President Trump’s Record on Health Care

The COVID-19 pandemic, the worst health crisis facing the global community in more than a century, has taken a particular toll on the United States. Although the U.S. only represents 4% of the global population, it accounts for 23% of all COVID-19 cases and 21% of all deaths as of early September and ranks number one among high income countries as measured by cases per capita. The Trump administration has not established a coordinated, national plan to scale-up and implement public health measures to control the spread of coronavirus, instead choosing to have states assume primary responsibility for the COVID-19 response, with the federal government acting as back-up and “supplier of last resort.” The President has downplayed the threat of COVID-19, given conflicting messages and misinformation, and often been at odds with public health officials and scientific evidence. Despite this, the Administration has taken a number of actions to address the pandemic, including declaring federal emergencies to free up resources and flexibilities, signing emergency spending bills passed by Congress, providing emergency use authorization for hundreds of tests and other devices, issuing guidance documents, and announced “Operation Warp Speed”, to produce and deliver coronavirus vaccines. On the global front, the Administration has reduced U.S. engagement in addressing the pandemic, including ended funding for the World Health Organization (WHO) and announcing withdrawal from WHO membership.

• Three federal emergencies have been declared, enabling the authorization of funds and allowing the mobilization of resources and enhanced flexibilities to respond to the pandemic: HHS declared a public health emergency on January 31 (renewed on April 21 and July 23 ) and, on March 13, the President declared national emergencies under the Stafford Act and under the National Emergencies Act .

• President’s initial response to the new outbreak was focused on sealing U.S. borders and preventing entry of the virus, beginning with China on January 31 , 2020. Other actions include: establishing screening and quarantine requirements for all persons arriving in the U.S. within 14 days after having been in mainland China, and suspended entry of those traveling from Canada or Mexico to the U.S. who would otherwise be held in a congregate setting (e.g., those seeking asylum).

• The Coronavirus Preparedness and Response Supplemental Appropriations Act enacted March 6
• The Families First Coronavirus Response Act (Families First) enacted March 18
• The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) enacted March 27
• The Paycheck Protection Program and Health Care Enhancement Act (Paycheck Protection) enacted April 24.

• A White House COVID-19 Task Force was established on January 27 with membership from government public health officials and political appointees. The leadership of the Task Force has shifted overtime and its public-facing and internal activities have diminished .

• The White House issued federal social distancing guidelines on March 16 for a 15-day period, extended through the end of April. Reopening guidelines were issued on April 16.

• The President signed into law emergency relief legislation that was passed by Congress to eliminate cost-sharing for testing and prevention and provide funds that can be used to enhance testing capacity and/or support clinical provision of tests, and require public and private health coverage of COVID-19 diagnostic testing with no cost-sharing.
• States have a new optional Medicaid eligibility pathway to cover COVID-19 testing and testing-related services for uninsured individuals with 100% federal matching funds. As a condition of receiving Medicaid enhanced federal matching funds during the public health emergency, states must cover COVID-19 testing and treatment, including vaccines, specialized equipment, and therapies, without cost-sharing.
• The Trump administration modified a $175 billion grant program for hospitals and other health care entities, making available a portion of funds to reimburse claims for COVID-19 testing and treatment for uninsured patients.
• The FDA has provided emergency use authorization for hundreds of tests and the CDC has developed tests and issued testing guidance.
• The Administration designated a “Testing Czar” to coordinate COVID-19 diagnostic testing across federal public health agencies, state and local authorities, and private sector.
• While there is no national testing or contact tracing plan, the White House has issued a Testing Blueprint and HHS has issued a federal COVID-19 Strategic Testing Plan, as required by Congress. These documents place primary responsibility for testing and contact tracing with the states.
• Despite these efforts, there have been ongoing challenges with COVID-19 testing including shortages of critical testing supplies; significant delays in turn-around times for results; and shifting and sometimes confusing federal guidelines.

• The Administration issued an emergency regulation extending the COBRA election period.
• The Administration declined to reopen ACA enrollment during the emergency period but increased the time available to sign up for marketplace plans following loss of other coverage during the pandemic.
• The Administration has approved Medicaid emergency authorities and provided guidance to help states address the COVID-19 emergency including related to nursing homes, provider support, eligibility, telehealth and community based LTSS.
• Congress passed legislation increasing the federal Medicaid funding match rate by 6.2 percentage points from January 1 through the end of the quarter in which the public health emergency ends.
• Congress passed legislation that includes several measures to address mental health and substance use disorder need (See more in Mental Health and Substance Use Section).

• The President has pushed schools to re-open in person and suggested emergency funding would be tied to in-person schooling.
• CDC issued school re-opening guidance on July 23, emphasizing the importance of in-person schooling. It has since updated and modified that recommendation.
• The CARES Act includes $13 billion for elementary and secondary schools and the President has called for Congress to pass $105 billion, including $70 billion for K-12 schools.
• The President has put forward eight recommendations to guide schools on reopening safely.

