Five threats to health care in second Trump term

January 2, 2025

By Jennifer Smith

Health care advocates expect to be “on high alert” during the second Trump administration – watching carefully for any attempts to undermine the Affordable Care Act and Medicaid funding.

“I think we're certainly in for an interesting ride,” said Amy Rosenthal, executive director of Health Care for All, on The Codcast. 

Despite the heightened rhetoric around health care during the 2024 campaign, “it is important to remember that there's a big difference between campaigning and then actually governing,” she told hosts John McDonough of the T.H. Chan School of Public Health and Paul Hattis of the Lown Institute. “I think we saw that the first time around in the Trump administration, and I anticipate to some extent we'll see that again. We're already seeing some of the nominees kind of walk back statements that they've already made. However, that does not mean that we should be letting our guard down.”

Before taking the helm at Health Care for All, which advocates for health justice in Massachusetts, Rosenthal worked for over a decade at the Boston-based national health care advocacy group Community Catalyst. Particularly significant portions of her federal work, she said, involved the reauthorization of the children's health insurance program and passage and implementation of the Affordable Care Act.

Health Care For All is preparing for five potential attacks on health care, Rosenthal said: undermining the ACA, slashing Medicaid, threats to immigrants and their health care coverage, restrictions on reproductive and gender-focused health care, and risks to public health.

Advocacy work during the first Trump presidency seems to have shifted the narrative from merely repealing the Affordable Care Act to needing a replacement, she said.

Though Donald Trump said he had "concepts of a plan" to replace the ACA during the September debate, Rosenthal noted “we still have never seen this great proposed replacement plan …  and so while I don't think I'm as worried about a full on repeal of the Affordable Care Act, I think that there's a lot of things that can still be done to undermine the Affordable Care Act, either through changes in regulations, chipping away at it, or not enforcing portions of it.”

McDonough, Hattis, and Rosenthal homed in on the threats to Medicaid, which serves some 80 million low income, elderly, or disabled people in the country and two million in Massachusetts. Medicaid and ACA funding are expected to be targets under a second Trump term with a Republican Congress, designed to offset the costs of Trump’s planned tax cuts.

Potential changes to the Medicaid system could include work requirements for non-disabled and non-elderly adults, changing the financing formula so that states will get less money from the program, or changing it to some kind of a block grant, McDonough said.

“Work requirements, to me, are just another barrier for eligible people to be able to access the coverage that they need,” Rosenthal said. "And in a lot of ways, it actually is a way that the federal government shifts costs onto states, so that they're not paying as much money and states end up having to pay more or make difficult choices. But the reality is when states get fewer dollars, people still get sick and they're still going to show up at hospitals and they're still going to need the care.”

Rosenthal cited recent data from the Kaiser Family Foundation that found most adults on Medicaid are working or have a reason why they're not already working.

Trump’s picks for significant health care oversight roles – notably vaccine skeptics Robert F. Kennedy Jr. and Mehmet Oz for health and human services secretary and leader of the Centers for Medicare and Medicaid Service, respectively – are concerning to Rosenthal.

“I think a lot about policies like fluoride in the water and some of the greatest public health victories in our lifetime,” she said. “And the idea of rolling back some of these advancements is, to be honest, somewhat mind boggling to me.” 

Rosenthal also said the potential contrast between the current expertise and the nominees is striking. Current CMS administrator Chiquita Brooks-LaSure is “just a brilliant thinker” and helped formulate health care affordability provisions that Rosenthal has been advocating for in Massachusetts, she added. Many of the Trump nominees have no practical experience managing large government health care operations, she noted, and their confirmation by the Senate is not a foregone conclusion.

Beyond that, “this is one of those areas where if they say, ‘you don't need to mandate vaccinations for public school children,’ I'm going to be very thankful that I live here in Massachusetts,” she said, “because I feel confident that our leadership here will continue to ensure that kids are getting vaccinated for polio and whooping cough and everything else in between.”

For more with Amy Rosenthal – on the discourse around vaccines, the local health care landscape in 2025, and rising prescription drug costs – listen to The Codcast on Apple Podcasts, Spotify, or wherever you listen to podcasts.