What to Expect in Health Policy from the Next Trump Administration
A Review of Plans for the U.S. Department of Health and Human Services from Project 2025
I was surprised by both the outcome and magnitude of the result of the election this past Tuesday. If you are like me, you are probably wondering what the next administration is likely to do in health policy over the next four years. Health and healthcare was conspicuously absent from the campaign trail this year despite being a hot button issue for most Americans.
In order to better understand potential policy goals and changes at HHS, I went to the Heritage Foundation’s 2025 Mandate for Leadership report and reviewed past actions of HHS under the last Trump Administration. In this article, I will outline key policies that may find their way into the next administration through Congress or via the Executive Branch. It is important to note, however, that Trump has publicly distanced from the contents of this Project 2025 Heritage Foundation produced report, so the degree to which the future administration aligns with this is unclear, however it is likely to contain a glimpse at areas of focus.
Importantly, if you are more politically aligned with the Democrats in healthcare, there is reason to take a breath. Despite the popular rhetoric, there are many health policies in this report that are reasonable and even potential bipartisan issues. In this article, I hope to provide a balanced, impartial review and analysis of the report and the potential impact to healthcare markets, healthcare innovation, and the health of our population.
However, I want to emphasize that there are themes of religion, primarily Christian religious values, and morality in the document surrounding issues like abortion, contraception, constructs of family, constructs of gender and sex, and more. These issues will be reported as presented in the report without my own judgements or beliefs applied. I recognize that these issues are of great moral and ethical debate.
As always, if this is useful to you please share with your colleagues and friends.
In this article, I will outline and briefly describe the policy areas in the report (not comprehensively) and I will outline areas of potential bipartisan action and other areas to watch that may not be explicitly outlined in the report.
Before I start walking through the chapter on HHS reform, I will outline the major themes that are present. First, generally this report contains a focus on the value of free market competition in improving quality and reducing cost in healthcare. To do this, the report relies on empowering patients to purchase healthcare using dollars in their own hands such as via health savings and flexible spending accounts and other incentives. The report also generally contains provisions that focus on efficiency in government operations and reduced administrative burden on healthcare providers. Interestingly, there is also a core focus on reform related to health emergency preparedness in the aftermath of Covid-19. There are also themes around trust restoration, transparency, and conflict of interest reduction (particularly centered around pharmaceutical regulation, the FDA, and the CDC). You will also notice that many of the tenants of this report can be viewed through the lens of religious belief, in particular those held by more conservative Christians, and that center around the issues of abortion, sex and gender, and the concept of both marriage and the nuclear family which are areas of core importance to the authors, it seems.
The following outline highlights the key areas from the report:
HHS Department-Wide Reforms: These reforms aim to reorient HHS back to what the authors refer to as “its core mission of serving all Americans while protecting life and religious freedom.” The changes are intended to increase accountability, reduce conflicts of interest with industry, and promote “family-centered policies” while moving away from “ideologically-driven initiatives.”1 Specifically, the section on Department-Wide Reforms covers the following overarching principles (my analysis or interpretation in parentheses):
Return HHS's mission to serving all Americans "from conception to natural death"(this section highlights a core orientation of HHS toward inhibiting abortion as a practice and also mentions medically-assisted dying as undesirable)
“Strengthen protection of life, conscience rights, and bodily integrity” (the report considers a life to begin at the point of conception, conscience rights as used in the document mostly refer to issues of religious belief and religious freedom as it relates to government policy and programs)
“Empower patient choices and provider autonomy” (this section focuses on allowing patients to choose medical care providers and reducing regulatory and administrative burden on providers of care)
Promote stable married families (this overarching theme is present throughout the document and 1. focuses on marriage as an institution (read Christian marriage values), 2. nuclear family models, and 3. the concept of “fatherhood.”
Reform emergency preparedness after COVID-19 lessons
Increase transparency and oversight, especially regarding conflicts of interest (there is a strong emphasis on increasing transparency, program integrity, and a reduction of conflicts of interest at the CDC and FDA, in particular)
Centers for Disease Control and Prevention (CDC): This report recommends the CDC be restructured into separate agencies for data collection (epidemiological data) and policy recommendations (practice recommendations, clinical guidance, public health information) to “prevent conflicts between these functions and improve transparency.” This reorganization comes in response to CDC's handling of COVID-19 and aims to “restore public trust” while ensuring clear separation between scientific data gathering and policy decisions.
