Second Trump presidency raises big questions for health care

Donald J. Trump’s second presidency may significantly alter health care and public health in Minnesota, especially if Robert F. Kennedy Jr. gets the opportunity to bring his vaccine skepticism to federal agencies such as the Centers for Disease Control and Prevention.

Trump’s pledge to let Kennedy “go wild” on those agencies drew concerns from former Minnesota Health Commissioner Jan Malcolm, especially as declining vaccinations caused Minnesota to have the second-most measles cases among U.S. states this year. She said Kennedy was a denier of established science, and that his efforts to influence federal health care policies won’t help win back skeptics who lost faith in public health during the COVID-19 pandemic.

“We’ve got to rebuild trust in science and public health, and things that really are meant to protect all of us, and not just some of us,” said Malcolm, who served as commissioner under Minnesota Govs. Tim Walz and Jesse Ventura. “I don’t know how you do that if you can’t agree that there are facts. We can disagree until the moon turns blue about what to do about the facts, but if we don’t even agree there are facts, I don’t know how you solve anything.”

Dr. Scott Jensen, who sees patients in Watertown, Minnesota, and ran unsuccessfully as a Republican for governor in 2022, disagreed, calling Trump the “breath of fresh air we need” and Kennedy the right person to rebuild trust by forcing overdue conversations about the safety of vaccines, food preservatives and other products.

“Sometimes we need to invite the naysayers, we need to invite in the skeptics, and say, ‘Tell us why you are skeptical,’” said Jensen.

The morning after the election, investors reacted positively to a Trump administration taking the reins of the nation’s health care.

The S&P 500 rose 2.5% to close at a record high last Wednesday, and several insurers outperformed it, such as Minnetonka, Minnesota-based UnitedHealth Group, whose stock rose more than 5%. Major medical technology companies with operations in Minnesota lagged, with Abbott Laboratories stock down for the day, and Medtronic and Boston Scientific up slightly.

Morningstar Analyst Debbie Wang said investors are nervous that changes to the Affordable Care Act and Medicaid may happen in Trump’s second term and could reduce the number of people it covers, resulting in patients using fewer medical devices. There’s also uncertainty about whether potential changes in the federal approval process for medical devices could become disruptive for these companies, though changes in regulations may mean fewer barriers to approvals, she said.

But investors view a second Trump administration as good news for insurers who take part in Medicare Advantage, the privatized alternative to the Medicare health insurance program for seniors. The Biden administration has been changing risk adjustment payments within the program in ways that insurers regard as a price cut, which has impacted UnitedHealth Group, the largest Advantage insurer in the nation.

“The switch to Republican leadership could ease those pressures a bit, given the Republicans support these privatized plans for senior citizens,” Julie Utterback, another analyst with Morningstar, wrote Wednesday in a research report. “At the very least, we would expect regulators to stop turning the screws so hard on Medicare Advantage beyond current risk-adjustment initiatives that are projected to be completed in 2026.”

RFK to work in public health?

One of the key areas of concern for state public health officials is Kennedy, who on Wednesday suggested to NBC News that a new administration should wipe out entire divisions of the Food and Drug Administration, such as its nutrition department.

In a post on X last month, Kennedy warned FDA leaders to “pack your bags” because the agency has been influenced by the pharmaceutical industry in its “aggressive suppression of psychedelics, peptides, stem cells, raw milk, hyperbaric therapies, chelating compounds, ivermectin, hydroxychloroquine, vitamins, clean foods, sunshine, exercise, nutraceuticals and anything else that advances human health and can’t be patented by Pharma.”

That list includes two drugs that were extensively studied by University of Minnesota researchers but ultimately determined to be ineffective as treatments for COVID-19. Kennedy also wants to halt the addition of fluoride to drinking water. Jensen said he was in dental training before medical school, and that there is solid science supporting its use to reduce tooth decay. However, he said he welcomed the conversation over its use.

The danger with Kennedy is that he misunderstands the ever-evolving nature of science and cherry-picks data and isolated reports of injuries to support anti-science views, said Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy who also served in Trump’s first administration as an envoy to other nations on influenza preparedness. He likened Kennedy to someone opposed to seat belts based on one case of the restraints trapping a driver in a burning car.

“Horrible situation,” he said, “but we would never say, ‘Stop using seat belts!’ for that reason. And I think that is what we’re seeing with vaccine today.”

Kennedy testified at a Minnesota legislative hearing in 2019 against a bill that would have prevented parents from opting their children out of school-based vaccine mandates based on conscientious objections.

Kristin Heinmets of the Vaccine Safety Council of Minnesota said she is encouraging Kennedy to now ban all school-based vaccine mandates and repeal protections that shield manufacturers from the costs of vaccine-related injuries.

Kennedy served on Trump’s transition team after ending his own bid to run for president in August. According to video obtained by CNN, Kennedy told supporters Trump had “promised” him a role in his administration overseeing matters of public health.

“The key that I think I’m — you know, that President Trump has promised me is — is control of the public health agencies, which are HHS and its sub-agencies, CDC, FDA, NIH and a few others, and then also the USDA, which is — which, you know, is key to making America healthy,” CNN quoted Kennedy as saying in the video.

The HHS is the U.S. Health and Human Services Administration, a sprawling $3 trillion federal bureaucracy that encompasses the Centers for Disease Control and Prevention, the Food and Drug Administration, and the National Institutes of Health, as well as the Centers for Medicare and Medicaid Services (CMS). The U.S. Department of Agriculture is its own federal department.

Trump told a rally crowd in Madison Square Garden on Oct. 27 that he would let Kennedy “go wild on health. I’m going to let him go wild on the food. I’m going to let him go wild on the medicines.” More recently, Trump’s transition team co-chair Howard Lutnicksaid Kennedy is not on track to become HHS secretary but rather is seeking government data that he says will show, for example, that vaccines are not safe.

Changing affordable care

In the early days of the first Trump administration, the phrase “repeal and replace” was a health policy mantra as officials repeatedly tried to terminate the federal Affordable Care Act (ACA).

It will be a different story going forward because the administration now sees Obamacare as “settled law,” said Stephen Parente, a health economist at the University of Minnesota who worked for Trump at HHS and the White House Council of Economic Advisers.

People under 65 who are self-employed or don’t get coverage from their employers buy coverage on the ACA’s health exchange marketplaces, such as MNsure. Parente said he could see Trump pushing for changes to allow lower-premium options that come with higher limits on out-of-pocket spending when people use health care.

Trump likely will change the ACA market so it’s more attractive to health insurers, such as by limiting special enrollment chances and shortening the annual sign-up period for health plans, said Peter Nelson, a senior policy fellow at the Center of the American Experiment in Minnetonka who worked on ACA policy during the first Trump administration.

The new administration also might try altering the structure of ACA tax credits, Nelson said, because subsidies to consumers get bigger as health insurance costs increase. As a result, “insurance companies have very little incentive to keep premiums down because they know the federal government’s going to pay,” he said.

Biden signed into law in 2021 the Inflation Reduction Act, which included enhanced subsidies for people buying ACA health plans. The new Trump administration might let those subsidies expire at the end of 2025, Parente said, to help pay for the extension of tax cuts that passed during his first term.