Another Trump Presidency: What Would It Mean For Health Care?
Posted February 22, 2024 9:30 am | 5 min read | analysis
Photo: Marcus Spiske via Unsplash | Columbia
County Observer graphic
By
Larry Levitt | via KFF & JAMA Network
NATIONAL – Donald Trump is the frontrunner for the Republican nomination for president in 2024. President Biden is the incumbent. With two likely candidates who have served in the White House, 2024 presents the possibility of 2 candidates having detailed records for comparison.
While health care is not likely to be the central topic in the 2024 campaign of Trump vs Biden, with the sharp contrasts seen before between their health policies, the election outcome will have momentous consequences for the future of health care.
The Trump campaign does not issue the typical policy papers that presidential candidates normally provide. But, from his prior record as president and his recent remarks, we can surmise how Trump might govern on health care, and how his priorities contrast with President Biden's positions.
The Affordable Care Act, aka Obamacare
As president, one of Trump's biggest political failures was his inability to persuade Congress to repeal the Affordable Care Act (ACA). However, the Trump administration did make significant changes to the ACA, including repealing the individual mandate penalty, reducing federal funding for consumer assistance (navigators) by 84% and outreach by 90%, and expanding short-term insurance plans that can exclude coverage of preexisting conditions. The Trump administration supported an ultimately unsuccessful lawsuit to overturn the ACA.
The Trump administration ended payments to ACA insurers to compensate them for a requirement to provide reduced cost sharing for low-income patients. At the time, Trump said this would cause Obamacare to be “dead” and “gone.” Insurers responded by increasing premiums, which in turn increased federal premium subsidies and costs to the federal government, likely strengthening the ACA.
In the current campaign, Trump has vowed several times to try again to repeal and replace the ACA, saying he would create a plan with “much better health care.”
The Trump administration never released a detailed plan to replace the ACA. Trump’s budget proposals as president included plans to convert the ACA into a block grant to states, cap federal funding for Medicaid, and allow states to relax the ACA’s rules protecting people with preexisting conditions. If approved by Congress, his plans would have reduced federal funding for health care by more than $1 trillion over a decade.
The Biden administration has reinvigorated the ACA by restoring funding for consumer assistance and outreach and increasing premium subsidies to make coverage more affordable, resulting in record enrollment in ACA Marketplace plans. The increased premium subsidies expire at the end of 2025, so the next president will be instrumental in determining whether they get extended.
The ACA is now much more popular than before the Republican repeal effort in 2017, though not with Trump’s Republican base. It is impossible to know if his previous proposals would resurface during a second Trump presidency, or if his comments are mainly meant to rally his voters.
Abortion and Reproductive Health
The healthcare issue most likely to figure prominently in the general election is abortion rights. In all the states where voters have been asked to weigh in directly on abortion (California, Kansas, Kentucky, Michigan, Montana, Ohio, and Vermont), abortion rights have been upheld.
Trump paved the way for the US Supreme Court to overturn Roe v Wade by appointing judges and justices opposed to abortion rights. Trump said, "For 54 years, they were trying to get Roe v Wade terminated, and I did it, and I'm proud to have done it." Trump has declined to say whether he supports a nationwide abortion ban and has been critical of Florida's 6-week ban. Without offering specifics, Trump says he would "sit down with both sides, and I'd negotiate something." President Biden has called for codifying abortion rights into federal law, which would require an act of Congress.
As president, Trump cut off family planning funding to Planned Parenthood and other clinics that provide or refer for abortion services. The Biden administration reversed this policy.
Addressing the High Price of Prescription Drugs and Health Care Services
Trump has often railed against the high price of prescription drugs, criticizing both the pharmaceutical industry and pharmacy benefit managers. His administration accomplished little to contain them.
The Trump administration created a demonstration program, capping monthly co-pays for insulin for some Medicare beneficiaries at $35. Late in his term, the US Centers for Medicare & Medicaid Services issued a rule to tie Medicare reimbursement of certain physician-administered drugs to the prices paid by other countries. The courts blocked it. The Trump administration also issued regulations paving the way for states to import lower-priced drugs from Canada. The Biden administration has followed through on that idea and recently approved Florida's plan to buy drugs from Canada, though barriers remain to make that work in practice.
President Biden signed into law the Inflation Reduction Act, far-reaching legislation that requires the federal government to negotiate the prices of certain drugs in Medicare for the first time. It also extends the $35 co-pay cap for insulin to all Medicare beneficiaries and caps out-of-pocket retail drug costs.
How Trump would approach drug price negotiations if elected is unclear. Trump supported federal negotiation of drug prices during his 2016 campaign. However, he did not pursue drug price negotiation as president and opposed a Democratic price negotiation plan.
Recently, Trump said he "will tell big pharma that we will only pay the best price they offer to foreign nations," claiming that he was the "only president in modern times whoever took on big pharma." Even though Trump has been inconsistent in his positions on drug prices, his public comments suggest the possibility of bipartisan cooperation.
Similarly, the Trump administration issued regulations requiring hospitals and health insurers to be transparent about prices, a policy that attracts bipartisan support.
Immigration
Anti-immigration policies and rhetoric have been at the center of Trump’s campaigns and his time in office, from building a wall on the border with Mexico to recent comments that undocumented immigrants are “poisoning the blood of our country.”
The Trump administration put in place a number of specific policies to restrict access to health care and discourage immigrants with potential health needs from entering the country. Trump issued a proclamation requiring proof of sufficient resources to pay for potential healthcare needs or insurance coverage. The Trump administration also changed the "public charge" rule, making it more difficult for people with low incomes or health needs to immigrate lawfully. Both policies, which had a chilling effect on access to care and benefits among immigrants, including those legally present, were challenged in federal court and rescinded by President Biden.
Trump has continued these themes in his current campaign, saying that “welfare is a gigantic magnet drawing people from all over the world.”
Trump’s Uncertain Agenda
Without detailed policy proposals, it is hard to say for sure what agenda Trump would pursue if elected again. There might be narrow opportunities for bipartisan cooperation on further measures to address prescription drug costs and achieve greater transparency for healthcare prices.
If history is a guide, it is important to take Trump’s rhetoric seriously on controversial issues. Trump’s record as president from 2017 to 2021, combined with recent comments on the campaign trail, suggest he would pursue policies to weaken the ACA, reduce federal spending on Medicaid, restrict access to abortion and family planning, and scale back benefits for immigrants if reelected as president in 2024.
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Larry Levitt is the executive vice
president for health policy, overseeing KFF’s policy
work on Medicare, Medicaid, the health care marketplace,
the Affordable Care Act, racial equity, women’s health,
and global health. He previously was editor-in-chief of
kaisernetwork.org, which was KFF’s online health policy
news and information service and directed KFF’s
communications.
Mr. Levitt holds a bachelor’s degree in economics from
the University of California, Berkeley, and a master’s
degree in public policy from the Kennedy School of
Government at Harvard University.