3 Health Care Decisions Awaiting the Next President

Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!

Dan Gorenstein (DG): Hi, it’s Dan. A quick clarification before we start. We say in this episode that the Congressional Budget Office estimates 7-8 million people would lose health coverage if enhanced Obamacare subsidies are allowed to expire after 2025. Seven to eight million people would be expected to drop ACA coverage, but the CBO estimates about half of them would get health care through work. We regret the error.

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DG: We are in the home stretch of the 2024 presidential election and as always, health policy is on the ballot.

Former President Donald Trump: For 52 years, they’ve been trying to get Roe v Wade into the states and through the genius and heart and strength of six Supreme Court justices, we were able to do that.

Vice President Kamala Harris: I pledge to you, when Congress passes a bill to put back in place the protections of Roe v Wade as president of the United States. I will proudly sign it into law.

DG: Today, we’ll dig into three major health policy decisions that Vice President Kamala Harris or former President Donald Trump will have to make, and what their different choices could mean for the country.  From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

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DG: Tradeoffs reporter Ryan Levi has been digging into the candidates’ health policies and talking with experts across the ideological spectrum. He joins us now. Hey, Ryan.

RL: Hey there, Dan.

DG: So this is my, okay, let me see, let me do the math. This is 2024. This is my sixth presidential election as a journalist. God, I am so old.  I did just turn 50, and I didn’t really feel 50 until just now. Thank you, Ryan Levi.

Ryan Levi (RL): Here to help. Here to help.

DG: Yes, indeed. Um, okay, so, um, I do feel like this time I’ve heard much less about health policy than in any of those other campaigns. I mean, there’s been a little bit about abortion, but other than that, not much.

RL: Not much. But as you know, Dan, there are some really important health policy choices that the next president will have to make. So what I want to do today is walk through three big specific decisions that a President Trump or a President Harris will have to make: one on Obamacare, one on prescription drug prices and one on abortion.

DG: Okay, that sounds good. Why don’t we start with Obamacare?

RL: Sure. So, a little primer here to remind folks of some of the most important provisions: It expanded Medicaid to more people. It set up this whole new system for folks to buy health insurance if they couldn’t get it through work. And it put new requirements on insurance companies. The biggest, of course, being that the companies now had to cover people who had pre-existing health conditions.

DG: I mean, that pre-existing health conditions thing, Ryan, that was insane. I remember graduating from high school, graduating from college, and this sort of like, constant hum and buzz of, you better get a job and it better have some real health benefits. Otherwise you will get screwed. And then the Affordable Care Act comes in and it’s like, wait a minute, this is a different day. It’s a different deal.

RL: Absolutely. And having that guarantee that you’re going to get coverage, even if you don’t have it through work, that has really helped sustain the law and protect it against what have been really continual attacks from Republicans and attempts to repeal the law. You know, it got closest in 2017 under then President Trump, as I’m sure you remember, that effort failed by one vote in the Senate.

DG: That’s right. I mean, the big thumbs down moment from Republican Sen. John McCain from Arizona.

Clip: Mr. McCain.
Sen. John McCain: No

RL: And, you know, after all those years of trying to get rid of it, a big repeal is not a part of President Trump’s platform this time around. But that doesn’t mean that there is no ACA talk this election, because the next president will have to decide whether to significantly cut the size of the federal subsidies that people get to help them afford that ACA coverage.

DG: Right. And, Ryan, can you just sort of explain a little bit the mechanics so we’re all following along about how the subsidies work?

RL: Totally, 100%. So one of the key elements of the ACA is that the federal government covers a portion of a lot of people’s health insurance premiums that they pay every month. So under the original law that federal help was only available to folks who made less than 400% of the federal poverty level, about $100,000 for a family of four. Now, during the Biden-Harris administration, Democrats in Congress got rid of that income cap on who could qualify, and they made these subsidies much more generous. Cynthia Cox, a vice president with the nonprofit health research shop KFF, told me that this allowed many more people to afford their health coverage.

Cynthia Cox (CC): We’ve seen that the number of people signing up for ACA marketplace plans has nearly doubled in the last few years. We’ve also seen that premium payments have been reduced almost in half, by 44%.

DG: To be clear, when Cynthia says premium payments have been cut almost in half, she’s saying consumers are paying less because the government is paying more of the premium.

