The Impact of the 2024 Election on Health Policy

Last night’s election has us all wondering what impact the outcome might have on health policy. Here, I can speak from my experience guiding clients through the 2017 efforts to repeal and replace the Affordable Care Act, the 2020 COVID-19 pandemic response, and the years between.

I share a few thoughts below, though this is not comprehensive of all health policy issues at stake -

What can we learn from the prior Trump administration and statements on the campaign trail?

There is much to learn. The biggest takeaway is that the president’s policy positions can sometimes be unpredictable or inconsistent. This can make understanding the direction of health policy more challenging. Therefore, scenario planning is essential.

A significant focus may be reversing prior administrations’ signature health policy achievements. The Affordable Care Act and the Inflation Reduction Act are likely the most prominent examples.

Public health will also be a significant focus, likely involving a wholesale focus on the federal, state and local public health enterprise—its authorities foci and functionality. The prior administration’s response to the COVID-19 pandemic suggests that there may be mixed messaging, specifically about vaccines.

What will happen to the Affordable Care Act?

The prior administration’s central goal was repeal, which occupied our attention in the summer of 2017. The House has voted on the repeal of the ACA close to six dozen times.

Speaker Johnson and President Trump made conflicting statements toward the end of the campaign about whether repeal would be a goal in the administration. Should Republicans gain a majority in the House, it’s not entirely out of the question that some version of repeal legislation would be brought to a vote. Even if the bill were to pass the House, with centrist Senate Republicans likely holding out, it is not a straightforward possibility that we see a bill pass both houses.

It's also important to note that the ACA’s popularity has only increased over time, given the number of people who have gained coverage and better coverage.

If repeal legislation were to move forward, the ACA could be repealed in its entirety, in select portions, or through specific policy replacements. This could include eliminating or reducing guaranteed health coverage and benefits for millions of Americans, including guaranteed coverage of vaccines, PrEP for HIV and disease screenings. It could also include structural changes to insurance markets, such as per capita caps for or block grants for Medicaid.

What could happen to the Inflation Reduction Act?

The IRA is the signature achievement of the Biden administration. Its significance to President Biden’s legacy may motivate President Trump and Republicans in Congress to repeal it in its entirety or partially.

Repealing the IRA could have significant implications, negative and positive, for drugs and vaccines, including -

1. The loss of guaranteed vaccine coverage with no patient out-of-pocket under traditional Medicaid and Medicare Part D
2. Eliminating the Medicare Drug Negotiation Program would be positive for biopharmaceutical companies. However, President Trump maintained a focus on drug pricing during his prior administration. Based on this and his campaign positions, we may see attempts to replace or tweak the negotiation program to his liking. He has consistently expressed interest in international reference pricing, which may not require legislation to implement.

What could happen to public health?

State and local public health officials retain the predominant authority to adopt public health measures and are the “boots on the ground.” However, many of the programs and activities carried out by these officials are very, if not wholly, dependent on federal funding. The discretion given to the administration by Congress for any particular funding stream could result in withholding this funding.

At the federal level, the CDC is vital in guiding the nation’s public health enterprise and actions to protect and improve public health. Regarding domestic public health issues, the CDC primarily operates under a broad grant of authority from Section 361 of the Public Health Service Act. The same authority it has to implement a variety of measures for the control of infectious diseases could conceivably give it the authority to retract those same measures. However, the statute’s stated purpose of the “control of communicable diseases” may be a limitation on allowable actions.

Given the breadth of the authorizing statutes underpinning them, we could see the overhaul, restructuring or elimination of health agencies (CDC) or committees (ACIP) focused on public health. Moreover, the suggestion has been floated that the president could reclassify many career civil servants to eliminate their job protections and, ultimately, their roles.

The FDA has many statutory obligations when it comes to carrying out its role but it operationalizes many of its processes through non-binding guidance, which could be changed. We could?see the introduction of subjective views on safety and efficacy. We could specifically see restrictions placed on mifepristone where prior restrictions were removed to facilitate greater access following the Dobbs decision. We could also see the revocation of specific approvals for drugs and vaccines.

Again, the prior administration’s response to the COVID-19 pandemic tells us that there may be mixed messaging, specifically about vaccines. This could create public confusion and stymy any advancements in vaccine policy, including:

1. The prospect of a vaccine safety net to provide access to the millions of Americans without health insurance is dim.
2. Legislative efforts to improve vaccine injury compensation programs may stall. Additionally, Robert F. Kennedy Jr. has specifically suggested eliminating liability protections for vaccine manufacturers. It is worth noting that these compensation/liability schemes were signed into law by two Republican presidents.

What if Robert F. Kennedy Jr. holds a prominent role in the administration?

Robert F. Kennedy Jr. could play a prominent role in the administration, such as HHS secretary, FDA commissioner or CDC director, positioning him to execute many of his positions and the above actions. He has consistently maintained an anti-vaccine position, encouraging the abandonment of vaccine programs and a focus on chronic rather than infectious diseases. His positions typically conflict with mainstream science or are grounded in conspiracy theories.

However, he might not garner enough support for the Senate confirmation required to hold a major role in the administration. At the very least, he will almost certainly hold an influential advisory role in the administration’s public health decision-making.

Anything else to watch?

It goes without saying that women’s health will be a persistent focus in the years ahead. The landscape here is complex, involving many questions about fundamental rights and the role of states, the federal government and courts.

I’m confident this isn’t a complete list of all possible health policy directions we could see the administration go or its impacts.

Again, scenario planning is essential.