An extremist agenda for health
Project 2025's architect would severely restrict the government's ability to protect the nation's health. The one exception? Abortion and reproductive health. Then it steps in big time.
This is the second of two articles on the future of health care in a second Trump administration. Part 1 appeared yesterday.
I was struck while reading the Project 2025 blueprint for the next Trump administration by how its non-culture wars proposals amounted to a dream list drawn up by lobbyists for insurance and drug companies and for-profit health care providers.
Its 54-page section on the Health and Human Services Department also calls for turning the employer-based insurance system, which provides health coverage for 153 million Americans, into an individual voucher system funded by employers. So much for keeping what you have.
But the main thrust of the document section penned by Roger Severino of the Heritage Foundation reads like a fever dream from the anti-abortion, anti-contraception, anti-gay and lesbian, anti-transgender and anti-public health religious right. Here’s just a sampling of his plans for the agency. He would:
Rescind the FDA’s approval of medication abortion drugs;
Eliminate all programs that benefit LGBTQ+ people;
Actively promote heterosexual marriage and procreation by using money previously earmarked for preventing child abuse;
Repeal all antidiscrimination policies that refer to gender identify or sexual orientation;
Forbid subsidized private insurance plans from paying for abortions, even in cases of rape, incest or to save the life of the mother;
Ban Planned Parenthood from participating in the Medicaid program for any of its services, not just abortion;
Prohibit any facility that receives Title X funding from distributing condoms;
Allow faith-based grantees that maintain a “biblically based, social-science reinforced definition of marriage and family” to receive government grants; and
Include “fertility awareness-based methods” (FAM) in women’s preventive services mandate under the ACA since they are “highly effective and allow women to make family planning choices.”
The document makes factual misrepresentations throughout. Take the latter claim that FAM, which besides avoiding sex during ovulation includes instruction on how to measure body temperature and cervical mucus, is “highly effective.” Anywhere from 12 to 24% of couples using FAM get pregnant in any given year. Birth control pills, by comparison, are well over 90% effective and condoms, if used routinely, can be as high as 98% effective.
The private sector agenda
But let’s turn first to its sections calling to revise private industry’s role in health care, which have received very little attention in the mainstream media. The Project 2025 agenda calls for legislation or rules that would:
Make Medicare Advantage the default enrollment option for all new enrollees in the program;
End “micromanagement” of MA plans;
Repeal drug price negotiations;
Expand the use of association and short-term health plans, which can discriminate against people with existing medical conditions and don’t have to include the 10 essential benefits required of Obamacare plans;
Restructure 340B subsidies so that safety net hospitals no longer benefit from the program;
Repeal the Biden administration guidance that clarifies when hospitals under the Emergency Medical Treatment and Active Labor Act (EMTALA) must perform abortions if needed to save the life of the mother or protect her health; and
Remove restrictions on the creation of new physician-owned hospitals.
Given the growing role of rural areas as the base of the Republican Party, you’d think the shrinking footprint of rural health care providers would be a major concern for Project 2025’s authors. Yet its three-paragraphs on the subject recommend only that the government reduce the regulatory burden “to unleash private innovation” and “increase telehealth access” and come up with less expensive alternatives to hospitals. What precisely? It doesn’t say.
There is exactly one sentence in the entire 922-page document devoted to the treatment of people addicted to opioids. Indeed, the word “opioid” appears just three times. Fetanyl appears 16 times, but each reference is in the context of calling for crackdowns on immigration, Chinese factories and Mexican cartels. Behavioral health is never mentioned.
Medicaid and social services on the chopping block
Finally, Project 2025 repeats the long-standing Republican position for reducing federal spending on Medicaid, the insurance program that covers the poor and near-poor. It would convert Medicaid to a block grant “to incentivize innovation and the efficient delivery of health care services.” This conveniently forgets that Medicaid is already the cheapest form of health care delivery since it pays providers less than either Medicare or the private market.
Severino also wants states to use those block grants to issue vouchers to the poor “to secure coverage outside the Medicaid program.” Given that private plans cost more, this would inevitably drive poor families into skinny plans that offer far less coverage with far more out-of-pocket costs.
Severino would also enforce “personal responsibility” by making work requirements a requirement for eligibility. He would make Medicaid beneficiaries pay for the program “at a level that is appropriate to protect the taxpayer” and establish a lifetime cap “to disincentivize permanent dependence.” Again, all this will cost the poor more.
The fate awaiting other HHS agencies
Project 2025 calls for eliminating the Head Start program. “Research has demonstrated that federal Head Start centers have little or no long-term academic value for children,” Severino writes. No research is cited.
My quick search on the subject turned up one recent paper published by the National Bureau of Economic Research that showed “low-income children who participated in Head Start were 2.7 percent more likely to finish high school, 8.5 percent more likely to enroll in college, and 39 percent more likely to finish college.”