And, Ryan, how many people now have Obamacare?

RL: So at last check there are now 21 million people that have coverage under the ACA, which is an all time high. But these, you know, they call them, you’ll hear them called the enhanced subsidies. They are set to expire at the end of 2025. And if that happens, there still will be subsidies, those original subsidies from the law, but fewer people will get them, and the people that do will get less money.

DG: So if these enhanced subsidies were to go away, what would that mean for people who are relying on Obamacare for coverage?

RL: If these subsidies went away, KFF estimates that people covered by Obamacare would see their monthly premiums double in many states. And the Congressional Budget Office expects 7 or 8 million people would lose health coverage.

DG: 7 or 8 million people. That is a lot of folks. And so what are the candidates’ positions on these enhanced subsidies. I could guess, but I’ll let you do the big reveal here.

RL: You don’t want to steal my thunder, but you were probably gonna guess them right. So, Vice President Harris says she wants to not just extend them, but make these subsidies, these enhanced subsidies permanent. Former President Trump, it’s actually not totally clear. He hasn’t taken a specific position on the subsidies. But we have heard from Republicans in Congress and former Trump advisers who say that these more generous subsidies are bad policy and that they should be allowed to expire.

DG: And what is the downside Republicans see to these enhanced subsidies beyond, of course, additional federal spending?

RL: Yeah. So the spending is definitely one big concern. They are pretty expensive, so about $335 billion over the next 10 years. But the other thing that conservatives will bring up is the potential for fraud. You know, we talked about these subsidies are more generous. So generous to the point that there are some folks, some low-income folks who actually pay no monthly premiums at all for their health insurance. The federal government covers everything. And so conservatives have said that because these subsidies allow for some people to pay no premiums at all, that it creates an incentive for people to lie about their incomes so they can get free health care.

DG: Is there any evidence that that’s happening or if that’s in any way widespread?

RL: So the Paragon Health Institute, which is a conservative think tank, put out a report this summer suggesting as many as 5 million people misstated their incomes to qualify for this free coverage, and that that could cost the federal government up to $26 billion. 

Now, other health policy experts think what’s happening is much less nefarious. So, Cynthia Cox from KFF, she told me it can be really hard, especially for low income folks, to guess how much they’re going to make in any given year. So what might look like fraud on paper in reality be a “best guess” that just turned out wrong.

CC: It might depend on how many tips you get, or how many rides you pick up, or how many shifts you work. So that’s where I think there’s some important nuance to consider. Like, is this really fraud or not?

RL: Cynthia also added that there are provisions in the law to make people pay back part or all of a subsidy they get if it was the incorrect amount based on their actual income.

Federal health officials, Dan, say that they have received 275,000 complaints this year about insurance brokers. So these are the folks who get a commission for every person they enroll in an Obamacare health plan. And we’ve seen that some of them are signing people up for coverage without folks’ consent. Michael Cannon, the director of health policy at the libertarian Cato Institute, blames the subsidies for this.

Michael Cannon: If more enrollees had to pay at least a little something in order to enroll in these plans, that would check a lot of this unscrupulous behavior by brokers.

RL: In response, the federal government says they’ve resolved almost all of those complaints, they’ve suspended 850 brokers, and they’ve proposed new rules to crack down further on these practices.

DG: And before we sort of move on, Ryan, to the next area, if you were going to try to like land the plane for us on how to kind of frame this contrast between Harris and Trump on enhanced subsidies, is it more than Harris supports making these enhanced subsidies permanent, and Trump is, it’s not clear, but there’s a real chance that these enhanced subsidies will sunset?

RL: Yeah. I mean, I think this one is pretty straightforward, Dan. The Democratic candidate wants to continue to support the Affordable Care Act, and the Republican candidate is less interested in that.

DG: When we come back, the big decisions the candidates will face on tackling prescription drug prices and access to abortion.

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DG: Welcome back. I’m here today with Tradeoffs reporter Ryan Levi talking about three big choices the next president — Donald Trump or Kamala Harris — will have to make on health policy.

We just talked about Obamacare subsidies. Ryan, I believe your second bucket is Medicare, right?