Reform test development and response capabilities (this report wants to leverage commercial organizations for screening and diagnostic test development for future pandemics instead of internal CDC laboratory resources. This is likely due to the success of Operation Warp Speed and BARDA which are popular among Republicans)
Ban pharmaceutical industry contributions through CDC Foundation (the report details the use of the CDC Foundation by the CDC to accept funding from commercial interests including pharmaceutical companies. The CDC uses the CDC Foundation to provide grants to states and other organizations for certain programs. This is a specific recommendation to prevent conflicts of interest)
Improve data collection systems (the report wants to enhance disease surveillance systems to improve data reliability and reduce administrative burden on providers. They recommend using existing systems, which I read to be electronic medical records and health information exchanges, to integrate with epidemiological systems to monitor disease incidence and prevalence. This lends itself to the work of the Office of the National Coordinator for Health IT, now ASTP)
Strengthen abortion reporting requirements (the report suggests that there be procedure and epidemiological surveillance of abortions broken down by reason for the abortion)
Food and Drug Administration (FDA): The FDA reforms focus on improving drug availability and affordability while seeking to change established safety/review protocols, particularly around abortion medications and vaccine development. The changes would, according to the authors, address conflicts of interest, improve generic drug competition, and restore stricter safety requirements for certain medications while expanding access to ethically-developed vaccines (defined as free from aborted fetal cell lines by the authors):
Reform generic drug approval process (in order to improve competition in the pharmaceutical market, the report suggests steps to incentivize companies to launch generic products; probably a tailwind for generic drug companies and insurers, but a headwind for brand-name drugs coming off-patent)
Improve laboratory testing regulations (this is focused on improving portability and reducing regulatory burdens in the laboratory developed test (LDT) market; probably a tailwind for laboratories)
Address drug shortages (this area focuses on reducing regulatory burdens and changing the methodologies used by the FDA for manufacturing quality reviews for pharmaceutical manufacturers; unclear on the impact of this here)
Reverse approval of chemical abortion drugs (this is focused on reversing approval for abortion drugs mifepristone and misoprostol; this serves to significantly curtail use of these drugs)
Restore “safety protocols for abortion medications” (this refers to requiring prescription of these drugs via in-person visits, disallowing mail order, and limiting the point in a pregnancy when this drug can be prescribed; serving to limit the use of these drugs)
Reform vaccine importation policies (this is focused on allowing U.S. companies to import vaccine products from other countries that were not developed using “fetal tissue and cell culture lines”; potential tailwind for foreign vaccine manufacturers)
National Institutes of Health (NIH): The NIH reforms would seek to eliminate what the authors refer to as “controversial research practices” and address significant conflicts of interest with the pharmaceutical industry. A key focus would be ending “fetal tissue research from elective abortions” while promoting ethical alternatives (read other types of cell lines) and implementing strict "cooling off" periods before regulators can work for companies they previously regulated (they suggest 15 years).
End research using fetal tissue from elective abortions
Reform conflicts of interest policies (typically around interactions between researchers and advisory board members and commercial healthcare organizations)
Impose "cooling off period" before regulators can work for companies they regulated (15 years is indicated; unclear how this impacts the decisions of scientists to participate in regulation)
Reform funding distribution system (here the report suggests decommissioning the CDC and NIH foundations, imposing term limits on NIH officials who direct research grants, and allocating research funds to states rather than central control via the NIH)
Eliminate gender ideology-based policies
Centers for Medicare and Medicaid Services (CMS): These proposed reforms aim to improve Medicare and Medicaid by empowering patients, reducing regulatory burdens on providers, and implementing stronger program integrity measures. The report, once again, supports work requirements for able-bodied Medicaid recipients, encourages site-neutral payments, and reforms to Medicare Advantage (MA) (this report supports a Medicare Advantage-first policy) while addressing waste, fraud, and abuse (specifically using artificial intelligence). In Medicaid, the report wants to generally reduce spending and increase budget predictability of the program for both states and the federal governments.