The Centers for Disease Control and Prevention, which came under fire from the political right for flip-flopping on its Covid recommendations and encouraging shutdowns during the pandemic, would be dismantled by a second Trump administration. Call Project 2025 the Pandemic Unpreparedness Playbook.
It calls for breaking the agency into two parts: one that collects and publishes data and the second a shrunken division “confined (in its) ability to make policy recommendations.” How confined? “Never again should CDC officials be allowed to say in their official capacity that school children ‘should be’ masked or vaccinated (through a schedule or otherwise) or prohibited from learning in a school building.”
“How much risk mitigation is worth the price of shutting down churches on the holiest day of the Christian calendar and far beyond as happened in 2020?,” the document asks. “What is the proper balance of lives saved versus souls saved? The CDC has no business making such inherently political (and often unconstitutional) assessments and should be required by law to stay in its lane.” Never mind that all CDC recommendations are precisely that – recommendations. It left to states to enact restrictions during public health emergencies.
The playbook’s plans for the National Institutes of Health are focused almost entirely on restricting what subjects can be researched. It would end federal funding for all research using fetal tissue, embryonic stem cells or human or animal chimera. Most of these restrictions were enacted during the first Trump administration for government researchers and remain in place.
Under Project 2025, they would be extended to extramural researchers at universities and elsewhere, who will have to submit scientific justification for why such research is necessary and why only fetal tissue can be used for the experiments. Many researchers consider fetal cell lines crucial to developing new cancer and AIDS drugs.
Severino would also prohibit NIH from funding “junk gender science,” which isn’t identified. But he does plan to fund studies of the “negative effects of puberty blockers, cross-sex hormones and surgeries, and the likelihood of desistence if young people are given counseling that does not include medical or social interventions.”
Project 2025’s main plan for the Food and Drug Administration is to wilfully ignore science when considering the safety and efficacy of drugs that can be used to induce abortion. Mifepristone and misoprostol will have their approval withdrawn since they are “proven to be a danger to women and by definition fatally unsafe for unborn children.” In fact, serious complications occur in only 3 in 1,000 cases. Compare that to the four times higher rate of complications from use of penicillin or ten times higher rate from use of Viagra.
Curbing conflicts of interest makes the cut
The FDA was the one agency, however, where I agreed with some of Project 2025’s proposals. The document calls for Congress prohibiting drug companies from sitting on their right to be the first to develop and sell generics of their own branded products when they lose patent protection. It would make brand manufacturers give generic companies data about branded product for generic development and ban “meritless” petitions by brand manufacturers designed to delay generic competition. It also calls for tightening rules over drug company media advertising.
The most liberal plank in Project 2025’s platform for health care involves reining in conflicts of interest at health-related agencies (a goal I pursued while working at the Center for Science in the Public Interest during the first decade of this century). It calls for lengthening the time before FDA advisers or staff can go to work for drug companies and reducing the royalties government scientists at NIH earn when their inventions are transferred to the private sector (the current limit is $150,000).
Yet it fails to mention restricting the earnings of NIH-funded extramural scientists who launch start-ups with their government-funded inventions. Those earnings often range into the hundreds of millions of dollars. Nor does it mention what is perhaps the biggest conflict of interest at FDA. The agency’s work on approving new drugs and devices is funded by user fees paid by the companies that make those products.
“We must shut and lock the revolving door between government and Big Pharma,” the document declares. Here! Here! Yet where are the agency leaders who served under Trump today? Scott Gottlieb, the former head of the FDA, left government to become a partner at the venture capital firm New Enterprise Associates (NEA). He also serves on the boards of Pfizer and the gene sequencing company Illumina, Inc. Seema Verma, who ran CMS, now runs Oracle Health, which includes Cerner, the nation’s second largest electronic medical health record vendor. Alex Azar, the former head of HHS and previously a vice president at Eli Lilly, left to advise Foresite Capital, a health care investment firm.
To be fair, Democratic appointees haven’t behaved differently. Marilyn Tavenner, who headed CMS under President Obama, left to run AHIP, the trade group for private health insurers. Andy Slavitt, a former Goldman Sachs executive before running CMS, formed his own health care investment firm.
Most of the political coverage of the presidential race dismisses policy proposals like Project 2025 by repeating Trump’s claim on Truth Social (his social messaging platform) that he knew "nothing about it" and disagrees with some of its proposals, which he described as "ridiculous and abysmal." Yet, as I wrote yesterday in leading off these articles, personnel is policy. Roger Severino, the sole author of the document’s section on HHS, must be considered a leading contender for a top role in a second Trump administration.
I recommend you take the time to read the RNC platform and the Heritage Foundation’s Project 2025 section on HHS. Should Severino become the next Secretary of HHS, don’t say you weren’t warned.
Would it be better if RFK, Jr became head of HHS? (Being facetious).