RL: Yes. And specifically Medicare drug negotiations, Dan, which I know you know a lot about. We’ve covered that a lot on the podcast. This is the new power that Medicare now has to directly negotiate lower prices for some of the most expensive prescription drugs out there. And this was one of the big wins of the Biden administration. This first year, the administration negotiated the price of 10 high-cost drugs, and they’ll add more in future years. The federal government says that when those lower prices take effect in 2026, they will save patients and the federal government $7.5 billion. But there are Republicans in Congress who want to repeal this new authority.

DG: Real quick, before you go on, what is the idea behind the repeal? What’s the concern of these lawmakers?

RL: So the concern is the same concern we always hear about letting Medicare negotiate these drug prices, is that if you take away or you lower the profits that these drugmakers receive, they could be less motivated to find the next big cure or the next breakthrough treatment for cancer, for ALS, for Alzheimer’s. And so as a result of this, yes, we might get lower prices now, but we’re going to lose out on some big breakthrough treatments and cures down the road.

DG: Because there are fewer financial incentives for drugmakers to do the hard work of finding these cures.

RL: Exactly. That’s the argument. And Stacie Dusetzina who is a professor of health policy at Vanderbilt University Medical Center, she said that these new powers granted to Medicare are still really vulnerable.

Stacie Dusetzina (SD): Once you give Medicare beneficiaries improved benefits, it’s really hard to take those away. But I think that because the negotiated prices won’t go into effect until 2026, no one will miss them.

DG: Right. I remember a lot, Ryan, of people talking about this with the ACA as well, when it was just first rolling out like, hey, we can still repeal something when no one really knows or understands the benefits. So there’s a kind of like window of time before expectations get set and it becomes much more difficult politically to repeal something.

RL: Exactly. So there is, you know, this real concern that a Republican administration with a Republican Congress could repeal this law, that these price negotiations could end before they even begin. Former President Trump has not said exactly how he feels about this repeal effort.

But let’s say, for the sake of argument, that the law sticks around. I talked with health economist Ben Ippolito at the conservative American Enterprise Institute, and he said that the next president will still have decisions to make.

Ben Ippolito (BI): There’s a ton of flexibility afforded to each administration. And so every single election, we’re going to be wondering, well, how is this next person going to use this new authority?

RL: So a new administration, Dan, they can pick how hard of a bargain do they want to drive to try to get those prices down? Vice President Harris, she says that she wants Medicare to negotiate on more drugs sooner, so that they can actually bring these prices down more quickly than even the current law would allow.

DG: And, Ryan, sure, the administration is going to have a lot of influence over what this process looks like. There’s no doubt. But what about Congress?

RL: So to make a change like Vice President Harris is proposing, she would need Congress’ help. But I think it does show that far from the potential for repealing the law, a Harris administration is going to want to make it more robust. If Harris was able to get Congress on her side for this, her campaign predicts federal spending on prescription drugs for Medicare would likely fall from its current $150 billion a year. And Harris says she wants to spend some of that saved money to pay for other policy proposals, like expanding home health care under Medicare. But Ben says the bigger unknown is what we talked about earlier, Dan, the impact this would have on drug development.

Ben Ippolito: You want to make sure that you’re not going too far and discouraging the kind of drugs that you really do like.

RL: As we talked about, Dan, drugmakers argue that if you reduce their profits, this will lead them to invest less in developing new breakthrough medicines. And even Stacie Dusetzina, someone who often pushes back on those kinds of concerns, she thinks there is some value in taking a bit of a wait and see approach right now.

SD: I want to see what does that mean for drug development? What does that mean for access for patients? And so I do think it’s worth being a little bit cautious about how big and broad you go immediately.

DG: That’s a really interesting point here, even people who support this idea of drug price negotiation being somewhat circumspect because at the end of the day, being able to have medicines that turn lethal cancers into chronic conditions is something that everybody wants to see. 

RL: 100%. Now, on the other side of the ballot, if you will, once again, we don’t have a clear sense of Trump’s position on this, what he would bring into these price negotiations if the law stuck around. Ben Ippolito suggested that Trump could try to use them to implement the so-called most favored nation policy that he proposed late in his first term. You probably remember, Dan, that this would have forced drugmakers to sell certain drugs to Medicare at much lower rates that other countries often pay for them. Lawsuits from the drug industry blocked that plan. And interestingly, actually, I was looking in prepping for this. I was going back to President Trump’s website to see his exact positions. And just within the last few weeks, his campaign has taken down all references to this most favored nation policy. And his spokespeople say that he is no longer in favor of it. So it really is unclear what he would do and kind of what philosophy he would bring to these negotiations if he were president.

