Quick, Last Take on Health Policy and the Election Before November 5

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This is a fork-in-the-road-election between one side—Vice President Harris—committed to building on existing public programs and protecting consumers, and the other—former President Trump—whose administration will attempt to devolve responsibility to states, deregulate, and dramatically cut federal health funding, both as a policy goal and to pay for tax cuts. 

Regardless of who is elected, there will be a debate about extending the enhanced ACA premium subsidies. It’s the one big debate we know for sure is coming. Republicans are opposed to the extension, and only a Democratic trifecta guarantees passage. If Harris wins and Republicans take the Senate, the issue likely will become a bargaining chip in a larger negotiation. The same is true of Harris’ proposals to cap out-of-pocket drug costs and insulin costs for everyone and to add a home care benefit to Medicare. The fate of all these policies, therefore, is unclear.

Premium subsidies sound obscure, but the consequences for people and spending are real and substantial:

• The subsidies affect about 20 million people
• Failure to extend them means a 79% increase in premiums, an average $705 increase.
• It costs $335 billion over 10 years to do it.

The biggest thing that happens if Vice President Harris is elected is that all of the possible dramatic changes a Trump administration could make for the federal role in health evaporate overnight. No Medicaid block grant or per capita cap with big cuts in federal spending. No effort to dial back matching rates for the Medicaid expansion population to undermine expansion and help pay for tax cuts. No Medicaid work requirements. The open season on waivers for red states to pursue similar policies in their states will never open. “Concepts of a plan” will not become an actual plan to weaken or replace the ACA. Agencies like the FTC and CMMI and, above all the FDA, will breathe a sigh of relief, not to mention the Department of Education. There will be no leadership position anywhere in the federal government in health for RFK Jr. Mifepristone will continue to be distributed as it is today. Equity will continue to be a priority in federal health programs.

On the other end of the political spectrum, the Democratic left will end its self-imposed silence with the Trump threat gone, and ideas like Medicare for All, Medicare Buy-In, and Public Option will re-emerge. 

If former President Trump wins, an alternative history will play out. Medicaid and Mifepristone are likely to be prominent targets; one to pay for tax cuts and the other because it’s the primary way women get abortions now. It goes without saying that health care for immigrants will be anything but a priority. Cheaper and thinner insurance options, which are likely to be expanded by a Trump administration, may benefit some healthier Americans, but sicker people could pay more. Federal health spending will be cut and potentially radically, putting pressure on state budgets.

Some ideas favored by Trump will get through, and others will hit a wall of laws and regulations and bureaucratic resistance. Trump cannot simply decree that RFK Jr. “go wild” on health, food and medicines, and, like Star Trek’s Captain Picard, “make it so.” But a lot will get through. Everyone will need a law degree as legal challenges to Trump regulations, waivers, executive orders and agency reorganizations dot the health policy landscape and command attention.

Philosophically, this election is a choice in health between aggressive incrementalism and a sharp right-hand turn in federal policy and spending, but take it from this political scientist: no one should doubt the capacity of our system and institutions to thwart dramatic change in any direction.