither has said whether Trump’s FDA would try to reverse a regulatory change allowing doctors to mail mifepristone. Mailed prescriptions of mifepristone have surged since Roe’s overturn.
Several state attorneys general have joined a lawsuit against the FDA, arguing that mailing mifepristone is illegal under an 1873 anti-obscenity law. Trump’s Justice Department will need to defend the FDA; or the agency could change its regulations, making the lawsuit moot, legal experts told STAT.
Separately, Trump has pronounced himself a leader on in vitro fertilization and said he would require insurers to cover the procedure. He has not discussed contraception access this election cycle, but in his first administration, health officials allowed coverage exemptions for employers who cited religious beliefs.
— Sarah Owermohle
Pandemic preparedness
Trump will have to contend with an issue that dogged the final year of his first term, and most of Biden’s tenure: How to better prepare for and manage infectious disease outbreaks.
The president-elect has promised he would disband the White House Office of Pandemic Preparedness and Response, calling it a “very expensive solution” that doesn’t work. Biden launched the office in July 2023 amid ongoing coronavirus cases, mpox surveillance and an emerging H5N1 bird flu outbreak. But Congress actually mandated its creation, with strong support from several Republicans, though it wasn’t given separate funding.
Eliminating the office would take congressional action. Kenneth Bernard, who served in both the Clinton and George W. Bush White Houses in biosecurity leadership positions, said there are informal ways to undermine the office. Officials on loan from other departments could be sent back to their regular positions, and the congressionally mandated leader of the office could be assigned a shared position with another role.
There are also questions about how a second Trump presidency works with the rest of the world on health issues. In his first term, Trump released a global health security strategy that promised working with other countries to improve disease surveillance and pandemic preparedness, but also called on other nations to “fulfill their financial commitments” in the effort.
A longtime presidential program to provide global HIV/AIDS support, PEPFAR, was ensnared in the abortion debate last year, before squeaking through this March on a short-term deal. That battle could reignite soon.
Trump will reenter office in a new, post-pandemic environment. Congressional talks to reauthorize a range of authorities under the Pandemic All-Hazards Preparedness Act have repeatedly stalled.
Overall, there is some simmering concern that a second Trump presidency, along with congressional Republicans eager to slash budgets, could back away from global health commitments.
“(Global health security) can be portrayed more as a welfare to others than as a national security, health security, economic security, protection for the U.S.,” said David Stiefel, director of global biological policy at the Nuclear Threat Institute and a former White House adviser. “If you can’t make that case, I think it’s very difficult to get global health security past the line.”
— Sarah Owermohle and Rachel Cohrs Zhang
Addiction and harm reduction
When it comes to addressing addiction, the Biden administration was arguably the most progressive in history. It expanded access to medications like methadone while embracing the philosophy of harm reduction: making substance use less risky while conceding that most people with addiction will continue to consume drugs. Under Biden, the federal government provided funding for harm reduction services like fentanyl and xylazine test strips and syringe exchange programs, and looked the other way as a nonprofit organization opened the nation’s first supervised consumption sites in Manhattan.
Under a second Trump term, momentum on harm reduction is unlikely to continue. Instead, the bigger question is which policies will survive, and which the new White House will attempt to rescind.
Regina LaBelle, a longtime Democratic drug policy official, expressed optimism that many of the Biden-era changes are seen as relatively uncontroversial, and might remain in place. She said the Trump administration might scale back hard reduction efforts, such as by cracking down on the supervised consumption sites, but predicted that federal support for distributing naloxone, the overdose-reversal medication, will continue. She also said she’s hopeful that the Trump administration will maintain broadened access to methadone.
Capitol Hill, meanwhile, hasn’t done much on addiction in the past decade, with two notable exceptions: a Democratic Congress loosened requirements surrounding the addiction medication buprenorphine in 2022, and a Republican Congress passed the SUPPORT Act to address the opioid crisis in 2018.
RFK Jr. is another question mark. Kennedy is a former heroin user in long-term recovery who, during his failed presidential campaign, said he would hold Alcoholics Anonymous meetings in the White House.
— Lev Facher
