WASHINGTON — A second Trump presidency could mean significant changes to health care access and costs, even if former President Trump is still working out the details.
There’s been plenty of conjecture about what the former president would do if reelected next month. Democrats have campaigned heavily against the Project 2025 agenda put out by a conservative think tank, despite Trump insisting he does not endorse the blueprint.
The outsized attention given that proposal has eclipsed some of the former president’s own words about his priorities with respect to abortion access, addiction policy and insurance coverage, surrogates and former officials say. Without many details from Trump himself during the campaign, they point to actions in his first administration.
“There are a number of organizations that are working to supply President Trump, if he does get elected, with decent options,” Joe Grogan, chair of the right-leaning think tank Paragon Health Institute, told STAT this month. “I think you just look back to the first term, and you see the tendency, and the direction he’s expected to go.”
Here’s a rundown of Trump’s health policy stances and his potential top priorities in a second administration.
Revisiting the Affordable Care Act
Trump has insisted he would not resurrect Republicans’ failed attempts to repeal and replace the sprawling Affordable Care Act, but has “concepts of a plan” to revise the sweeping law and provide Americans with lower cost options.
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“If we can come up with a plan that’s going to cost our people, our population, less money and be better health care than Obamacare, then I would absolutely do it,” Trump said during a debate with Vice President Harris.
His running mate, Ohio Sen. JD Vance, offered a bit more detail after the debate in an interview with NBC. Vance’s comments suggest that a Trump administration would let insurers divide enrollees into different risk pools and offer different plans based on those health risks — and costs. Democrats pounced on the comments, warning that the plan would return Americans to pre-ACA days when insurers could deny coverage to people with pre-existing conditions.
Vance later talked about “reinsurance regulation,” another potential route for states to cover ACA enrollees with high medical costs.
Congress will debate next year whether to extend enhanced ACA plan subsidies, expanded during the Biden administration, past 2025. Many Republicans argue they are skewing incentives and increasing costs, and should be applied only to the sickest enrollees. Trump has not talked about these subsidies specifically yet, but his comments about wanting to improve Obamacare suggest he’s open to reassessing these multibillion tax credits.
“We have the most sophisticated risk-adjustment system in the whole world, in Medicare Advantage, and what we ought to do is apply that same system to the Obamacare exchanges,” said John C. Goodman, president and CEO of the Goodman Institute for Public Policy Research.
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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.
Public health agency reforms
Trump has pledged to take on a “stunning” rise in chronic illnesses and their drivers that could see him reshape the federal health agencies that oversee that research, outreach, and new drug development.
“It is time to ask: What is going on? Is it the food that they eat? The environment that we live in? The over-prescription of certain medications? Is it the toxins and chemicals that are present in our homes?” he asks on his campaign website. Trump pledges that he would establish a presidential commission to look into the rise in chronic diseases.
The comments parallel a rising “Make America Healthy Again” movement that blames ultra-processed foods, environmental factors, and the pharmaceutical industry for increases in autoimmune disorders, obesity, and autism. The drive has brought Trump some unusual allies, such as former Democrat and longtime anti-vaccine advocate Robert F. Kennedy Jr.
Trump has said in recent days that he is committed to putting Kennedy in a second administration. RFK “cares more about human beings and health and the environment than anybody,” Trump told supporters at Madison Square Garden on Oct. 27. “I’m gonna let him go wild on health. I’m gonna let him go wild on the food. I’m gonna let him go wild on medicines.”
This initiative also comes amid Republicans’ simmering frustration with the Covid-19 response and public health agencies’ guidance on vaccines, masks, and shutdowns. Congressional Republicans have recommended splitting the Centers for Disease Control and Prevention into two entities, one charged with infectious diseases and the other with chronic illness. GOP committee leaders have also proposed restructuring the National Institutes of Health.
Those efforts could find traction with Trump, who in his first administration sought to limit terms for NIH leadership.
Reshaping a Medicaid program under pressure
While Trump has not spoken much about Medicaid specifically this campaign, this is another arena where his first administration provides some clues. That administration laid out how states could implement work requirements in Medicaid plans and approved 13 waivers to roll them out.
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President Biden reversed several of those approvals, while others were later withdrawn. Medicaid later rescinded the Trump-era guidance. But there is still an appetite among GOP leaders to institute some work conditions in the program; South Dakota is voting on a measure next month to set up requirements.
The potential for a fresh round of waiver requests comes as Medicaid programs predict budget pressures and ballooning costs for popular new drugs.
