Trump vs Harris: What will the next president do for health care?

The next president could have a huge influence on major issues in American health care, so analysts are hunting for clues about what might happen in the next four years depending on who takes a seat in the Oval Office.

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Democratic nominee Vice President Kamala Harris and Republican nominee former President Donald Trump will meet in Philadelphia tonight for their first debate, and maybe their only one.

So far on the campaign trail, neither candidate has unveiled any health care policy showstoppers.

“None of these issues are easy ones, which makes it very challenging in a political year because most candidates don’t want to talk about complex solutions for a variety of reasons, and so they aren’t,” said Web Golinkin, an author and former executive who advocates for affordable and accessible health care. “What little I know now, I don’t really see either of them definitively taking a strong health care position, other than on the Democratic side, you’ve got abortion and protecting the Affordable Care Act. On the Republican side, Trump four years ago was all about repeal and replace. You don’t hear that anymore from Republicans. I think they’ve tacitly accepted that the Affordable Care Act is here to stay. It’s reasonably popular and they’re not likely to be successful in changing it.”

Track records

While campaign promises may seem vague right now, the candidates will take the stage with track records about issues in medicine and health care.

Trump has hammered on elements of the Affordable Care Act, though rhetoric around repealing it has cooled in the last few years. He has claimed credit for appointing the Supreme Court justices who overturned the landmark Roe v. Wade decision, which in turn allowed states to regulate abortion access.

In 2019, Harris pitched “My Plan For Medicare For All,” at the time saying “we are also at a crisis point for health care in America.” A strong supporter of reproductive rights, she became the first vice president to visit an abortion clinic and her campaign’s Reproductive Freedom bus tour started in Florida last week. Harris has touted her role in President Joe Biden’s administration tackling health care and drug costs.

Changing positions and time

Both candidates could have challenges. Harris has helped implement the Biden administration’s health care policies. That could be a roadmap for her, but as a separate candidate, she has freedom to deviate from that and make her own mark, said Joe Albanese, a senior policy analyst at Paragon Health Institute. He has worked in the White House’s Office of Management and Budget during the Trump and Biden administrations.

“I think one potential weakness is that her past positions on health care issues, particularly when she was a candidate in the 2020 presidential election, were more to the left than President Biden's,” Albanese said. “So that's a political issue that she might have to grapple with now that she's at the top of the ticket and she'll have to defend that record or find a way to justify whatever changes she makes to her platform and her agenda.”

As president, Trump may try to restore rules from his first term that were overturned by Biden. Time also could be a factor for Trump. He would be term limited to four years, “so he wouldn't be looking at a potential eight-year timeline to enact his policies, so he has less time to put them into full effect before the end of his term,” Albanese said.

Health insurance

The Biden administration has touted the expansion of subsidies for people to pay for health insurance through the ACA and state marketplaces, leading to a national record low rate of people without health insurance.

The enhanced ACA subsidies will expire at the end of 2025, and those have potential to be biggest near-term issue in American health care, Albanese said.

“The administration and Congress will likely need to address that issue right away, and it could help set the stage for their health care agenda for the rest of the term,” he said.

Free market reforms

There is bipartisan support for policies that would lead to a more competitive market environment by removing disparities in treatment for different health care providers, Albanese said. New allowances for physicians practices and ambulatory surgical centers could shift care away from hospital systems as the primary source of health care services, he said.

Specifically, the Medicare trustees have cited savings by allowing joint replacement in outpatient settings, which was made possible by removing restrictions in federal policy, Albanese said.

“These kind of big picture reforms that allow for more competition and choice in the health care sector are going to be important in the long term, and you might just see different emphases based on what the next administration is,” Albanese said. “For example, you might see a Harris administration that really relies more on the FTC (Federal Trade Commission) and antitrust actions, versus a Trump administration that might focus more on these market reforms like price transparency.”

Harris and a single-payer system

Harris’ 2019 “My Plan For Medicare For All” still is easy to find online.

The prospect of implementing a single-payer system in the United States is a complicated subject, Golinkin said.

“First of all, there is no one single-payer system. Different countries have different versions of single-payer that cover different things,” he said. Great Britain’s National Health Service may be the best known. It has a “huge problem” relating to timeliness and amount of care for patients, because it runs out of money, he said.