• Families First and the CARES Act provide emergency short-term paid sick leave benefits and longer-term paid family leave through the end of 2020, although at least 69 million workers are not guaranteed access to this benefit due to the law’s exclusions and the Department of Labor’s subsequent guidelines offering additional exemptions.
• Families First and the CARES Act created new unemployment compensation programs for those affected by the pandemic, including a “Federal Pandemic Unemployment Compensation benefit,” which has since expired. By executive order, the President temporarily extended a portion of the federal unemployment supplement in states that could share in the cost.
• The President has activated the Defense Production Act to direct domestic industry to expedite and expand supply of medical countermeasures, which can be used to help frontline health care workers.
• OSHA has issued standards and requirements to prevent occupational exposure to COVID-19.

• The Army Corps of Engineers and National Guard constructed temporary hospitals and medical centers to treat patients with COVID-19, and the Navy’s two hospital ships, the USNS Mercy and USNS Comfort, were deployed.
• The CARES Act and the Paycheck Protection Act together provide $175 billion in grants to health care providers. The administration allocated a portion of the funds to reimburse providers for COVID-19 care provided to uninsured patients.
• The CARES Act accelerated and increased payments to hospitals for the treatment of Medicare inpatients diagnosed with COVID-19 by 20%.
• The Administration temporarily broadened access to telehealth benefits under Medicare during the emergency period.
• The Administration has issued numerous guidance to and recommendations for nursing home and long-term care facilities to address COVID-19 outbreaks, including requiring nursing facilities to report COVID-19 cases and deaths and establishing an independent commission to assess their COVID-19 response. However, significant problems remain. The number of cumulative deaths in long-term care facilities has increased 7-fold from 10,000 deaths in mid-April to more than 70,000 deaths in August.
• CDC collected data from hospitals and maintained a dashboard, activities which have since been shifted to HHS.

• The President has activated the Defense Production Act which has been invoked for ventilators and respirators, to prevent hoarding and price gauging and for testing.
• The Administration launched “Project Airbridge” to procure and transport critical supplies and equipment from overseas to the U.S.; it has since ended.
• The President announced restructuring of the federal Strategic National Stockpile (SNS).
• HHS announced a new partnership between Biomedical Advanced Research and Development Authority (BARDA) and private sector companies, to ensure the supply of critical medicines and pharmaceutical ingredients.

• Two of the four emergency spending bills passed by Congress provide funding for COVID-19 vaccines, therapies and diagnostics. As of September 2, an estimated $10.7 billion had been spent on vaccine research and development.
• In June, the White House announced “Operation Warp Speed,” with the goal of delivering “300 million doses of a safe, effective vaccine for COVID-19 by January 2021.”
• HHS and DoD have announced efforts to advance domestic manufacturing capabilities for vaccines and therapeutics, syringes for future vaccines, and vials that may be used for vaccines and treatments.
• None of these emergency measures addresses vaccine pricing. Administration officials have said they would ensure access to vaccines without imposing price controls.
• The White House decided not to participate in the WHO-led international R&D collaborative that was launched in April.

• Dissolved the National Security Council’s Directorate for Global Health Security and Biodefense.
• Announced it would not participate in the WHO-led global research and development initiative for drugs and vaccines.
• Suspended funding for WHO and announced its intention to withdraw the U.S. from WHO membership.

Affordable Care Act – Private Health Insurance

President Trump’s record on the Affordable Care Act (ACA) marketplaces and private insurance began on his first day in office, when he issued an executive order stating, “It is the policy of my Administration to seek the prompt repeal of the Patient Protection and Affordable Care Act.” Pending such repeal, he ordered executive branch agencies to exercise all authority and discretion available to waive, defer, grant exemptions from or delay implementation of any provision that would impose a fiscal or regulatory burden on any state, individuals, families, health care providers or health insurers. A few days later, the Administration cancelled advertising and outreach activities already scheduled and paid for to promote signups during the final week of Open Enrollment in 2017; enrollment during that week declined compared to the same period in 2016. In addition to supporting Congressional repeal of the ACA and a federal lawsuit to overturn it, the Trump Administration has taken other steps to modify how it operates.

• Congressional repeal/replace measures were debated throughout 2017; one was approved by the House of Representatives; none passed in the Senate.
• The House-passed measure would replace income-related premium subsidies with a more limited, flat tax credit. It also would allow states to waive coverage of essential health benefits, allow insurers to charge higher premiums to people based on their health, and to permit pre-existing condition exclusion periods for people who experience a gap in coverage.
• Congressional Budget Office estimated this would increase the number of uninsured individuals by 23 million by 2026 and reduce the federal deficit by $119 billion over 10 years.
• Later in 2017, the President signed a new tax cut law that reduced the individual mandate penalty to $0.

• In 2018, a group of Republican-led states filed suit in federal court (California v. Texas, formerly Texas v. US.) arguing the entire ACA is invalid.
• The Trump Administration is not defending the ACA and agrees the entire law should be invalidated. However, it has asked the Supreme Court to prohibit it from enforcing only those provisions (unspecified) that are found to harm the individual plaintiffs. Oral argument is scheduled for November 10, 2020, one week after the election.
• The ACA affects nearly everyone in some way; if the entire law were to be invalidated, this would have complex and far-reaching impacts throughout the health care system.

