Health Policy: What’s On the Table for the Second Trump Administration?

Coming off the end of a historic election year with major emphasis on the economy, inflation, and border security/immigration, health policy seemingly took the backseat in terms of campaign focus, with limited communication of specific action items regarding topics such as the Affordable Care Act (ACA), Medicaid, and immigration health policy.

Notwithstanding, we will likely see movement in each of these areas later in the first year of President Trump’s second term. Below is a recap of policy discussions surrounding the ACA, Medicaid, and immigration health policy.

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ACA

Discussion regarding administrative action relative to the ACA has focused on changes in enrollment policies. Fraudulent and unauthorized enrollment in the ACA Health Insurance Marketplace (Marketplace) by agents and brokers to enhance commissions is viewed as a key issue by both Republicans and Democrats.[1] The Centers for Medicare and Medicaid Services (CMS) received 183,553 complaints that consumers were enrolled in Federally Facilitated Marketplace (FFM) plans without consent and received 90,863 complaints that consumers had their FFM plan changed without their consent during the period of January 2024 through August 2024. CMS has since suspended 850 agents and brokers from participating in Marketplace enrollment.[2] We can expect to see continued focus and action from the Trump administration to place tighter regulations around enrollment processes to protect against fraud. Additionally, the Trump administration will likely move to provide individual states greater flexibility concerning Marketplace eligibility via work requirements and other verification policies which has broader implications concerning Marketplace enrollment, taxes, and ACA funding.

Additionally, ACA subsidies introduced during the Biden administration through the Inflation Reduction Act leading to increased Marketplace enrollment are scheduled to expire in late 2025. If congressional action is not taken to renew the subsidies, Marketplace enrollment is estimated by the Congressional Budget Office (CBO) to drop from 22.8 million in 2025 to 18.9 million in just one year, reaching as low as 15.4 million in 2030 as premiums will take a sharp increase upon expiration of the subsidies. Alternatively, the CBO estimates the taxpayer cost of permanently extending the subsidies to be $335 billion over ten years.[3] Therefore, the Trump administration may shift focus to reinsurance waivers to address state-specific Marketplace issues as an alternative to increased ACA costs.[4]

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Medicaid

Conversations around changes to Medicaid center around the reinstatement of waivers which allow states to implement Medicaid enrollment requirements. Other Medicaid regulations set in place by the Biden administration to be enacted over the next few years could be altered, delayed, or undone, with key focus likely placed on rules that have increased Medicaid eligibility access.[5]

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Immigration Health Policy

Consistent with the Trump administration’s focus on restricting unlawful immigration into the U.S. and its impact on government spending, President Trump’s second term will likely revisit the status of the Deferred Action for Childhood Arrivals (DACA) Program and Public Charge Policy. After the Biden administration introduced regulation to extend Marketplace eligibility to DACA recipients, 19 states filed a lawsuit which ultimately led to the blocked extension of eligibility to DACA  recipients in those states.[6] Despite the focus in his first term to end the DACA program entirely, President Trump has recently stated he will work with Democrats to address and find solutions surrounding the DACA program and Marketplace eligibility.

Federal officials can deny entry to the U.S. or change green card status for persons deemed to be a public charge (i.e., individuals likely to become primarily dependent on government benefits). President Trump introduced regulation in his first term which included the use of Medicaid and the Children’s Health Insurance Program (CHIP) in public charge determinations. The Biden administration reversed these policy changes in 2022 which once again placed Medicaid and CHIP program use as inadmissible in public charge determinations.[7] President Trump has not stated plans to reinstate regulations enacted in his first term, but the issue will likely be considered in initial policy changes.

Despite Republicans gaining control of the House and Senate, health policy changes during President Trump’s second term are expected to be gradual, while maintaining key campaign stances and establishing a policy baseline for the Republican party.

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Reprinted with Permission from Healthcare Administration Leadership & Management Journal, Volume 3, Issue 2, pages 59-60, Copyright © 2025, American Association for Physician Leadership, (800) 562-8088; www.physicianleaders.org.