Ryan Levi of Tradoffs (be forewarned, an NPR spinoff) has posted about the three major health care issues which we now know will be decided by the U.S. President elected today:

https://tradeoffs.org/2024/10/24/health-policy-decisions-next-president/

3 Health Care Decisions Awaiting the Next President
By Ryan Levi - October 24, 2024

The next U.S. president will have to make consequential choices about the Affordable Care Act, prescription drug prices and abortion. We compare the positions of candidates Kamala Harris and Donald Trump on these major health policy issues.

Scroll down to listen to the full episode, read the transcript and get more information.

Tradeoffs is a nonprofit news organization that reports on health care’s toughest choices. Sign up for our weekly newsletter to get Tradeoffs’ latest stories in your inbox each Thursday morning.

As the 2024 election heads into its final weeks, the direction of American health policy affecting the lives of millions of Americans is at stake.

The next president and Congress will have the power to put their mark on major health care programs like Medicare and Medicaid that combined cover nearly 150 million Americans. They’ll be able to direct resources for how the United States fights the drug overdose crisis and how the country prepares for the next pandemic.

With the exception of abortion, health care concerns have largely taken a back seat to the economy and immigration in the 2024 presidential cycle. Vice President Kamala Harris has dropped her support for Medicare for All, which dominated the Democratic primary in 2020. Former President Donald Trump has backed away from his 2016 pledge to repeal the Affordable Care Act.

A recent survey, however, found that two-thirds of Americans say health care should be receiving more attention in the presidential campaign, and there are several crucial health policy choices the next president is likely to face in their first year:

Should Congress extend the Affordable Care Act’s enhanced subsidies?

As part of the ACA, the federal government covers a portion of the monthly health insurance premiums that many people pay. Under the original law, lawmakers capped that assistance to individuals who made up to 400% of the federal poverty level – today that’s about $125,000 for a family of four.

Democrats in Congress removed the income cap in 2021 and increased the size of the subsidies. Consumers’ portion of their premiums have been nearly cut in half, according to the nonpartisan health research organization KFF. Since the subsidy increase, the number of people signing up for ACA coverage has nearly doubled to more than 21 million people.

The so-called enhanced subsidies are set to expire at the end of 2025. If that happens, KFF estimates monthly premiums for people with subsidized ACA plans would double in many states, and the Congressional Budget Office expects 7 or 8 million people would drop their Obamacare health coverage. (The CBO estimates about half of those people would instead get coverage through work.)

Vice President Harris says she wants to make these subsidies permanent, costing Washington an estimated $335 billion over the next decade. Former President Trump has not stated a position, but many Republicans, including former Trump officials, argue the benefit should expire.

Many Republicans point to a report issued this year by the conservative Paragon Health Institute that found as many as 5 million people misstated their incomes, potentially attempting to defraud the government and qualify for $0-premium health plans. According to Paragon, this activity cost taxpayers up to $26 billion.

Other health policy experts say there’s a less nefarious explanation. Cynthia Cox, a vice president with KFF said it can be very difficult, especially for people in many low-wage jobs, to forecast their annual earnings. What may look shady on paper may in reality be a best guess gone wrong.

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

There are provisions in the law, Cox added, to force people to pay back all or part of their subsidy if their estimate was incorrect.

Michael Cannon, the director of health policy at the libertarian Cato Institute, blames the subsidies for fostering another form of fraud – perpetrated by insurance brokers. Federal health officials have received 275,000 complaints this year about brokers signing people up for Obamacare coverage without their consent. Brokers receive a commission for every person they enroll in coverage, and consumers who don’t have to pay a monthly premium may be less likely to notice a change in their insurance.

“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,” Cannon said.

Federal officials have suspended 850 brokers, proposed new rules to crack down on unscrupulous broker behavior and have resolved nearly all complaints.

What’s the future of Medicare’s drug price negotiations?

The Biden-Harris Administration scored a historic win by giving Medicare the power to directly negotiate the prices of some of the most expensive prescription drugs. Federal health officials say when the first 10 negotiated prices take effect in 2026, patients and Medicare will save $7.5 billion all together.

Some high-ranking Republicans want to repeal that authority, arguing that reducing drugmaker profits will shrink their incentive to develop the next blockbuster treatment. Several pharmaceutical companies have also sued the federal government, claiming that Medicare negotiating powers are unconstitutional.

Trump has not said if he supports the price negotiation law or would move to repeal the measure. Stacie Dusetzina, a professor of health policy at Vanderbilt University Medical Center, views Medicare’s new authority as still vulnerable to repeal.

“Once you give Medicare beneficiaries improved benefits, it’s really hard to take those away,” Dusetzina acknowledged. “But I think that because the negotiated prices won’t go into effect until 2026, no one will miss them [if they are repealed].”

Harris has said on the campaign trail she wants Medicare to “accelerate the speed of negotiations so the prices of more drugs come down faster.” Experts believe that would likely mean either negotiating the price of more drugs, or beginning to bargain earlier in a drug’s lifetime. Either move would require congressional sign-off.

Harris’ campaign says she would invest any additional savings in new policy proposals, like expanding Medicare coverage for home health care. But a recent report from the Congressional Budget Office estimates that additional funds from such an effort would be minimal.

Dusetzina said it’s also unclear whether Harris’ plan would slow the pipeline for new drugs.

“I think it’s worth being a little bit cautious about how big and broad you go immediately,” she said. “I want to see, what does that mean for drug development? What does that mean for access for patients?”

Trump has not explained how his administration would run the negotiations if they remain in place. Health care experts note a Trump administration would have limited ability to undermine the law, because the rules direct Medicare which medications to pick for negotiation, and sets minimum discounts the government must seek.

Will medication abortion remain available?

Nearly two-thirds of abortions in the U.S. are now so-called medication abortions, typically involving a regimen of two pills – mifepristone and misoprostol. In June, the U.S. Supreme Court dismissed an attempt by anti-abortion advocates to strike down the Food and Drug Administration’s long-standing approval of and expanded access to mifepristone. But, depending on the election, new leaders at the FDA could move to restrict (or further expand) access to medication abortion.

Under the Biden-Harris administration, the FDA has allowed doctors to prescribe mifepristone to any patient via telehealth instead of requiring patients to see a provider in-person. Telehealth prescriptions now enable one in five abortions in the U.S., and Harris has made protecting and expanding abortion access a centerpiece of her campaign.

Trump has flip-flopped. On some occasions the former president has said he would not restrict access, and on others that he would be open to federal restrictions. Project 2025, the conservative governing blueprint authored by former Trump officials and other close advisers, calls for the FDA to withdraw its approval of mifepristone.

“I think a lot of people don’t know that we can trust what he’s saying because it’s consistently different,” said Ederlina Co, an associate professor of law at the University of the Pacific.

If a Trump administration did restrict or cut off access to mifepristone, people could still have medication abortions using just the other pill, misoprostol. Misoprostol used alone is safe but slightly less effective than the two-pill combination.

Lots of uncertainty around Trump’s health policy

Harris’ position on these three issues are clear. She supports expanding ACA enhanced subsidies. She backs medication abortion and would like to hit the gas on Medicare drug negotiations.

It’s “a little bit harder to predict” how a Trump administration would tackle these issues, said Ben Ippolito, a health economist at the conservative American Enterprise Institute.

For example, until recently Trump’s clearest position on prescription drug prices was the “most favored nation” policy he proposed late in his first term. It would have forced drugmakers to sell certain drugs to Medicare at rates paid by other countries. Within the last few weeks, Trump’s campaign has removed any reference to that policy from his website.