Reduced navigator funding and standards

• Open Enrollment in the federal marketplace was reduced to 45 days in 2017 (previously had been 90 days or longer).
• Mid-year enrollments in federal marketplace were limited as of June 2017. Consumers must now document eligibility for a Special Enrollment Periods (SEP) before they can enroll. The number of SEPs in the federal marketplace fell from 1.6 million during 2015 to 800,000 over two years, 2018-2019.
• Funding for navigators in federal marketplace states was cut from $63 million in 2016 to $10 million in 2019 and outreach was reduced by 90%. The Administration also changed navigator standards including ending the requirement that navigators maintain a physical presence in a state.
• Nearly 5 million consumers tried unsuccessfully to find enrollment assistance during the last open enrollment. Roughly one in four marketplace enrollees who were helped by a broker or who enrolled through a commercial website say they were offered non-ACA compliant plans instead of or in addition to a marketplace plan.

• The Administration ended CSR payments to insurers weeks before Open Enrollment for 2018 coverage began.
• Uncertainty about the future of CSR payments and the repeal/replace effort prompted many insurers to exit the marketplace for 2018, while those remaining increased silver plan premiums by 32% on average. So-called “silver loading” of premiums increased the dollar value of premium tax credits for marketplace participants, which helped to stabilize enrollment in 2018.
• CBO estimated termination of CSR payment to insurers would increase the federal deficit by $194 billion over 10 years.

• Short-term policies have lower premiums than ACA-compliant coverage because they can exclude pre-existing conditions and they don’t cover essential health benefits or meet other ACA standards.
• A Congressional report documented enrollment of more than 3 million people in 2019 under short term policies offered by 9 insurers.

• The federal government suspended oversight of network adequacy standards, relying instead on states or private organizations, and reduced the number of essential community providers marketplace plans must cover.
• The Administration gave insurers flexibility to substitute covered benefits within and between categories of essential health benefits.
• The Administration raised the threshold of annual premium increases that trigger rate review from 10% to 15%.
• The Administration reduced insurer user fees that support healthcare.gov and other implementation activities from 3.5% of premium to 3%.

• In evaluating whether a state ACA waiver would result in at least the same level of health coverage and affordability, the Administration will permit states to count coverage under short-term plans that exclude pre-existing conditions. It also eliminated a requirement to measure coverage access and affordability specifically for individuals with low-income or pre-existing conditions. Through waivers, states could also apply marketplace subsidies to non-ACA compliant plans and make other changes.

• This 2018 regulation changed standards for coverage offered through association health plans (AHPs). Under certain circumstances, the regulation defined the AHP to be a large “employer” under federal law and not required to cover essential health benefits.
• In 2019 a federal court found major provisions of this regulation to be unlawful and “clearly an end-run around the [ACA.]” The Administration is appealing this decision.

• Expand employer ability to offer HRAs that can fund (pre-tax) premiums and out-of-pocket costs associated with individual coverage.
• Also create a new “excepted benefit HRA” option that employees can use to pay (pre-tax) premiums for non-ACA compliant policies such as short-term policies or dread-disease policies.
• A new proposed rule, issued in June 2020 (not yet final), would allow employers to reimburse employees through an HRA for fees for health care sharing ministries and direct primary care arrangements.

• For ACA-related changes pertaining to abortion, contraceptive coverage, non-discrimination policies and other changes pertaining to women’s health, see section below on Sexual and Reproductive Health.

Medicaid

Overall, the Trump Administration has made efforts to reduce federal spending for Medicaid and limit eligibility through proposed legislation and budget proposals, new state demonstration waivers and its support of litigation to overturn the ACA.

• ACA repeal would eliminate:
  • the ACA Medicaid expansion that currently provides coverage for 15.6 million (12.5 million newly eligible under the ACA) with implications for access to care, utilization and state financing
  • requirements for simplified and streamlined eligibility and enrollment processes
  • certain options for states to expand community-based long-term care services.
  • Reduce federal funding for Medicaid over time with large variation in impact across states.
  • Shift Medicaid financing risks to states, providers and enrollees by eliminating guaranteed federal match that could have greater risks for populations and providers that disproportionately rely on Medicaid, like people with disabilities, children with special health care needs and long-term care users and providers.
  • Resulted in coverage loss of over 18,000 Medicaid enrollees in Arkansas from implementation of work and reporting requirements before litigation halted implementation in Arkansas and other states. Currently seeking Supreme Court review.
  • Waivers could:
    • result in broader coverage losses from work and reporting requirements if implemented nationally
    • allow states to deviate from federal minimum standards related to design and oversight for some populations in exchange for capped federal financing.
    • Proposes to relax Medicaid managed care plan network adequacy rules and requirements for beneficiary protections.
    • Proposes to limit states’ ability to use certain financing mechanisms and make supplemental payments.
    • Encouraged state use of periodic eligibility checks to improve program integrity that may have contributed to Medicaid enrollment declines.
    • Approved IMDSUD waivers in 28 states and IMD mental health waivers in 3 states (DC, ID, IN).
    • Signed the SUPPORT Act with new options to use Medicaid to address the opioid crisis (See more in Mental Health and Substance Use Section).
    • Released policyproposals to allow closed formularies in Medicaid (May 2018 and January 2020).
    • Signed into law the Continuing Appropriations Act, 2020, and Health Extenders Act of 2019, which included a provision to change calculation of prices used for Medicaid rebates (September 2019).
    • Released a proposed rule (not yet final) that would make significant changes to the Medicaid Drug Rebate Program.
    • Released guidance on PBM rebates/price concessions and MLR claims calculations for Medicaid MCOs (May 2019) (See more in Reducing Prescription Drug and Other Health Care Costs Section).
    • Implemented legislation to increase the federal match rate by 6.2 percentage points with maintenance of eligibility requirements during the COVID-19 public health emergency.
    • Provided guidance and approved Medicaid state plan amendments and waivers to help address COVID-19 related to nursing homes, provider support, eligibility, telehealth, and community based LTSS(See more in COVID-19 Response Section).