DG: Okay, Ryan. So we have talked about the enhanced subsidies for the Affordable Care Act. We have talked about Medicare’s historic new power to negotiate drug prices. Now, I believe we are going to tackle the one topic that has gotten some attention: abortion.

RL: Yes. The big decision that the next president will have to face is what to do specifically around medication abortion.

DG: Ryan, before you get too deep into this, can we just define our terms here real quick? Medication abortion. What are we talking about?

RL: Sure. So medication abortions are as opposed to a surgical abortion. And nearly two-thirds of abortions in the United States these days are medication abortions. So people actually take pills, usually a combination of two drugs, mifepristone and misoprostol. And this is how most abortions in the U.S. happen now. I talked to Ederlina Co about this. She’s an associate professor of law at the University of the Pacific, and she said that the next administration will have the power to make some really big decisions about the availability of medication abortion.

Ederlina Co (EC): This will all come through the FDA and whether or not the FDA decides to revisit medication abortion. And so who is running that agency can make a difference.

RL: Ederlina points out, Dan, that the FDA under the Biden-Harris administration allowed doctors to prescribe mifepristone via telehealth instead of making folks go in and see a provider in person. And telehealth abortions now make up 1 in 5 abortions in the U.S. Earlier this year, the administration defended a lawsuit against the FDA by anti-abortion groups who tried to block people’s access to mifepristone, by arguing the FDA’s approval of the drug and expanded access was flawed. As you know, Dan, the Supreme Court unanimously threw out that the case, saying the anti-abortion groups lacked standing. And I think the Biden administration’s actions make it clear that the next president will have a lot of discretion around mifepristone access.

Vice President Harris has made protecting and expanding abortion access a centerpiece of her campaign.

Harris: To make sure that doctors can legally prescribe, that pharmacies can dispense and women can secure safe and effective medication.

RL: And Former President Trump has said that he will not try to restrict access to abortion medication.

Trump: The Supreme Court just approved the abortion pill, and I agree with their decision to have done that, and I will not block it.

RL: But Project 2025, the conservative governing blueprint that was written by many former Trump officials, is very explicit that the FDA should revoke its approval of mifepristone, and Ederlina says that Trump has also seemed open to this idea.

Ederlina Co: I think a lot of people don’t know that we can trust what he’s saying because it’s consistently different.

DG: So Ryan, when it comes to medication abortion — access to mifepristone — what are the stakes from a health perspective for people?

RL: Yeah. So if mifepristone got much harder to access or it became impossible to access, people could still have medication abortions. They would still be able to use that other pill, misoprostol, on its own. But misoprostol is slightly less effective than the two pills combined, and it is more likely to cause medical complications when it’s used on its own. And we’re talking about the human stakes here, Dan, that could be a really big deal, especially for folks in the 13 states that have total bans on abortion. We’ve already seen women die in Georgia because the women and their doctors were afraid of going to jail if they did any abortion-related care. So medication abortion would not disappear if mifepristone went away, but it would likely become harder and more dangerous.

DG: One thing that I really noticed throughout this conversation is you consistently said things like, as it pertained to candidate Trump: muddled, less clear, don’t have a clear sense, unclear. It seems like you’re painting a picture of we don’t really know what to expect from a health policy perspective if Donald Trump is elected president.

RL: I think that’s right. I mean that’s what I heard from the experts I talked to again across the ideological spectrum. It was a lot harder for them to give me a sense of what the impact of a Trump presidency would be on these health policy issues, even these really concrete decisions that we know the next administration is going to face, because it’s so unclear what he would do. On the other side, Vice President Harris, there is a clear understanding of what experts expect and what voters can expect her to do on these key issues. They can expect her to defend and continue to try to grow the Affordable Care Act. They can expect her to defend and continue to try to grow Medicare’s ability to negotiate drug prices, and they can expect her to continue to defend and try to grow abortion rights and abortion access.

DG: Ryan Levi, thank you so much for your reporting on this.

RL: Thank you, Dan. 

DG: You can find more details on the candidates’ health policy records and their proposals on numerous issues on our website tradeoffs.org

I’m Dan Gorenstein. This is Tradeoffs.