How former President Donald Trump would approach health policy if elected to a second term is of great interest to many voters, but specific predictions about the initiatives he would pursue may be more challenging given that neither he nor his campaign have revealed many detailed plans. But Trump鈥檚 first-term policy actions, which included several significant health policy changes, help illuminate his potential priorities in this domain if he is elected to 4 more years in office. Three areas seem ripe for reform by his administration if Trump is reelected: price transparency, prescription drug pricing, and the Affordable Care Act (ACA).
During his presidency, Trump advanced measures to improve price transparency by health care organizations and payers alike. His administration requiring hospitals to publish their prices including negotiated discounts on a list of 200 services, and required that the data be furnished in a machine-readable format. Noncompliance with the regulation, which went into effect in January 2021, carries financial penalties, although some studies have concluded that many hospitals have only partially complied or not complied at all.1 Another concluded that the quality of the data provided was mixed and the data that had been furnished was not necessarily useful for the kinds of consumer price comparisons the regulation intended.
The Trump administration also promulgated the rule that required most group health plans, as well as many health insurance issuers, to disclose price and cost-sharing information to consumers. Insurer compliance with the rule has been more widespread since requirements went into effect in mid-2022, in part because of the stiffer penalties associated with noncompliance, but also because both state and federal regulators are responsible for enforcing the rule.2
During a second term, Trump would likely advocate strongly for statutory changes, such as the 鈥�,鈥� which was introduced in Congress in 2023. This legislation would strengthen penalties for noncompliance with price and cost-sharing transparency rules for both health care organizations and insurers, as well as bolster the transparency requirements and expand them to other entities, such as pharmacy benefit managers. He might also pursue regulatory avenues to achieve similar policy goals, if Congress remains deadlocked on legislation.
Since the early days of his 2016 presidential campaign, Trump has voiced tough rhetoric on drug pricing and supported policy proposals that have been broadly opposed by the pharmaceutical industry. In fact, this is a policy area where analysts that both Trump and Vice President Kamala Harris would pursue policies that place the federal government squarely in the middle of drug pricing debates.
During Trump鈥檚 presidency, his administration finalized permitting drug reimportation from Canada, and proposed a that required federally funded health centers to extend pharmaceutical manufacturer discounts on insulin and epinephrine (EpiPen) directly to patients. The most controversial of Trump鈥檚 proposals in this space was the so-called , which instituted a Medicare demonstration project that tied US drug prices to lower prices charged in other high-income countries.3 The rule was challenged in federal court by a large cohort of pharmaceutical companies, from going into effect by a federal judge in 2021, and eventually by the Biden administration in 2022.
Since he came into office, President Joe Biden led the passage of the which instituted a first-of-its-kind direct price negotiation between the federal government and drugmakers for Medicare鈥檚 most popular prescribed drugs. Congressional Republicans have advocated for upending parts of the IRA, including the drug price negotiation scheme, and if elected, Trump might be convinced to support that approach so that he can instead reinstate the MFN model. Trump has an executive order that would 鈥渆nd global freeloading on American consumers once and for all,鈥� likely by initiating a process to reissue regulations that would restore the MFN model that he has supported. Regardless, expect Trump, if elected, to pursue policies that will make major pharmaceutical manufacturers unhappy, an issue on which he has exhibited consistency in both rhetoric and action.
Trump tried unsuccessfully to repeal the ACA several times during his term in office鈥攁n effort formally ended by the late-Senator John McCain鈥檚 emphatic thumbs-down gesture on the floor of the US Senate in 2017. In the recent presidential debate with Harris, Trump again pledged that he would pursue repeal and replacement of the ACA. Trump has not unveiled a specific replacement plan, but he claims to have 鈥溾�� that he would advocate for if the ACA were repealed.
Although it is unlikely Trump would be successful in making wholesale changes to the ACA, his past presidency provides a sense of the ways in which he might look to affect continuing implementation of the law. For example, it is unlikely he would continue the enhanced originally passed in the American Rescue Plan Act and extended through 2025 by the IRA. Further, Trump would likely look to enhance the attractiveness of health savings accounts and . One idea that a former Trump adviser has floated, for example, would allow ACA rather than sent directly to an insurer. In addition, a Trump win might also mean a move away from the Biden administration鈥檚 efforts to strengthen Medicaid. This could include efforts to change the federal matching rate for enrollees (nonelderly adults made eligible for Medicaid by the ACA) in Medicaid expansion or to reinstitute , a policy that drew significant backlash from progressives during Trump鈥檚 first term.
Trump has never adopted a traditional Republican or conservative view on a whole host of policy issues, including many policies related to health care. His unpredictability and tendency to break with orthodox views has made it challenging for a variety of health care stakeholders to prepare if Trump is reelected. But looking at the many health policy actions he undertook during his 4 years in office gives a sense of the policies he would likely pursue if reelected in November.
Published: October 10, 2024. doi:10.1001/jamahealthforum.2024.4057
Open Access: This is an open access article distributed under the terms of the CC-BY License. 漏 2024 Chen LJ. JAMA Health Forum.
Corresponding Author: Lanhee J. Chen, JD, PhD, Stanford University Hoover Institution, 434 Galvez Mall, Stanford, CA 94305 (lanhee.chen@stanford.edu).
Conflict of Interest Disclosures: None reported.
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