    Medicare

    In his most recent State of the Union address, President Trump said his Administration will “protect” Medicare just as he has vowed to protect Social Security. President Trump signed into law multiple pieces of legislation that had the effect of accelerating the insolvency of the Medicare Hospital Insurance Trust Fund. The Trump Administration has proposed changes to the Medicare program, including reductions in Medicare spending through changes (or proposed changes) to provider payments, and regulatory requirements for providers and Medicare private plans (Medicare Advantage and Part D). The Administration has issued many proposals relating to Medicare prescription drug costs, most of which have not been implemented (See more in Reducing Prescription Drug and Other Health Care Costs Section).

    • ACA repeal would eliminate provisions that closed the Medicare prescription drug “donut hole”; provided free coverage of preventive services; reduced Medicare payments to hospitals and other health care providers and Medicare Advantage plans, which improved the solvency of the Medicare Hospital Insurance Trust Fund; and established the CMS Innovation Center.
    • Signed the Tax Cuts and Jobs Act of 2017, reducing federal income tax rates, which lowered payroll tax revenues, and repealed the ACA individual mandate penalty, which increased Medicare spending, both of which adversely affected the solvency of the Medicare Hospital Insurance Trust Fund.
    • Signed the Bipartisan Budget Act of 2018, repealing the Independent Payment Advisory Board (IPAB) – a change that increased projected Medicare spending and adversely affected the solvency of the Medicare Hospital Insurance Trust Fund.
    • Signed the Further Consolidated Appropriations Act of 2020, repealing the “Cadillac Tax” (the excise tax on employer-sponsored group health insurance premiums above a specified level), which lowered payroll tax revenue and adversely affected the solvency of the Medicare Hospital Insurance Trust Fund.
    • Provided expanded coverage of telehealthduring the COVID-19 public health emergency.
    • Provided additional funds for health care providers ($100 billion in loans and $175 billion in grants).
    • Provided 20% increase in hospital payment rate for COVID-19 admissions during the public health emergency (See more in section on COVID-19 Response).
    • Required nursing facilities to report COVID-19 cases and deaths beginning in May 2020, and established independent commission to assess nursing facility COVID-19 response (See more in section on Long-Term Care).
    • Proposed in FY2021 Budget ~$450 billion in net Medicare spending reductions over 10 years largely through changes in provider payments.
    • Proposed reductions in net Medicare spending in FY2020 Budget and FY2019 Budget (did not propose reductions in Medicare spending in FY2018 Budget).
    • Signed the Bipartisan Budget Act of 2018, which accelerated the phase out of the Part D “donut hole.”
    • Developed Innovation Center model to cap insulin copays for some Medicare Part D beneficiaries (to take effect in 2021).
    • Issued Advanced Notice of Proposed Rulemaking in October 2018 to limit prices under Medicare for certain drugs administered by physicians, based on international reference prices (but did not issue proposed or final rule) and signed executive order in September 2020 to test “most favored nation” drug pricing model for certain high-cost Medicare Part B and Part D drugs; not yet implemented.
    • Issued proposed rule in February 2019 (withdrawn in July 2019) and signed executive order in July 2020 to ban prescription drug rebates in Medicare Part D; not yet implemented.
    • Proposed restructuring Medicare Part D Benefit Design, including cap on out-of-pocket drug spending (FY Budget 2021; not implemented).
    • Finalized site-neutral payment rules to address payment differences between different sites of service, reducing projected Medicare spending.
    • Signed executive order in July 2017 and introduced the “Patients Over Paperwork Initiative” to revise and remove regulations.
    • Signed executive order in October 2017 and introduced the “MyHealthEData Initiative” in March 2018 that allows Medicare beneficiaries to view and download current and past claims and share these healthcare data in a universal digital format.
    • Issued final rule in December 2018 that makes changes to the Medicare Shared Savings Program and requires participating ACOs to ultimately take on risk.
    • Signed executive order in August 2020 on “Improving Rural Health and Telehealth Access” that would test payment models for rural health care (CHART model below) and review telehealth policies that were expanded during the public health emergency.
    • Introduced the Community Health Access and Rural Transformation (CHART) Innovation Center Model in August 2020 to provide funding to rural organizations and provide advanced payments to rural-focused ACOs that join the Medicare Shared Savings Program.
    • Signed executive order in July 2019 on “Advancing American Kidney Health,” and announced Innovation Center models to change kidney care
    • Issued final rule in September 2020 for the End-Stage Renal Disease Treatment Choices (ETC) Model, which will take effect in January 2021.