Those programs are also still sorting out the changes from the redetermination process, during which states removed millions of people from Medicaid enrollment after the coronavirus emergency ended. There are early signs that while millions of people switched over to ACA plans, sicker people with higher costs remained in Medicaid. That has led insurers to seek federal approval to amend their rates for higher-cost enrollees, according to Medicaid programs surveyed by KFF.
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, leaving a policy vacuum in this policy area.
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That’s largely because of the Inflation Reduction Act, which allows Medicare to directly negotiate certain drug prices, Trump surrogates say. The former president would have to wrestle with how to make his plans work within that law — or stir Congress to dismantle it, an unlikely prospect.
Trump has promised to “rescind all unspent funds under the misnamed Inflation Reduction Act” and gut its climate requirements, but has stayed away from its health care policy provisions, which also include a $2,000 out-of-pocket spending cap on prescription drugs for Medicare enrollees.
But there are other ways he could attack the law and seek to change the negotiation process.
Grogan floated pushing Congress to reassess Medicare Part D, the program that covers prescription drugs, and possibly even eliminating it as more seniors move into private Medicare Advantage plans. GOP leaders have also called for more transparency in the negotiations between Medicare officials and pharmaceutical companies.
Trump also made cracking down on pharmacy benefit managers a top priority in his first administration. While he has not talked about those proposals — including the failed rule to eliminate rebates paid to PBMs — on the campaign trail, pharmaceutical industry leaders appear confident he will return to those goals in a second administration.
“We have been heartened by former President Trump’s support before going after middlemen,” PhRMA CEO Stephen Ubl said during a media briefing this month.
Reproductive rights
The former president is still walking a line between boasting about shaping the Supreme Court that overturned Roe v. Wade, and insisting that he would not further limit abortion rights. Trump’s rhetoric has evolved this year as voters repeatedly signaled they do not support national restrictions. He said he would veto a national ban if it got to the Oval Office.
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However abortion rights advocates warn there are myriad other ways that abortion access and reproductive care could be narrowed in a future Trump presidency. Some, we have seen before: In his first term, the Health and Human Services Department allowed some insurers to opt out of an ACA requirement to cover birth control at no cost to enrollees, if it violated their religious belief.
There also is the specter of the Comstock Act, a 150-year-old law that has not been enforced for decades, but could be used to bar mailing the abortion pill mifepristone, which is used in a majority of abortions. Trump said this summer that he would not use Comstock to limit mifepristone, a position that angered anti-abortion advocates.
Comstock may come up anyway in his administration, as more attorneys general joined the original mifepristone case that the Supreme Court sent back to a Texas district court. With Missouri, Idaho and Kansas now involved in the case, the arguments around the legality of mailing mifepristone have sharpened.
Separately, Trump has vowed to protect access to in vitro fertilization and to mandate insurance coverage of the procedure. The promise came after repeated Democratic attacks on GOP lawmakers for abortion laws that inadvertently jeopardized IVF access.
Substance use and border policy
Trump has perhaps been most detailed about his plans for controlling the opioid crisis, though most of his answers have to do with the justice system and border policy. His campaign website pledges a naval embargo and military efforts to tackle drug cartels, death penalties for fentanyl traffickers, and permanently putting fentanyl in the highest category of controlled substance (it and related chemicals’ Schedule I classification expire this year.)
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Trump has also promised more economic support for people with addiction and family members who are providing care. His proposals include paid leave for those caregivers, which is current law, and public-private partnerships to create jobs for people in recovery.
Overdose deaths rose sharply in the last year of Trump’s presidency and had increased steadily in the years prior. Trump blamed the Covid-19 pandemic and Biden’s border policies for recent setbacks.
“We were doing very well on addiction until the Covid came along,” he said during his debate with Biden.
Barring gender-affirming care
One of the issues Trump has used to inflame his base is gender-affirming care for minors. The former president has pledged to “end left-wing gender insanity” and bar any 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.”
Trump has also repeatedly falsely claimed that children are undergoing reassignment surgeries at school, without parents’ permission. There is no evidence of that occurring; major medical associations all recommend parental consent for minors’ surgery, including any gender-affirming surgical procedures, which is exceedingly rare.
Gender-affirming care for minors more often includes psychiatric care and therapy. State restrictions on this type of care and use of hormone blockers will soon be before the Supreme Court, as Tennessee is slated to defend its ban in December.
