Trump surrogates indicate how he might reshape U.S. health care policy

WASHINGTON — Seven months before the presidential election, Donald Trump’s health care priorities remain vague at best. But one thing is certain: A second Trump administration would put its own stamp on a host of critical issues that voters hold dear.

The former president has vacillated on federal abortion bans, the prospect of repealing the Affordable Care Act and ways to lower drug costs, struggling to deliver a message that will resonate with voters who support the approach to have largely supported President Biden on these issues. Most Americans support federal abortion protection and more than half view Obamacare favorably. A majority also support the government’s negotiations on drug prices, although many don’t give Biden credit for championing that policy.

But while Trump’s message on abortion and insurance has shifted in recent months, Medicare’s bargaining power could work in his favor if he revives first-term efforts to reform drug pricing policy. Former officials — many of whom speak to the campaign on an informal basis — say Trump would not sidestep Biden’s signature drug pricing plan but would tweak it in his own way.

STAT spoke to six former officials and people close to Trump, who highlighted his interest in reforming Medicare drug pricing policy and capturing the ACA markets, but downplayed a renewed “repeal and replace” threat.

“He is 100% right that the ACA costs more and delivers less than the authors intended,” said Theo Merkel, a former White House health adviser who is now a senior fellow at the Paragon Health Institute. “There’s an opportunity to say, ‘We’re not going to eliminate the ACA, but we’re going to give people…options outside of it.’

Merkel and others warned that the Trump campaign is still in the early stages of creating its health policy agenda, and that he has few confirmed health advisers on his team. As he has during his presidency, Trump often speaks directly to voters and based on his most recent conversations, they said. Most spoke on condition of anonymity because they did not want to appear out of step with the former president’s evolving messaging.

“Trump himself is usually his best surrogate and mouthpiece,” said one former senior official.

Still, Trump has heard from a group of think tankers and veterans of the first administration, from former White House aides to health and human services officials now posted to Paragon, America First Policy Institute and the Heritage Foundation, among others.

Several of these informal consultants once touted a plan to base certain U.S. drug prices on much lower prices in a basket of comparable countries, a model called the most-favoured-nation approach. Trump announced the plan via executive order in the final months of his presidency, but Biden was able to withdraw it.

“He has been very attached to MFN for a long time,” said a policy expert and former official. “It’s this intuitive feeling that Americans are being ripped off.”

But reviving that approach could hit a roadblock of Republicans’ own making. In the Medicare bargaining plan passed as part of the Inflation Reduction Act, lawmakers excluded the program from using a price measure, the quality-adjusted life year, that many patients and experts say is discriminatory, especially against people with disabilities. Many of the countries that could be grouped in a most favored nation model include QALYs in their pricing discussions with drug manufacturers.

However, that does not make it impossible, experts tell STAT. Trump could try to implement the model with Medicare Part B drugs, which are not subject to price negotiations for at least two years and were the original focus of his plan.

While reworking the IRA toward a favored nation model is difficult, some experts say it is a much more likely approach than simply withdrawing the negotiating plan, as the Heritage Foundation’s Roger Severino, a former senior HHS official, said earlier this year suggested. Even if Republicans manage to win both the Senate and House of Representatives in the November elections, the majorities are likely to be slim, and the caucus could easily fall apart in a fight to repeal a law that has already passed. popular with voters.

Withdraw or refine?

Trump has already run into trouble for his messaging on Obamacare, as Republicans make clear they don’t want to relive the embarrassingly long fight against repeal.

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 firestorm of Biden campaign messaging about the law’s popularity and record-high enrollment in the ACA market.

“Donald Trump was one vote away from repealing the Affordable Care Act,” Biden wrote on X in March. “Now he is determined to try again, to ‘end’ it — and cut Medicare and the Social Security while he’s at it.”

Days later, Trump said in a post on Trust Social, his social media platform, that he “does not intend to end the ACA” but to make it “MUCH BETTER, STRONGER AND MUCH LESS EXPENSIVE.” He reiterated his reversal in early April, saying in a video post: “We are going to make the ACA much better than it is today.”

Although Trump has not provided details about that plan, former officials and advisers point to his initial introduction of short-term plans (called “junk plans” by Democrats) and his efforts to end premium tax credits that insurers in the program kept. The Biden administration has scrapped short-term plans and increased subsidies.

Conservative policy experts and Trump surrogates argue that these subsidies — which currently go to the majority of plan participants — artificially inflate perceptions of the law’s success, increasing enrollment while depriving Americans of quality or sustainable coverage.

Instead of an all-out fight against repeal, people in Trump’s inner circle, like former Louisiana Governor Bobby Jindal, are pushing a “radical incrementalist strategy” that involves repealing “key portions” of the law while simultaneously targeting “conservative reforms are implemented that make additional reforms more likely’.

Finding the right abortion message

Trump also faces challenges in communicating his position on abortion in a way that appeals to most voters.

While many Republicans believe in abortion restrictions, voters have repeatedly gone to the polls to rebuke states’ restrictive bans and strengthen protections. Trump himself has moved on from the issue, despite regularly taking credit for the Supreme Court decision that overturned Roe v. Wade. And after seemingly endorsing a federal cap with certain exceptions earlier this year, he instead emphasized 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, following a state court ruling that he said “went too far.”

His position on the issue threatens to inflame his base.

“He will put pressure internally and externally for (more) socially conservative policies, especially given what he has said about leaving abortion to the states,” said a former senior health official.

That’s not where Trump wants to be right now, people involved in conservative policy discussions said. That could be another reason for him to focus instead on lowering health care costs — an issue for which there could be broader public support.

“He plays the hits,” said one former official.