    Reducing Prescription Drug and Other Health Care Costs

    The Trump Administration has issued many proposals to lower prescription drug prices and spending, although most have not been adopted by the Congress or implemented by the Administration through the regulatory process, and pending proposals are unlikely to be adopted prior to the November election. President Trump signed into law legislation passed by Congress that banned “pharmacy gag” clauses and accelerated the phase out of the Medicare Part D “donut hole” and is moving forward with an Innovation Center model that will lower insulin costs for some Medicare beneficiaries (to take effect in 2021). In addition, the Trump Administration has moved forward on a hospital price transparency initiative that aims to give consumers better information to help lower costs.

    • Signed legislation that prohibits “gag clauses” in pharmacy contracts, meaning pharmacists can tell customers when they can save money on their prescriptions by paying the pharmacy’s lower cash price instead of the price negotiated by their insurance plan.
    • Signed the Bipartisan Budget Act of 2018, which accelerated the phase out of the Medicare Part D “donut hole.”
    • Proposed restructuring the Medicare Part D Benefit Design, including adding a cap on out-of-pocket drug spending (Administration’s FY2021 Budget; not implemented).
    • Developed Innovation Center model to cap insulin copays for some Medicare Part D beneficiaries (to take effect in 2021).
    • Released policy proposals to allow closed formularies in Medicaid. The drug pricing blueprint included a demonstration for five states to negotiate their own formularies. The Healthy Adult Opportunity 1115 demonstration also includes an option for closed formularies for waiver populations (May 2018 and January 2020).
    • Signed into law the Continuing Appropriations Act, 2020, and Health Extenders Act of 2019, which included a provision to eliminate the use of authorized generics in the price used to calculate Medicaid rebates. (September 2019).
    • Released a proposed rule (not yet final) that would make significant changes to the Medicaid Drug Rebate Program, including
      • changing the definition of best price to allow for more commercially negotiated value-based agreements.
      • broadening the definition of line extension drugs for purposes of manufacturer Medicaid rebate obligations.
      • changing policy around manufacturer coupons/copay cards for patients and calculation of rebates (June 2020).
      • Released guidance related to excluding PBM rebates/price concessions from MLR claims calculations for Medicaid MCOs (May 2019).
      • Approved state plan amendments from eight states for supplemental rebate agreements for value-based arrangements with manufacturers.
      • Issued Advanced Notice of Proposed Rulemaking in October 2018 to limit prices under Medicare for certain drugs administered by physicians, based on international reference prices (but did not issue proposed or final rule) and signed executive order in September 2020 to test “most favored nation” drug pricing model for certain high-cost Medicare Part B and Part D drugs; not yet implemented.
      • Issued proposed rule in February 2019 (withdrawn in July 2019) and signed executive order in July 2020 requiring the HHS Secretary to promulgate regulations to ban prescription drug rebates, which is projected to reduce copays for some drugs, but increase total Medicare spending and Part D premiums; not yet implemented.
      • Issued final rule in May 2019 to require drug companies to disclose prices in TV ads to give consumers have more knowledge about their potential drug costs (U.S. District Court struck down proposal in July 2019; U.S. Appeals Court upheld ruling in June 2020).
      • Issued proposed rule and FDA draft guidance in December 2019, signed executive order in July 2020, and issued final rule and FDA guidance in September 2020 to allow importation of prescription drugs, subject to safeguards
      • Signed executive order in July 2020, and issued proposed rule in September 2020 that requires Federally Qualified Health Centers (FQHCs) that participate in the 340B program to make available insulin and injectable epinephrine at 340B price; not yet implemented.
      • Signed legislation requiring Part D plans (both stand-alone drug plans and Medicare Advantage drug plans) to provide up to a 90-day (3 month) supply of covered Part D drugs to enrollees who request it during the COVID-19 public health emergency.
      • Signed legislation requiring COVID-19 vaccine to be covered under Medicare Part B with no cost-sharing.
      • Issued an executive order and final rule that requires hospitals to disclose “standard charges” (negotiated prices) so consumers can shop for lower prices, expected to take effect in 2021 (currently being challenged in federal court)

      Sexual and Reproductive Health

      The Trump Administration has made efforts to reduce access to contraception by issuing regulations that allow employers to opt out of the ACA’s requirement to offer no-cost contraception in its health plans and that exclude family planning clinics that provide or refer for abortion from the Title X family planning program for low-income people. The Administration has also sought to limit access to abortion coverage and care by appointing judges opposed to abortion rights and issuing restrictive rules and regulations.

