GOP offers hints on healthcare agenda as RNC kicks off

When Republican National Convention meets in Milwaukee this week to nominate Donald Trump for another term in the White House, the party is not expected to reveal a detailed healthcare platform.

But the former president's record and his allies' ambitions offer significant insight into what health policy might look like under a unified GOP government.

Indeed, the four-day event convention begins less than a week after the House Appropriations Committee advanced a very specific document chock-full of spending details and policy provisions — the Health and Human Services Department budget.

The majority Republican panel seeks major reductions in spending on a plethora of government programs in areas such as HIV/AIDS, substance use disorder and contraception.

While the Republican National Committee's platform is sparse, that House bill is just one indicator of what Trump and a Republican-held Congress could achieve starting in 2025.

The conservative Republican Study Committee, which includes most House Republicans, has laid out its agenda for next year. And the Heritage Foundation's 900-page Project 2025 tome, penned by veterans of the first Trump administration, previews a second Trump administration agenda.

Related: Trump attack on ACA elevates healthcare in 2024 election

President Trump

There is also Trump's own record from four years in the White House.

The contrast between Trump and Democrats including his predecessor Barack Obama and successor Joe Biden is stark. As president, Trump sought to repeal the Affordable Care Act of 2010 and to curtail benefit programs such as Medicaid, for example, while Obama and Biden strove to broaden health coverage.

Trump oversaw a failed effort to repeal "Obamacare" but took a number of steps to weaken ACA programs, such as slashing enrollment counseling budgets, withholding billions of dollars owed to health insurance exchange carriers and enacting a law ending the individual mandate for health coverage.

Trump also permitted broader availability of short-term insurance plans that did not comply with ACA coverage and benefit standards.

On top of that, the Trump White House pitched block grants for Medicaid and weaker guarantees of coverage for people with preexisting conditions, much like the Republican Study Committee and Project 2025 plans.

In addition, Trump touted several policies to reduce prescription drug prices and regularly railed against the pharmaceutical industry, but left office before most of these plans were in place. He also supported greater transparency of healthcare prices.

A second term

Based on the Republican Study Committee and Project 2025 platforms, if Trump wins the presidency and the GOP wins Congress, more of the same may be on the horizon.

Taken together, their policies would dramatically reshape healthcare financing and delivery.

The Republican Study Committee proposed shifting Medicare to a voucher-like system, reducing Medicaid funding via block grants and repealing the recently enacted Medicare drug price negotiation authority, for example.

Project 2025 calls for similar treatment of Medicaid and Medicare, including making Medicare Advantage the default enrollment option over fee-for-service Medicare. Project 2025 also promotes separate individual market insurance risk pools for subsidized and unsubsidized people.

Trump has said little on the campaign trail about healthcare, other than again vowing to repeal the ACA and declaring "Obamacare sucks." But Trump never proposed a "replacement" for the ACA and faces even tougher politics since the law has grown more popular and exchange enrollment has surpassed 20 million.

That makes the ACA an unlikely target in 2025, said Larry Levitt, executive vice president for health policy at KFF. But Trump is not expected to extend the enhanced exchange subsidies Biden enacted as part of COVID-19 relief, which are set to expire at the end of next year, he said.

"The big fight will come over whether to extend the enhanced ACA premium subsidies, which have led to record enrollment, especially in red states that have not expanded Medicaid," Levitt said. "If the enhanced ACA subsidies are not extended, millions will lose coverage, and millions more will be hit with big premium increases."

Trump also probably would restore the his ACA policies from his first term, including widening the availability of short-term, limited-duration health insurance plans, Levitt said.

As president, Trump hesitated to tinker with Medicare. The 2024 RNC platform is the same. But Project 2025 and the Republican Study Committee plan diverge from that, and many GOP lawmakers are eager to take on Medicare.

Medicaid is more vulnerable, Levitt said. "If Republicans are in charge, there will be enormous pressure to cut spending to reduce the deficit and fund tax cuts, so big Medicaid cuts though block grants to states or capped federal funding are likely," he said.

Trump oversaw significant changes to Medicaid, such as the introduction of work requirements, looser regulations on Medicaid managed care carriers, tougher eligibility verifications for Medicaid applicants and limits on budgetary schemes states use to maximize federal Medicaid funding.

On Capitol Hill

Republicans control the House but Democrats hold a narrow majority in the Senate during the current Congress. That could change after Election Day, and GOP lawmakers are laying down a marker for 2025.

The House Appropriations Committee bill on HHS spending offers a preview of the types of high-profile and divisive issues such as abortion, gender identity and climate change the GOP may emphasize.

Only about 10% of the HHS budget is discretionary and subject to congressional action, while Medicare, Medicaid and other benefits are funded with $1.7 trillion in mandatory spending. Yet Republicans made a statement about their intentions with the measure even without touching those major programs.

For instance, the bill contains several anti-abortion provisions, including language that would allow medical professionals to sue federal agencies on claims they were punished for refusing to perform abortions or refer patients to abortion providers.

The bill also would eliminate Title X family planning grants, cancel the Ending the HIV Epidemic Initiative and zero out funding for programs on rape prevention, suicide prevention, opioid overdose surveillance and prevention, tobacco control, climate change research, and firearms injury and mortality research.

The GOP budget would trim HHS spending by 7% to $108 billion. The Centers for Disease Control and Prevention and the Advanced Research Projects Agency for Health would see big cuts. The Agency for Healthcare Research and Quality would get no funding.

Community health centers, the National Institutes of Health and the Substance Abuse and Mental Health Services Administration would not be subject to budget reductions under the House Republican bill.