WASHINGTON — Seven months before the presidential election, Donald Trump’s health care priorities remain fuzzy at best. But one thing is certain: A second Trump administration would put its own stamp on a host of critical issues that are top of mind for voters.
The former president has seesawed on federal abortion bans, the prospect of repealing the Affordable Care Act, and ways to lower drug costs, struggling to hone in on a message that will resonate with voters who have largely backed President Biden’s approach on these issues. Most Americans support federal protections for abortion and more than half view Obamacare favorably. A majority also back government negotiations on drug prices, though many don’t credit Biden with championing that policy.
But while Trump’s messaging on abortion and insurance has shifted in recent months, Medicare negotiating power could work in his favor as he resurrects first-term efforts to reform drug pricing policies. Former officials — many of whom are speaking with the campaign on an informal basis — say Trump would not kill Biden’s signature drug pricing plan, but tailor it his own way.
STAT spoke with six former officials and people close to Trump’s orbit who emphasized his interest in reshaping Medicare’s drug pricing policies and taking on ACA markets, but downplayed a renewed “repeal and replace” threat.
“He is 100% right that the ACA costs more and is delivering less than the authors intended,” said Theo Merkel, a former White House health adviser, now a senior fellow at Paragon Health Institute. “There is an opportunity to say ‘we’re not going to be eliminating the ACA, but we are going to give people…options outside of it.”
Merkel and others cautioned that the Trump campaign is still in early stages of creating his health policy agenda, and he has few confirmed health advisers on his team. Much like during his presidency, Trump often speaks directly to voters and based on his most recent conversations, they said. Most spoke on the condition of anonymity because they did not want to seem out of step with the former president’s evolving messaging.
“Trump himself is usually his best surrogate and mouthpiece,” said one former senior official.
Yet Trump has heard from a cadre of think tankers and first administration veterans, from former White House aides to Health and Human Services officials now placed at Paragon, America First Policy Institute, and the Heritage Foundation, among others.
Several of those informal advisers once touted a plan to base certain American drug prices on much lower prices in a basket of peer countries, a model dubbed the most-favored nations approach. Trump announced the plan in an executive order in the final months of his presidency, only for Biden to revoke it.
“He’s been very attached to MFN for a long time,” said one policy expert and former official. “It’s this intuitive sense that Americans are getting ripped off.”
But resurrecting that approach could run into a roadblock of Republicans’ own making. In the Medicare negotiation plan passed as part of the Inflation Reduction Act, lawmakers barred the program from using a pricing metric, the quality-adjusted life year, that many patients and experts argue is discriminatory, especially to people with disabilities. Many of the countries that could be grouped into a most-favored nations model incorporate QALYs into their pricing talks with drug manufacturers.
However, that does not make it impossible, experts told STAT. Trump could try to implement the model with Medicare Part B drugs, which won’t face price negotiations for two more years and were the original focus of his plan.
While reworking the IRA to a favored nations model is tricky, some experts say it is a far likelier approach than simply repealing the negotiation plan, as the Heritage Foundation’s Roger Severino, a former senior HHS official, suggested earlier this year. Even if Republicans manage to win both the Senate and House in November’s election, majorities are likely to be slim, and the caucus could easily splinter in a fight to repeal a law already popular with voters.
Repeal or refine?
Trump has already run into messaging trouble with his Obamacare comments as Republicans make clear that they do not want to revisit the embarrassingly long repeal fight.
The former president said in November that he is “seriously looking at alternatives” to the Affordable Care Act if he wins a second term. But he has avoided repeating such language amid a storm of Biden campaign messaging about the law’s popularity and record-high ACA market enrollment.
“Donald Trump was just one vote away from repealing the Affordable Care Act,” Biden posted on X in March. “Now, he’s determined to try again, running to ‘terminate’ it — and cut Medicare and Social Security while he’s at it.”
Days later, Trump said in a post on Trust Social, his social media platform, that he is “not running to terminate the ACA” but to make it “MUCH BETTER, STRONGER, AND FAR LESS EXPENSIVE.” He reiterated his reversal in early April, saying in a video post, “We’re going to make the ACA much better than it is right now.”
While Trump has not provided specifics for that plan, former officials and advisers point to his first-term introduction of short-term plans (dubbed “junk plans” by Democrats) and efforts to end premium tax credits that kept insurers in the program. The Biden administration axed short-term plans and infused more subsidies into the marketplace.
Conservative policy experts and Trump surrogates argue that those subsidies — which at this point go to the majority of plan enrollees — are artificially inflating perceptions of the law’s success, helping enrollment surge, while Americans are not getting high-quality or sustainable coverage.
Instead of a full-out repeal fight, people in Trump’s circle like former Louisiana Gov. Bobby Jindal are pushing a “radical incrementalism strategy” of repealing “important portions” of the law while “enacting conservative reforms that make additional reforms more likely.”
Finding the right abortion message
Trump also faces challenges communicating his stance on abortion in a way that appeals to most voters.
While many Republicans believe in abortion limits, voters have repeatedly taken to the ballot box to rebuke states’ restrictive bans and shore up protections. Trump himself has flip-flopped on the issue despite regularly taking credit for the Supreme Court decision that overturned Roe v. Wade. And after seemingly endorsing a federal limit with certain exceptions earlier this year, he instead stressed that abortion rights issues should be left to individual states.
More recently, Trump and Republicans in Arizona have struggled to distance themselves from the abortion ban there, triggered by a state court decision that he declared “went too far.”
His stance on the issue risks inflaming his base.
“He will have pressure internally and externally on [more] socially conservative policies, especially given what he’s said on abortion being left to the states,” said one former senior health official.
That’s not a place Trump wants to be in right now, people involved in conservative policy discussions said. Which could be another reason for him to focus instead on lowering health care costs — an issue where there could be broader public support.
“He’s playing the hits,” said one former official.