Health care — and not just reproductive care — was on the ballot, and it lost big

It was perhaps natural that campaign coverage of the presidential candidates’ health care policies began and ended with abortion rights; since June 2022, when the Supreme Court overturned Roe v. Wade, 20 states have banned abortions or enacted draconian restrictions on the procedure.

That landscape could turn even more dire with the reelection of Donald Trump. But many other health care issues were implicitly on the ballot Tuesday. Republicans may well feel empowered to continue their long campaign against the nation’s public health infrastructure, to step up their attacks on science, and to spread the anti-vaccine mantra of Robert F. Kennedy Jr., who has worked his way into Trump’s inner circle. The Biden administration’s progress in making health care more accessible and affordable for all Americans, especially seniors on Medicare, is almost certain to be rolled back. RFK Jr. and other health care quacks, such as Florida Surgeon General Joseph Ladapo, may move into national policy-making. Religion-based policies may move to the fore, shouldering science-based policies aside. The plundering of health care institutions by private equity investors could pick up steam.

If any of these eventualities come to pass, America’s health profile will be in danger of declining, and sharply. The main victims would be women, seniors and low-income households. Let’s examine the particulars. Some of these derive from the Heritage Foundation’s notorious Project 2025, a road map to a reactionary future that is sure to animate many Trump administration policies. But others reflect policy efforts already tried in red states or promoted during Trump’s first term.

ABORTION: Protections for abortion rights were on the ballot in 10 states, and passed in seven — not including Florida, where a measure rolling back the state’s draconian abortion ban garnered 57% of the vote but fell short of the 60% required to pass. (That threshold was enacted in 2006 after it was placed on the ballot by a Republican-controlled legislature; as it happens, the 60% rule passed even though it did not itself garner 60% of the vote.)

In only two other states is a supermajority required to pass a ballot measure: Colorado (55% required) and New Hampshire (two-thirds, or 66.7%).

The seven states in which voters protected abortion rights by enshrining them in the state constitution were Arizona, Colorado, Maryland, Missouri, Montana, New York and Nevada. Measures failed in South Dakota and Nebraska.

Republican and conservative hostility to abortion rights has persisted despite the ghastly deaths of pregnant women because doctors were unwilling to terminate their pregnancies because the treatment would break the law in their states, even in an emergency, and expose the doctors to consequences including criminal prosecution.

Trump has specifically said he would not support a national abortion ban “under any circumstances,” but that leaves open a multitude of ways he could achieve that goal by another name, whether by applying an ancient federal law to constrain the shipment of abortion pills, installing reproductive rights opponents at federal health care agencies as he did in his first term, or some other means. Plainly, abortion rights aren’t safe in a Trump presidency.

GENDER:Trump made gender-related medical treatments a target of his campaign, spinning a deranged fantasy about schools subjecting children to gender-changing surgery behind their parents’ backs; Project 2025 disdains what it calls “the new woke gender ideology, which has as a principal tenet ‘gender affirming care’ and ‘sex-change’ surgeries on minors.”

This parallels laws passed in several red states barring any gender-affirming care for minors. In fact, surgery is not part of the standard of care in gender-affirming cases involving children and adolescents. The authors of Project 2025 advocate barring transgender individuals from serving in the military.

AFFORDABLE CARE ACT: The repeal of Obamacare, as it’s familiarly known, has been a prime goal of Republicans since the law’s enactment in 2010. The law was saved from repeal in 2017, during the last Trump administration, by a single “no” vote from the late Sen. John McCain (R-Ariz.).

It’s still a target. House Speaker Mike Johnson (R-La.) vowed last month that there would be “No Obamacare” in another Trump term. The law is popular, however, favored by 62% of Americans according to a KFF opinion poll in May. Trump has repeatedly promised to offer an alternative program, but never has done so.

Project 2025 calls for giving more latitude to bare-bones health plans such as association health plans and short-term health plans. These don’t meet ACA standards because they often exclude essential health care services and can mislead consumers into thinking an illness or treatment is covered — learning the truth only when they try to obtain coverage.

The road map also calls for curtailing the ACA’s contraceptive mandate, which it says “has been the source of years of egregious attacks on many Americans’ religious and moral beliefs.” (Of course, the ACA doesn’t require that anyone actually use a contraceptive, only that they be covered without cost-sharing.)

It calls for removing the “morning-after pill” Ella from the contraceptive mandate. It also calls for turning the clock back on the Food and Drug Administration’s safety approval for the abortion pill mifepristone, which is currently the target of a lawsuit file by antiabortion activists.

MEDICAID and MEDICARE:These crucial federal health care programs — the first serving low-income Americans and the second serving seniors — are in the GOP’s gunsights. Project 2025 claims that they are “the principal drivers of our $31-trillion national debt. … In essence, our deficit problem is a Medicare and Medicaid problem.”

Never mind that the single biggest driver of federal deficits is the tax cut for corporations and the wealthy signed by Trump in 2017, which could add $5.2 trillion to deficits over the next 10 years.

By Project 2025’s reckoning, Medicare and Medicaid together cost $17.8 trillion from 1967 through 2020, a span of 53 years. This year, the two programs enroll more than 140 million Americans, or more than 41% of the population. (Medicare members also pay premiums for some of its parts.)

Although Trump has vowed not to cut Medicare benefits, conservative antagonism toward Medicaid, the state-federal health care program for low-income Americans, has never ebbed. In 2014, under former Speaker Paul Ryan (R-Wisc.), House Republicans proposed converting the program from one that covered a percentage of state spending on health care to enrollees into a block-grant structure, that lacked the flexibility needed to confront disease outbreaks as they occur. Ryan’s plan would have cut Medicaid funding by 26% over a decade.

It failed, but the idea was taken up by Trump in his first term, though it wasn’t enacted. Expect it to be considered again. Project 2025 advocates adding work requirements to Medicaid, an idea that has proved in the past to achieve nothing in terms of reducing joblessness or improving enrollees’ health, but did end up throwing thousands of people out of the program.

Permission that the last Trump administration granted some states to impose work requirements for Medicaid was overturned by a federal judge in 2019; the Biden White House consigned the idea to the dumpster. Project 2025 asserts that the ACA “mandates that states must expand their Medicaid eligibility standards” to include everyone at or below 138% of the federal poverty level. This is a lie. Following a Supreme Court ruling, the ACA leaves it to individual states to cover childless low-income individuals; 10 states, all of which are under the control of GOP governors or legislatures, still haven’t done so. The project also calls for eliminating the 90% government match of the cost of that coverage and reducing it to a “fairer and more rational level,” presumably lower.

How much worse will things have to get before the public wakes up to the consequences? Why in heaven’s name would anyone want to find out?