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November 29, 2023
John E. McDonough
Jan 25, 2024
Dec 21, 2023
Back to The Milbank Quarterly Opinion
National and state polls are still early and close regarding the 2024 presidential race between likely nominees President Joe Biden and former President Donald Trump. What might a second Trump Administration mean for US health policy? Except for the issue of abortion, public conversation about future federal health policy beyond 2024 is scarce, though some strands are visible for those looking closely enough. What can we foresee?
Checking multiple websites of Republican presidential candidates Chris Christie, Ron DeSantis, Nikki Haley, and Vivek Ramaswamy reveals zero references to health policy positions except relating to abortion. If any of these candidates have health policy planks, they are keeping them concealed.
A Trump campaign spokesperson told Axios that “(T)he campaign’s Agenda47 is the only official comprehensive and detailed look at what President Trump will do when he returns to the White House.” I checked the site’s segment labeled: “Better Health Care Choices at Lower Costs.” It contained five sentences with only the last two referring to future policy:
“He (Trump) will stop all COVID mandates and restore medical freedom, end surprise medical billing, increase fairness through price transparency, and further reduce the cost of prescription drugs and health insurance premiums. President Trump will always protect Medicare, Social Security, and patients with pre-existing conditions.
On November 25, Trump wrote on his social media channel: “I’m seriously looking at alternatives” to the ACA. He included no details or timeline, a consistent pattern regarding the law. Beyond campaigns, the most detailed 2025 health policy agenda comes from the conservative Heritage Foundation, specifically a June 2023 document titled “Mandate for Leadership; The Conservative Promise.” Since 1980, Heritage has produced nine sets of comprehensive policy recommendations for prospective Republican Presidential Administrations in the fall of the general election year, either pre- or post-election. The new Heritage report came out 19 months prior to the January 2025 inauguration, by far their earliest such effort. Experience from the Reagan and Trump Administrations shows that these recommendations are treated seriously by winning Republican presidents, and not filed away.
The new volume—included in a four part “Project 2025” activist program—comes in at 887 pages, with 52 of them devoted to the US Department of Health & Human Services. Lead author for the DHHS chapter is Roger Severino, who served as Director of the DHHS Office of Civil Rights during the Trump Administration between 2017 and 2021 and is now Heritage’s Vice President for Domestic Policy. The full report lists 54 conservative organizations and 274 individuals as contributors, without indicating section authorships.
What is on their minds?
Goal number one is a full-on anti-abortion agenda referenced more than any other health issue. For example, the Centers for Disease Control and Prevention (CDC) should ensure that it is not “promoting abortion as health care… (should) fund studies into the risks and complications of abortion…and not promote misinformation regarding the comparative health and psychological benefits of childbirth versus the health and psychological risks of intentionally taking a human life through abortion…” The Food and Drug Administration (FDA) should “reverse its approval of chemical abortion” and “eliminate dangerous tele-abortion and abortion by mail distribution.” The National Institutes of Health (NIH) should “promote a research agency that supports pro-life policies and explores the harms, both mental and physical, that abortion has wrought on women and girls.”
Medicaid should “prohibit abortion travel funding” and “prohibit Planned Parenthood from receiving Medicaid funds.” The Health Resources and Services Administration (HRSA) should “eliminate the week-after-pill from the women’s preventive services mandate.” The Secretary also should “install a pro-life task force to ensure that all of the department’s divisions use their authority to promote the life and health of women and their unborn children.”
The DHHS chapter has lots more from where these came, including “robust enforcement” of conscience laws, denying sexual orientation and gender identity discrimination as civil rights, banning Secretarial policy statements that “conflate sex with gender identity or sexual orientation,” restoring “religious and moral exemptions to the contraceptive mandate,” and permitting “medical practitioners to refuse provision of sex changes or similar services.” In sheer volume, nothing competes for attention more than abortion and sex. Oh yes, and under goal three—Promoting Stable and Flourishing Married Families—“HHS should prioritize married father engagement in its messaging, health, and welfare policies.”