      • Nearly 200 federal judges have been appointed since Trump took office. Many states have enacted abortion bans and restrictions, hoping these new judges will rule in their favor or that they are on a trajectory to the new conservative majority at the Supreme Court to reconsider the abortion precedents of Roe v. Wade and Planned Parenthood v. Casey.
      • The network of clinics receiving federal family planning funding has been reduced. Twenty-six percent of Title X clinics have left the network, including all Planned Parenthood clinics, which may limit low-income women’saccess to low- or no-cost reproductive health care.
      • Some federal Title X family planning funding has been redirected to faith-based organizations (“crisis pregnancy centers”) that do not provide contraception, including condoms for STI patients, and may only provide counseling on abstinence and natural family planning methods.
      • Workers with health insurance provided by employers with a religious or moral objection to contraception are no longer entitled to that coverage. Female workers and dependents will have to pay for contraception out of pocket.
      • Insurers who offer plans that cover non-Hyde abortion services would have to send enrollees two separate bills, one for the portion of the premium attributable to abortion coverage and another for all other health care coverage. Policyholders would be required to make two separate payments.
      • Issuers in states that do not require private plans to include abortion coverage may choose to no longer cover it due to administrative burden, resulting in reduced access to abortion coverage for people buying or enrolled in a Marketplace plan.
      • It is unclear how these regulations would impact issuers in the 6 states that require most private plans to include coverage for abortion. Litigation brought by these states is pending.
      • Providers may discriminate against patients on the basis of termination of pregnancy.
      • Patients in need of abortion or other health care services that violate a provider’s religious beliefs could be denied, delayed, or discouraged from seeking care, placing them at risk of serious or life-threatening results in emergencies and other circumstances where the individual’s choice of health care provider is limited.
      • Litigation is ongoing.
      • See LGTBQ Health section below for details on anti-discrimination regulatory provisions related to protections for LGBTQ patients.
      • The Trump administration approved a waiver from Texas’s Medicaid program to block Medicaid payments to Planned Parenthood and other providers affiliated with an abortion provider for non-abortion family planning services.
      • Disregarding Medicaid’s ‘free choice of provider’ provision limits low-income people’s access to affordable, comprehensive reproductive health care.
      • Short-term plans allowed by the Administration typically do not cover maternity care, mental health, or prescription drugs, meaning enrollees may have to pay out-of-pocket for these services or forgo them. See ACA section for more details.
      • In 2017, the Trump administration notified TPPP grantees nationwide that their funding would end two years early. In 2018, a district court blocked the administration from cutting the grants.
      • Federal funding supports abstinence-until-marriage programming that has already been demonstrated to be ineffective in preventing teen pregnancy and STIs and potentially harmful.
      • If the ACA is found to be unconstitutional, women could lose access to coverage for no-cost preventive care including mammography screenings, contraception, well woman visits, Pap smears, and other services.
      • Insurance reforms that ban gender rating (charging women more than men for the same coverage) and require plans to include services such as contraception and pregnancy care would be eliminated.
      • Approximately 700 women die each year in U.S. as a result of pregnancy or delivery complications. The Preventing Maternal Deaths Act of 2018 authorized the CDC to increase support for state and tribal maternal mortality review committees to collect, analyze, and report data related to pregnancy-associated deaths.
      • In January 2017, the President reinstated and expanded the Mexico City Policy, now called “Protecting Life in Global Health Assistance.” The policy requires foreign non-governmental organizations to certify that they will not “perform or actively promote abortion as a method of family planning,” even with their own funds, as a condition of receiving most U.S. global health assistance. This marks a significant expansion of the policy from prior Republican administrations.

      Mental Health and Substance Use

      The Trump Administration has taken steps to address the opioid epidemic and high suicide rates among veterans. The Administration also supports overturning the ACA and increased the duration of short-term health plans, steps that would ultimately reduce coverage of mental health and substance use disorder services and limit the scope of mental health parity rules. President Trump also proposed budget reductions to the Substance Abuse and Mental Health Services Administration (SAMHSA) and Medicaid, key funders for substance use disorder services. Most recently, during the COVID-19 pandemic, President Trump signed legislation providing some additional funding to SAMHSA and to support mental health services for isolated veterans.

      • The ACA extended mental health parity requirements to the small group, individual, and Medicaid managed care markets; and required coverage of mental health services as an “essential health benefit” in many private health plans (except large employer plans). Overturning the ACA would reduce coverage for mental health services and substantially limit the scope of mental health parity rules.
      • Insurers can now sell short-term health plans that provide coverage for twelve months, as opposed to three months.
      • Short-term health plans do not have to comply with ACA requirements, typically do not cover mental health services or substance use treatment, and generally exclude people with pre-existing conditions such as serious mental illnesses.
      • Created a commission on opioids in 2017 that released a number of recommendations and proposals. However, very few recommendations were implemented.
      • Released a five-point opioid strategy to address prevention and treatment, access to Naloxone, improve data collection and research.
      • Signed legislation approving additional grant funds to combat the opioid epidemic, including the SUPPORT for Patients and Community Act in 2018. However, President Trump’s proposed 2021 budget decreased overall funding to SAMHSA and Medicaid, key funders for substance use disorder services. The proposed budget for opioid response programs in rural areas under HRSA shows a decrease from 2019 funds.
      • Through the executive order, the PREVENTS task force was created to focus on suicide prevention among veterans.
      • Proposed 2021 budget for the Department of Veterans Affairs allocates roughly 30% more in funding for suicide prevention among veterans than the 2020 enacted budget.
      • Proposed 2021 budget for SAMHSA includes a small increase in funding for specific grant-based suicide prevention programs.
      • The 2021 budget proposal for Health Resources and Services Administration (HRSA) includes an increase in funding (by over 20%) for behavioral health workforce development programs from 2019 to 2020. However, funding would remain flat for 2021.
      • Allocated a $425 million appropriation for use by SAMHSA
      • Created provisions aimed at expanding coverage for, and availability of, telehealth and other remote care for those covered by Medicare, private insurance, and other federally-funded programs
      • Allowed for the Department of Veterans Affairs to arrange expansion of mental health services to isolated veterans via telehealth or other remote care services
      • Extended duration of, and expanded, Certified Community Behavioral Health Clinics, which are currently underway as part of efforts to increase care access and quality at community behavioral health clinics.