Reform Medicare Advantage (make changes to risk adjustment and capitation methodologies and encourage a Medicare Advantage default enrollment. This would be a huge “subsidy” for big national MA plans like United Health and Humana)
Implement site-neutral payments (this requires Medicare to pay the same amount for a service regardless of where it is delivered; potential tailwinds for certain providers)
Replace the fee-for-service system with value-based payments (there appears to be strong support for value-based payment rather than the Medicare Physician Fee Schedule process)
Codify price transparency regulations
Remove price negotiation from Medicare Part D (a potential tailwind for the pharmaceutical industry)
Add work requirements for able-bodied Medicaid recipients (this policy has been implemented in states before via waivers during the prior Trump administration; candidly, evidence suggests it does not have the desired impact)
Reform eligibility determinations for Medicaid (the report suggests a desire to incentivize states to accurately apply eligibility criteria and penalize states for improper determinations; potential headwinds for Medicaid Managed Care Plans like Centene)
Reform state financing mechanisms for Medicaid (this is common of the last decade of Republican Medicaid policy and incorporates per-capita caps which are annual or lifetime limits to spending per enrollee, block grant mechanisms which are lump sum annual payments to states as a fixed budget for Medicaid rather than the current shared payment model, and aggregate caps for the federal and state shares of Medicaid financing; headwinds for companies like Centene and other MCOs)
Incentivize “personal responsibility” in Medicaid (this involves adding patient responsibility to Medicaid payments including co-pays and co-insurance).
Strengthen program integrity (specifically using artificial intelligence to reduce fraud, waste, and abuse)
Eliminate Medicaid waiver processes (interestingly, the report suggests eliminating the waiver process for certain services thus providing states with more creative authority over their programs without federal review. The report suggests retaining waiver requirements for programs like work requirements, but suggests relaxing requirements for “non-healthcare benefits” and programs aimed at “climate change.” It is interesting to note this section references climate change and non-healthcare benefits)
Remove barriers to direct primary care (DPC) (the report, in line with the goal of empowering consumers to spend healthcare dollars, suggests allowing the use of HSA and FSA dollars to pay for DPC subscriptions by “clarifying they are not insurance premiums”)
Price Transparency and No Surprises Act (generally speaking the report wants to increase price transparency and allow patients to benefit from choosing more cost-effective options rather than the insurance companies and encourages public reporting of provider quality measures)
Prohibit Planned Parenthood from Medicaid Funds
Telehealth promotion (they suggest legally redefining the locus of payment to the providers location rather than the patient’s for telehealth services and are generally supportive of telehealth and reference the interstate commerce clause of the Constitution allowing the federal government to regulate licensure for telehealth, which is typically managed at the state level)
Rural health (huge support for rural health and telehealth)
Repeal the Medicare Shares Savings Program (MSSP) and enact the Direct Contracting Model at CMMI (it appears that there is a negative view of the MSSP, which I assume is related to administrative burden, and a positive view of the direct contracting model from CMMI)
Administrative Reforms: Administrative changes specifically target “religious freedom protections” and reform programs like Title X to better align with “pro-life” and “pro-family values.” The reforms would also target adoption and foster care processes while allowing “faith-based organizations' ability to operate according to their beliefs.”
Reform Title X family planning program
Strengthen “religious freedom protections”
Reform adoption and foster care policies
Improve rural healthcare access
Reform Office of Refugee Resettlement
Strengthen “conscience protections”
Align the U.S. Public Health Service in a model more similar to the other uniformed services (rather than embedding service members into other federal health agencies; this is an interesting distinction)
Emergency Response: Emergency response reforms would establish defined criteria for declaring and ending public health emergencies. The changes reflect the experience with COVID-19 and aim to “prevent overreach while outlining requirements for a future response.”
Define clear thresholds for declaring public health emergencies
Reform Strategic National Stockpile (reflect supply needs during global conflict and pandemics and reiterate its purpose as a supplier of last resort)
Improve state-federal coordination
Family and Life Policies: These policies, according to the authors, “strengthen traditional family structures through marriage promotion programs and improved child support enforcement while protecting conscience rights in healthcare.” The reforms would end federal funding for abortion providers while increasing support for adoption and programs that help families stay together.
Emphasize “marriage promotion programs”
Reform child support enforcement
Improve adoption processes
End funding for entities that perform abortions (mostly Planned Parenthood)
Protect “conscience rights in healthcare” (primarily refers to traditional Christian beliefs in the report, so it will be crucial to watch the implementation of this concept as it relates to freedom of other religions and freedom from religion as are enshrined in the U.S. constitution)
Highlighted Bi-Partisan Issues
This report generally shows alignment in the transition of CMS payment to value-based, support for rural health policies, telehealth, programs to reduce fraud, waste, and abuse, price transparency, and increased competition in healthcare markets. Removing barriers to Direct Primary Care as a concept is likely to be bipartisan however this does not solve major issues in primary care financing and access and should probably be looked at more wholistically.
Generally, I think the anti-corruption firewalls and policies that are discussed may be a bipartisan issue if implemented in a manner that is consistent with this document and that does not involve any other subversive purposes or effects.