Though goal #4 is titled “Preparing for the Next Health Emergency,” nothing in it bolsters federal capacity to address future pandemic risks. Labeling the CDC as “the most incompetent and arrogant agency in the federal government,” Heritage proposes splitting the agency into two, one to collect and publish epidemiological data from states, and the other to formulate public health recommendations and policies, “an inescapably political function.” The CDC “must be prohibited from taking on a prescriptive character…never again should CDC officials be allowed to say in their official capacity that school children ‘should be’ masked or vaccinated…” The CDC Foundation—as well as the FDA and the National Institutes of Health—should be prohibited from accepting any funding from pharmaceutical companies.
Regarding Medicare, the federal government’s largest health program, Heritage proposes to “(r)emove restrictions on physician-owned hospitals” and to “(e)ncourage direct competition between Medicare Advantage and private plans”—an odd proposal for a program already organized around private plan competition for Medicare enrollees. Concerning the federal government’s “value based care” agenda launched under the 2010 Affordable Care Act (ACA), the plan calls for replacement of fee-for-service payment with value-based payment by repealing “harmful health policies under the Obama and Biden Administrations such as the Medicare Shared Savings Program…” Also odd given that the MSSP has been a cornerstone of the Obama/Trump/Biden Administrations’ efforts to replace fee-for-service with value-based payment. The Medicare Part D outpatient drug program’s new initiative—created in the 2022 Inflation Reduction Act—to negotiate prices with pharma companies “should be repealed.”
The Heritage agenda on Medicaid contains familiar ideas from prior Republican administrations, including enabling all states to impose work requirements as a condition for enrollment as well as “targeted time limits or lifetime caps on benefits to disincentivize permanent dependence.” States would have more financing flexibility via “a more balanced or blended match rate, block grants, aggregate caps, or per capital caps” including elimination of “current waiver and state plan processes…”
On private health insurance and the ACA, priorities include removing barriers to direct primary care, revisiting the “No Surprises Act” on surprise medical billing, as well as separating the subsidized ACA exchange market from the non-subsidized market. Association and short-term health plans, as well as individual coverage health reimbursement arrangements (ICHRA) would also be promoted for expansion. The plan gives no indication of whether enhanced ACA marketplace subsidies, implemented by the Biden Administration with Congressional approval, should continue beyond their current extension up to December 31, 2025.
Also missing: Medicare’s tenuous financing as Medicare Advantage (Part C) became the preferred choice for a majority of enrollees for the first time in 2023; health equity; public health and prevention (beyond splitting the CDC into two agencies); the nation’s medical debt crisis; the maternal mortality crisis (and the disproportionate impact on African American and Native American women); and growing hospital and health system consolidation, to name a few. The document makes no reference to “repeal and replace the ACA,” the GOP’s favored health policy mantra until that effort’s collapse in 2017.
Perhaps the most consequential part of the Heritage agenda goes beyond the written pages of the blueprint. Called the “Presidential Personnel Database,” Heritage is pre-recruiting thousands of pro-Donald Trump ideological conservatives to “take back our government” and be ready to jump into federal service in January 2025. First, they must answer a short set of questions such as: “Name one living public policy figure whom you greatly admire and why.” No suggested answer is provided.
In health policy as elsewhere, the stakes in the November 2024 federal elections are as high as ever.
John E. McDonough, DrPH, MPA, is a professor of public health practice at the Harvard University TH Chan School of Public Health in the Department of Health Policy and Management. Between 2008 and 2010, he served as a senior adviser on national health reform to the US Senate Committee on Health, Education, Labor, and Pensions, where he worked on the writing and passage of the Affordable Care Act. Between 2003 and 2008, he was executive director of Health Care For All, a Massachusetts consumer health advocacy organization, where he played a leading role in the passage of the 2006 Massachusetts health reform law. From 1985 to 1997, he was a member of the Massachusetts House of Representatives where he cochaired the Joint Committee on Health Care. His articles have appeared in the New England Journal of Medicine, Health Affairs and other journals. He has written several books including Inside National Health Reform in 2011 and Experiencing Politics: A Legislator’s Stories of Government and Health Care in 2000, both by the University of California Press and the Milbank Fund. He holds a doctorate in public health from the University of Michigan and a master’s in public administration from the Kennedy School of Government at Harvard University.
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