      Immigration and Health

      Since taking office, the Trump Administration has taken numerous actions to reshape immigration policy. These efforts have included limiting entry into the country, including restrictions for humanitarian immigrants such as refugees and asylees; enhancing interior enforcement efforts and expanding the scope of individuals targeted for removal; and discouraging legal immigrants from using public programs for which they are eligible, including Medicaid. A number of these actions have particularly significant implications for the health and well-being of immigrant families, including their children, who are primarily U.S.-born citizens.

      • Implemented a zero-tolerance policy in 2018 that resulted in the separation of thousands of children from their parents when they were taken into criminal custody for entering the country without authorization. Family separations were largely halted in June 2018 following an executive order and a preliminary injunction, although some separations are ongoing due to broader criteria for separating children from parents deemed to be unfit or a danger to the child.
      • Implemented Migrant Protection Protocols, under which families with children are sent to Mexico to await their U.S. asylum cases, and other policies that limit avenues to claim asylum in the U.S.
      • Through a 2017 executive order, expanded the scope of individuals targeted for removal, which has contributed to growing fear and uncertainty and negative health and financial effects among immigrant families.
      • Also sought to withhold federal funding from jurisdictions that limit cooperation with federal enforcement agencies (i.e., sanctuary cities); this action has been blocked by the courts.
      • In September 2017, rescinded the DACA program, which had granted permission to certain undocumented youth who came to the U.S. as children to stay in the U.S. and work for temporary renewable periods.
      • On June 18, 2020, the Supreme Court ruled that the termination of DACA violated federal law. However, in July 2020, the administration issued a memorandum to limit the program, including eliminating eligibility for new applicants and reducing the renewal period from two years to one.
      • In August 2019, issued regulatory changes to public charge inadmissibility policies. (In addition, the State Department made parallel changes for individuals seeking visas or adjustment to LPR status from outside the U.S.).
      • Under the changes, the federal government will newly consider potential future use of certain health, nutrition, and housing programs, including non-emergency Medicaid for non-pregnant adults, when determining whether someone is likely to become a public charge and denied entry or LPR status. It also will consider age, income, health insurance coverage, and health status, among other factors. Implementation remains subject to ongoing litigation.
      • The changes to public charge policy will make it more difficult for individuals with lower incomes and health needs to obtain LPR status or immigrate to the U.S. Further, prior to implementation, it was already contributing to decreased enrollment in public programs and decreased use of health care among immigrant families beyond those directly affected by the rule.
      • On October 4, 2019, issued a proclamation suspending entry of immigrants into the United States unless they provide proof of health insurance within 30 days of entry or have financial resources to pay for reasonably foreseeable health insurance costs. Court action has blocked implementation of this requirement.
      • After abandoning efforts to add a question on citizenship status to the 2020 Census, in July 2019, issued an executive order directing every federal agency to share records on citizenship status in connection with the Census data collection. In July 2020, issued a memorandum ordering the exclusion of undocumented immigrants from the Census count. Key questions remain about the legality and feasibility of this action.
      • Continued broad enforcement actions, curtailing of the Census period for follow-up response, and the emphasis on excluding undocumented immigrants from the Census count may result in lower response rates among immigrant households. Lower responses would affect the apportionment of Congressional representation and may also result in resources being shifted away from areas with higher shares of immigrants because the data are used to determine distribution of federal funds to the states.

      Long-term Care

      The Trump Administration has proposed changes to Medicaid financing that would have affected the program’s ability to pay for long-term services and supports. In addition, the Administration supported repeal of the ACA which would eliminate some options for states to expand access to Medicaid home and community-based services. Prior the onset of COVID-19, the Administration proposed changes to relax certain requirements for nursing homes, and subsequently relaxed additional requirements at the onset of the pandemic while imposing new ones to prevent the spread of the virus. Since March, as the number of COVID-19 deaths in long-term care facilities increased substantially, the Trump Administration issued new guidance and waivers, established a new commission to make recommendations, required nursing facilities to report cases, deaths and shortages, distributed tests to facilities and made additional funds available to nursing facilities and assisted living facilities.