Vaccination (which probably should not be a political issue) is going to be an issue to watch due to speculation that Robert F. Kennedy Jr. may be involved with the FDA and other health policies. This report focuses on sourcing vaccines that were not developed using fetal tissue cell lines and seeks vaccines developed using other cell lines, but does acknowledge that childhood vaccinations are beneficial in the following quote: “The FDA should restore the waiver [in reference to importation of vaccines] to comply with RFRA and for the obvious public health benefits of increased childhood vaccination by families seeking ethically derived alternatives.”
On health IT issues, it will be important to watch how telehealth develops under a potentially full-Republican administration and Congress. This may pave the way for allowing permanent telehealth flexibilities which is a bipartisan issue. Importantly, artificial intelligence and improved data informatics systems for disease surveillance are specifically mentioned and are likely to be bipartisan issues in nature.
It will also be critical to watch the reform of the Centers for Medicare and Medicaid Innovation (CMMI) and the approach to payment model innovation given that it is a hot topic due to the lackluster performance of many of the evaluated payment models. This is an area with much written around how to improve the performance of CMMI. However, some at The Heritage Foundation have written about abolishing CMMI and having Congress reclaim model development and innovation.
Also, on the payment policy front, it is interesting to see the component about waiving Medicaid waiver requirements for certain state programs. Depending on the details, this may be a bipartisan issue. The report does appear to support the use of Medicaid funds for non-healthcare programs in Medicaid and for climate-change related services, which are likely bipartisan issues.
Price transparency and consumer-driven purchasing are also likely to be key themes in the next administration. The continued promotion of health savings accounts, flexible spending accounts, and cost-based shopping for health services by patients are likely to continue and are fairly bipartisan solutions. It is my opinion that these changes are relatively minor in their effects without strong anti-trust action to promote competition in insurance and care delivery markets. Consumer price and quality shopping does not work when there is a single provider in a given geography.
On competition policy, watching the actions of the FTC under Donald Trump will be critical. The current FTC regime is marked by significant anti-trust rulemaking and the extent to which that continues is unclear. If Republicans are serious about fostering competition, an active FTC and efforts to reduce hospital and insurance company consolidation are critical.
A Comment on Ideology, Religious Freedom, Conscience Laws, and Morality
It is clear that the by far largest area of health policy from this report is advancing an anti-abortion agenda through HHS. There is no question that the recommendations from this report seek to advance an anti-abortion agenda-in-all-policies as a core strategy. There also appears to be a desire to repeal tenants of what the authors call “ideology-based policies” which most often refer to policies, programs, and definitions that deal with the constructs of gender and biological sex. Throughout the document there is reference to “conscience laws and rights” (which, for all intents and purposes, appears to refer to individual rights to object to certain policies and programs on the basis of individual morality). It is clear in this report that the dominant system of morality employed is rooted in components of traditional Christianity. It is also clear that “religious freedom” is a theme, which again, appears to draw primarily from traditional Christian constructs rather than from a Constitutional perspective wherein freedom of religion and freedom from religion are core to the interpretation. This is an area to watch the juxtaposition of these policies and beliefs with those of Donald Trump. However, it is clear that abortion access and services will be a core target of the next administration.
This is the only area where I want to make an important comment. The division between church and state is a critical one. It is foundational to the formation of the United States of America. There is almost no concept more American than the need to maintain a clear division between church and state. Freedom of religion is also a core American construct which includes freedom of practice, exercise, and belief for Christians, but also all other religions and beliefs, and includes freedom FROM religion as well. We would do well to remember that there are many different systems of religion, morality, and philosophy—the respect for which should be held in the utmost importance. The extent to which the authors and implementors of policies for the purpose of protecting individuals freedoms should be closely watched with the hope that the policies are respectful and evenly applied to all belief systems in the United States. The extent to which certain policies impact the health of the public and the collective wellbeing of our society is also critical to monitor.
Conclusions
It is clear from the report that abortion and implementing policies related to the “pro-life agenda” are the top priority for the authors of the HHS section of the report. However, there are other very impactful policies put forward some of which are bipartisan issues and others that are core to the platform of the contemporary Republican Party. With respect to magnitude, the proposals related to Medicare Advantage and Medicaid financing are quite significant as are the policies related to telehealth, rural healthcare, and changes to the CDC. For health tech it appears the future may be positive.
Despite their claims of desiring to move away from “ideology",” I would just like to say that anything related to morality, religion, spirituality is a form of ideology when those beliefs are not universally held. I read the use of this term in the report as moving away from policies in health held by liberals and progressives (the referenced “ideology”).