The Health Divide: Elections have consequences for health equity

Ed. Note: We normally send out the Health Divide newsletter on Monday, but given this week’s flood of impactful news, we’re sending out this week’s roundup a little early. 

When it comes to the elections’ implications for health and equity, there’s a lot to digest — and much uncertainty over what’s to come. Across the country, voters decided ballot measures that could change the way people access abortion care and health insurance. On top of state measures, a new Trump administration is widely expected to emphasize deregulation, cost-cutting, and potentially big changes to the Affordable Care Act and Medicaid programs. Another big question on the minds of health policy experts and observers: What role will Robert F. Kennedy Jr. assume and what does that mean for public health? In this week’s roundup, we spotlight some of the biggest health and health equity stories of the election. 

Trump presidency will have major implications for health – and health equity 

During Donald Trump’s victory speech, he reiterated his earlier pledge to give vaccine skeptic Robert F. Kennedy Jr. a key role on health in his administration, adding “and he’s going to help make America healthy again.” Such a role for Kennedy could have far-reaching implications for public health, from vaccination campaigns to drinking water fluoridation. “I’m going to let him go wild on health; I’m going to let him go wild on the food; I’m going to let him go wild on medicine,” Trump said shortly before the election. 

“The reverberations will be felt far beyond Washington, D.C., and could include an erosion of the Affordable Care Act’s consumer protections, the imposition of work requirements in Medicaid and funding cuts to the safety net insurance, and challenges to federal agencies that safeguard public health,” writes Stephanie Armour of KFF Health News, in a story on the election’s health care reverberations.  

Trump admin slated to reshape health agenda, agencies  

Trump’s victory portends a “new era for federal health agencies” as well as the industries they oversee, writes STAT’s Washington correspondent Sarah Owermohle. That could range from defunding public health institutions to reshaping federal health programs, all of which would have an impact on how Americans access health. 

The Make America Healthy Again (MAHA) movement championed by Kennedy aims to disrupt what he sees as corrupt connections between the food and pharmaceutical industries and the government agencies that regulate them, explains Politico. Kennedy’s MAHA web site calls out the pharmaceutical industry, food additives and ultra processed foods as drivers of the country’s chronic disease crisis. 

Lawrence Gostin, a professor of global health law at Georgetown University described the potential impact of Kennedy’s influential anti-vaccine and anti-science theories in a Bloomberg article, saying: “And now he’s likely to join at a high level in the White House — that should send shivers down the spine of anyone who thinks that health, safety and the environment are important.” 

ACA and Medicaid could see big changes  

While Trump’s campaign has only offered vague gestures towardreplacing the Affordable Care Act (he mentioned “concepts of a plan”), health policy experts will be closely watching how the new administration handles health insurance protections and costs. That includes potential changes to Medicaid, including the return of work requirements and potential funding cuts by way of block grants. 

“Medicaid will be a big target in a Trump administration,” said Larry Levitt, executive vice president for health policy at KFF. 

Health policy experts will also be monitoring the future of enhanced subsidies for individual insurance plans purchased on the ACA marketplace. Those tax credits, which were put into place in 2021, will expire in 2025, making them a potential target for cost cutting. Without that financial support, the country’s overall uninsured rate could tick up, KFF reports. 

Price transparency, cutting costs on the agenda 

Vice President-elect JD Vance touted the prior Trump administration’s efforts to boost price transparency in health care as an example of how to drive down health costs. During his last term, Trump signed into law a bill banning “gag clauses” among pharmacists, pharmacy benefit managers and insurers, a provision that had kept pharmacists from sharing cheaper options, explains The Hill.  

During his first term in office, Trump also issued two executive orders that aimed to lower prescription drug costs, as the Scientific American recently outlined in an article on health care affordability policies during the election. 

More federal changes to abortion? 

Health and legal experts will be closely monitoring the new administration’s stance on mailing abortion medications. Further restrictions could come via enforcement of the Comstock Act, an 1873 federal law that prohibits abortion-related items being sent via mail. The act was never formally repealed, though the overturning of Roe v. Wade had rendered the old restriction irrelevant. While Trump has said he won’t invoke this old law, many people in his orbit are on record urging him to do so, Vox reported.   

More restrictions could also come via appointing anti-abortion leaders to federal agencies, from the Department of Health and Human Services to the Department of Justice, where they could impact regulations and enforcement.  

Gender-affirming care in the crosshairs 

The Trump presidency could influence gender-affirming care in numerous ways, according to an article published in The 19th. One possible move: Trump could ask Congress to stop federal tax dollars from paying for procedures in Medicare and Medicaid health insurance plans. Other changes could come via an executive order that would stop federal programs from promoting sex and gender transition at any age, as well as penalizing hospitals for offering gender-affirming health care and school districts “if any teacher or school official suggests to a child that they could be trapped in the wrong body.”  

Even so, the president can’t change transgender health policies unilaterally and would likely be immediately challenged in court if he did so, explains KFF Health News. 

Ballot measures alter health landscape nationwide 

Voters throughout the country enacted ballot measures that how people access and pay for health. Here are a few of the ballot measures that could impact health equity: 

Voters support abortion measures 

In seven states, voters further supported abortion access or removed restrictions: Maryland, Missouri, Arizona, Colorado, New York, Montana and Nevada. But measures to enact similar protections failed in Florida, South Dakota, and Nebraska, where voters approved a competing measure to restrict abortion. Despite these outcomes, though, actual access currently remains largely unchanged. That’s because preexisting state abortion laws could stay in place until they face court challenges “a process that could take months or longer,” reports KFF Health News.  

More broadly, the country is still a patchwork of abortion restrictions, reports STAT. But the changes to state constitutions in places that already protected abortion rights, like Maryland and New York, “further shore up the blue states’ positions as safe havens for abortion.” 

South Dakota voters approve Medicaid work requirements 

South Dakotans voted in favor of allowing the state to impose a work requirement for people who receive expanded Medicaid benefits. In 2023, the state expanded Medicaid to low-income adults.  

The first Trump administration supported allowing states to add work requirements to their Medicaid programs. During Trump’s first term, the Centers for Medicare and Medicaid Services (CMS) approved 11 demonstration programs, but most were not implemented because of court and legal challenges. 

Gun tax will support mental health programs 

Colorado voters passed a ballot measure (Prop KK) that imposes a 6.5% tax on firearms and ammunitions. The funds will go in part to support mental health programs. That makes the state the second in the country after California to use an additional gun sales tax to fund social services, as the Colorado Sun explains. The tax is expected to generate about $40 million annually to support mental health programs and support services for crime victims, programs that have faced dwindling federal funding. 

State measure exempts child and adult diapers from taxation 

Nevada voters overwhelmingly passed Question 5, a measure that will exclude both child and adult diapers from the state’s sales tax, cutting the costs of these products for consumers. Reporting by Center for Health Journalism Fellows has explored the impact of diaper costs on struggling families. In the United States, nearly half of families with young children struggle to pay for diapers, according to the National Diaper Bank Network. "Diaper need is a public health crisis,” the Network said.