“This is a subject that, if Vice President Harris brings this up again and advocates for it, that would be a massive transition that has huge implementation risks,” Golinkin said.

Medicare problems

Whoever wins the White House, the next president must address an issue 12 years out. Medicare insolvency is looming, Golinkin said. The 1983 bipartisan reforms led by President Ronald Reagan and House of Representatives Speaker Tip O’Neill bought about 50 years of life for the system, he said. This year’s Medicare Trustees report projected that the Medicare Hospital Insurance (HI) Trust Fund will become insolvent in 2036.

Medicare Part A has been failing financial adequacy tests for 20 years and nothing has been done about it. It’s the background for everything else in health care because health care costs are rising, more people are being covered, and the system is on its way to a form of bankruptcy, Golinkin said. If that happens and Medicare Part A installed an immediate 11% cut to services, it would be “extremely harmful” to all Medicare participants, he said.

Medicare remains a third rail of American politics.

“Nobody wants to say that they’re going to take Medicare away or change Medicare in any way,” Golinkin said. “Yet they accuse the other party of wanting to do that, and they imply that no changes are really necessary, and that Medicare in its current form can continue to exist. And the reality is, there has to be a fix to Medicare, and it probably involves increasing revenue and reducing costs.”

Medicare Advantage

The analysts predicted the next president will be influential in reforming Medicare Advantage (MA).

The program has strong bipartisan support in Congress. “At the same time, there’s also bipartisan openness to regulate things like prior authorization,” Albanese said.

The Biden administration has pursued regulatory policies to adjust the way Medicare Advantage plans are paid, and to regulate things like marketing and prior authorization. A Harris administration could continue those, possibly with tighter regulation for benefit design or prior authorization, Albanese said.

A Trump administration could bring a friendlier stance toward Medicare Advantage, with regulatory flexibilities that existed during his first term, Albanese said. The former president has showed openness to achieving some savings, or trying to reduce overpayment. An example: the MA Risk Adjustment Data Validation (RADV) program, used by the U.S. Centers for Medicare & Medicaid Services to address improper overpayments to Medicare Advantage organizations. That program was finalized during Biden’s term, but it originated in Trump’s first term, Albanese said.

Telemedicine

No matter who wins, supporters of telemedicine hope to have a friend in the White House, said Kyle Zebley, senior vice president for public policy for the American Telemedicine Association (ATA).

As president during the COVID-19 pandemic, Trump enacted the telehealth flexibilities that made it easier for people to gain access to care. Those allowances continued during the term of Biden, Zebley said.

ATA has billed 2024 as the “Road to the Telehealth ‘Super Bowl,’” because the current rules expire at the end of 2026, so those will be in play for the next president, and telemedicine advocates hope the next president will make them permanent. Telehealth has strong bipartisan support in Congress, and the decision of the nation’s chief executive “is still very much paramount,” Zebley said.

“Telehealth, I think it’s safe to say, can live or die based on the preferences of a president, so it’s enormously important,” he said.

As a senator, Harris was ahead of the curve, compared with many policymakers, for supporting telehealth, Zebley said. He added Trump’s allowances to telemedicine received praise from the medical community and he probably won’t back away from that in another term.

“I think that a difference between the two potential administrations that are before us could also be on the regulatory front, and that’s harder to pinpoint exactly what the implications for telehealth will be,” he said.

It appears Harris would want to keep the rulemaking process as predictable as it has been under the Biden administration. Trump has shown a lack of deference to standard processes and may want to shake things up, Zebley said.

“I think it’s safe to say that the regulatory approval process, the rulemaking process, regulations in general, would be, simply put, less predictable under a Trump administration, for good or ill,” Zebley said. “We just don’t know yet, but it will have consequences to telehealth stakeholders.”

Compare and contrast

Health policy analysis organization KFF has developed “Compare the Candidates on Health Care Policy,” a side-by-side comparison of the candidates on a number of health issues. This summer, the American Enterprise Institute hosted a forum, “Health Policy and the 2024 Election,” in person and online. The Commonwealth Fund has this analysis, “What’s at Stake in the 2024 Election for Women’s Health.”