Health policies under Trump

The second term of office of US president elect Donald Trump looks set to be characterised by loss of influence of scientific and medical expertise. Scepticism and hostility to expertise portend poorly for policies on vaccines, health insurance coverage, Medicaid, and female reproductive rights.

Trump’s choices of staff for the new administration is a case in point. Robert F Kennedy Jr, nominated as health secretary,1 has displayed ignorance of how science and medicine work, hostility to vaccination, a penchant for spreading misinformation, ignorance of how Medicare and Medicaid—the government’s main health programmes— operate, and has no management experience or knowledge to lead a department with a $1.8tn (£1.4tn; €1.7tn) budget and 80 000 employees.23 These deficiencies are clearest in his scheme to dismantle the nutrition and food sections of the already understaffed Food and Drug Administration.

Policy changes to undercut mandates for vaccines and reimbursement are likely to result in declines in vaccination rates.45 Less noticed is the effect on vaccine research and development. The administration’s aversion to vaccines will increase the risks surrounding FDA vaccine approvals and Centers for Disease Control and Prevention (CDC) recommendations for vaccination and payment. It could also result in less National Institutes of Health funding for research into infectious disease and vaccines6 and appointing vaccine sceptics to the CDC’s advisory committee on immunisation practices (ACIP). With threats posed by H5N1 influenza78 and the potential health benefits of developing new vaccines outlined by the World Health Organization,9 this could be damaging, not just for the US, but for the world.

Trump is unlikely to repeal the Affordable Care Act (ACA),10 which extended health insurance access to 45 million Americans,11 as the act has widespread support,1213 but changes are likely. First, substantial increases in ACA marketplace subsidies enacted during the covid pandemic will expire at the end of 2025 and are unlikely to be renewed,1415 potentially leaving four million people without coverage from 2026. Second, policies from the first Trump administration that decreased enrolment—such as shorter open enrolment periods16 and fewer navigators to help people buy insurance1718—might be reinstated.

The new administration is likely to make changes to Medicaid. These could include lower payments to states, work requirements to get coverage, and block grants—lump sums for health with state discretion about how it is spent. Block grants have previously been open to misuse and misallocation.19

Trump and his vice president elect, JD Vance, have offered mixed messages on whether they support a national abortion ban.20 In the November election, 7 of 10 states where abortion was on the ballot passed laws supporting it.21 Even without a ban, however, further restrictions on abortion are possible.22 For example, the administration could place restrictions on sending abortion pills such as mifepristone through the post.

The “America First” attitude of this administration is likely to mean a reduction in global health assistance. In recent years Republicans have tried to reduce or end the President’s Emergency Plan for AIDS Relief.23 Trump is hostile to WHO, and this could endanger funding and support for the organisation.

The administration faces many other health and healthcare issues, from Medicare drug price negotiations to lax oversight over mergers and consolidation of insurers and hospital systems leading to healthcare inflation. Progress in health equity will slow. Difficult times lie ahead for the US, as it faces an administration that shows little regard for the expertise of physicians, nurses, public health experts, and researchers to address health and healthcare problems.