What Could Change Under Second Trump Term?

The new administration of President-Elect Donald Trump could mean the end of extra premium subsidies under the Affordable Care Act (ACA), skepticism of vaccines, and a focus on rooting out perceived corruption at federal healthcare agencies, health policy experts said on Wednesday.

During his first administration, Trump said he would repeal and replace the ACA. He has not presented a new plan for the healthcare law.

But health policy analysts said that enhanced premium tax credits — which were enacted in 2021 and due to expire in 2025 — will be targeted by a second Trump administration.

ACA Changes Predicted, Consumer Costs Could Rise

Some 21.3 million Americans obtained health insurance through the ACA in 2024. The majority — an estimated 19.7 million — received breaks on their premiums, which led to increased enrollment, according to the Center on Budget and Policy Priorities, a progressive think tank. Some subsidies are set to expire in late 2025, Cynthia Cox, vice president of the Kaiser Family Foundation, wrote on X, predicting that “millions will drop coverage.”

“Subsidies would almost certainly die under unified Republican control,” Patrick N. O’Mahen, PhD, and Laura A. Petersen, MD, MPH, wrote in JAMA just before the election. While the US Senate has flipped to Republican control, the fate of the House remains unclear while votes are still being counted.

Researchers at Georgetown University’s Center on Health Insurance Reforms noted in a post-election blog post that the Heritage Foundation’s “Project 2025,” seen as a blueprint for a new Trump administration, urged rolling back the ACA’s preexisting condition protections. 

“These proposals, if implemented, would result in a significant loss of healthcare access and an increase in healthcare costs for millions of Americans,” they wrote.

Changes in Store for Medicare, Medicaid, Drug Price Caps

The America First Policy Institute, which has also been advising the Trump campaign, has suggested that doctors and patients would be better served by moving to a direct primary care model, in which patients pay a monthly fee for a defined set of services.

Both America First and Project 2025 also have proposed that Medicare switch to “site neutral payments,” which means paying the same amount for a procedure whether it is in a hospital or at an outpatient site, like an ambulatory surgery center.

The conservative groups propose shifting more Medicare beneficiaries into private health plans under Medicare Advantage. Project 2025 also calls for the repeal of the Medicare Shared Savings Program.

Most likely, a Trump administration would seek to reduce enrollment in Medicaid by reducing enhanced matching for states and imposing work requirements and benefit limits, experts said. The first Trump administration granted waivers to states for those work requirements, which were reversed by the Biden administration.

A Trump administration could also seek to eliminate Medicare and Medicaid payment for gender-affirming care for adults and children. On his campaign website, Trump said that any healthcare provider that “participates in the chemical or physical mutilation of minor youth” will be terminated from Medicaid and Medicare. Trump also said he would “support the creation of a private right of action for victims to sue doctors” who have treated minors.

The President-Elect has said states should decide abortion policy. Although Project 2025 calls for the US Food and Drug Administration (FDA) to reverse its approval of abortion medications, Trump told CBS News he would not restrict the sale of abortion pills by mail. He also said during the presidential debate that he supported the Supreme Court’s June decision to allow access to the abortion pill mifepristone.

The new Trump administration could also revisit a Medicare policy that tied US drug prices to lower prices charged in other countries, wrote longtime Republican health policy advisor Lanhee J. Chen, JD, PhD, of the Hoover Institution at Stanford University, Stanford, California, in JAMA Health Forum. Drug makers challenged that policy, and it was withdrawn by the Biden administration, he wrote.

Republicans have said they now want to eliminate the drug price negotiation model instituted under the Inflation Reduction Act, and “Trump might be convinced to support that approach so that he can instead reinstate” the Medicare policy, wrote Chen.

Chen expects Trump “to pursue policies that will make major pharmaceutical manufacturers unhappy, an issue on which he has exhibited consistency in both rhetoric and action.”

Reforming agencies

President-elect Trump has said he would put Robert F. Kennedy, Jr., who has been skeptical of vaccines and pharmaceutical and food manufacturers’ influence over the federal government, in a position to examine those relationships and weigh in on health- and food-related issues.

“The president has asked me to clean up corruption and conflicts at the agencies and to end the chronic disease epidemic,” Kennedy told the Washington Post.

Project 2025 has called for ending industry funding from federal health agencies, including the National Institutes of Health, Centers for Disease Control and Prevention, and FDA.

Kennedy said on X that he would target the FDA for its “aggressive suppression of psychedelics, peptides, stem cells, raw milk, hyperbaric therapies, chelating compounds, ivermectin, hydroxychloroquine, vitamins, clean foods, sunshine, exercise, nutraceuticals, and anything else that advances human health and can’t be patented by Pharma.” 

Known as a COVID-vaccine skeptic, Kennedy, through his Children’s Health Defense organization, claims without evidence that vaccines are making children sicker with more chronic illnesses and autism. Kennedy has also said he would seek to have fluoride removed from public water supplies.

The President “has no power to ban vaccines or water fluoridation. Those are state powers,” wrote Lawrence Gostin, O’Neill Chair in Global Health Law at Georgetown University Law Center, Washington, DC, on X.

Alicia Ault is a Saint Petersburg, Florida–based freelance journalist whose work has appeared in publications such as JAMA and Smithsonian.com. You can find her on X @aliciaault.