      • Caps on Medicaid funding would limit federal funding for long-term care. Medicaid is the primary payer for long-term care, financing over half of these services nationally.
      • ACA repeal would eliminate some state options to expand access to Medicaid home and community-based services.
      • Proposed changes to relax requirement for infection preventionist, psychotropic drug use, grievance process, staffing data retention, and quality assurance and performance improvement program.
      • In March 2020, CMS suspended state inspections of nursing homes, except for those related to infection control and immediate jeopardy. CMS also required facilities to restrict all visitors except for compassionate care circumstances and cancel all communal dining and group activities.
      • In April 2020, CMS issued guidance directing facilities to screen all staff, residents, and visitors for symptoms, ensure staff use PPE “to the extent available,” and designate separate staff and facilities or units for COVID-19 patients. CMS also announced the formation of an independent commission to conduct a comprehensive assessment of facility response to COVID-19.
      • New interim final regulations require nursing homes to report COVID-19 cases and deaths weekly to the CDC, beginning in May 2020. CMS also issued nursing home reopening recommendations and an informational toolkit with best practices for states to mitigate COVID-19 in nursing homes.
      • In June 2020, CMS issued additional guidance to states on COVID-19 survey activities and enhanced enforcement for infection control deficiencies.
      • In late July 2020, CMS began requiring, rather than recommending, that all staff be tested weekly in nursing homes in states with a 5% or greater positivity rate. HHS distributed rapid diagnostic tests to nursing homes in COVID-19 hotspots through a one-time procurement to facilitate on-site testing of residents and staff.
      • In August 2020, CMS issued an interim final rule requiring long-term care facilities to test residents and staff for COVID-19.
      • The Administration also issued an emergency Section 1135 blanket waiver to allow nursing homes to employ nurse aides who do not meet federal training and certification requirements longer than four months to address potential staffing shortages due to COVID-19.
      • HHS announced two targeted distributions of the Provider Relief Fund for skilled nursing facilities: in May 2020, nearly $4.9 billion or skilled nursing facilities and in August, 2020, an additional $2.5 billion was made available for skilled nursing facilities and other qualified nursing homes. In September 2020, HHS announced that assisted living facilities are eligible to apply for funds.

      HIV/AIDS Policy

      President Trump has taken steps to address the domestic HIV epidemic. In 2019, he launched a new effort, the Ending the HIV Epidemic (EHE): A Plan for America, which aims to drive down new HIV infections, especially in hard hit areas, and includes new funding for domestic HIV programs. It has helped to focus new attention and resources on HIV in the United States. At the same time, other actions of the Administration, such as ongoing attempts to overturn the ACA, which has helped to expand insurance coverage for people with HIV, and the removal of protections for LGBTQ people in health care, threaten to undermine the reach of the EHE. On the global front, the President has publicly supported PEPFAR, but called for significant budget cuts to PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria each year.

      • The Administration did not appoint a director of the White House Office of National AIDS Policy, an executive office role that has been filed under both Democratic and Republican administrations since its inception in the early 1990s. HHS leads the EHE.
      • The Ending the HIV Epidemic (EHE): A Plan for America was announced during the 2019 State of the Union address and is a targeted federal approach to address HIV in the U.S., aiming to reduce new HIV infections by 75% in five years and by 90% in ten years by focusing first on the hardest hit areas of the country.
      • The initiative was funded at $270 million in FY20 and the Administration nearly tripled that figure with their FY21 request. It marks the first significant funding increases for CDC HIV prevention and the Ryan White HIV/AIDS Program in over a decade.
      • A cornerstone of the initiative expands access to pre-exposure prophylaxis (PrEP) to prevent HIV acquisition among those at higher risk.
      • STLDs plans are exempt from ACA requirements prohibiting medical underwriting, pre-existing condition exclusions, and other protections and generally will not cover individuals with HIV.
      • Trump Administration removed regulatory health care protections based on gender identity and sexual orientation put in place by Obama Administration (though a recent Supreme Court decision calls these actions into question and pending litigation is challenging this action).
      • Requires service members who have been “non-deployable” for 12 months to be processed for separation from military, allegedly used to discharge members with HIV. A suit challenging these discharges is pending and discharges are currently blocked.
      • The CARES Act, the third major legislative initiative to address COVID-19, included $90 million for the Ryan White HIV/AIDS Program to prevent, prepare for and respond to coronavirus and $65 million for HOPWA to maintain operations and for rental assistance, supportive services, and other necessary actions, in order to prevent, prepare for, and respond to coronavirus.
      • The President has publicly supported PEPFAR and signed bipartisan reauthorization legislation for the program in 2018. However, he has requested significant budget cuts to PEPFAR and the Global Fund each year (which have been rejected by Congress).

      LGBTQ Health

      The Trump Administration has implemented or supported several policies that remove or reduce protections for LGBTQ people in in health care. Many of these actions have occurred against the backdrop of protections for “provider conscience.” In some cases, these policies have been halted or are still being considered by the courts.

      • The Trump Administration issued final regulations regarding Section 1557 of the ACA removing health care protections based on gender identity and, through conforming amendments to ten other regulations, sexual orientation. Without these protections, providers could, for example, potentially refuse to serve individuals who are transgender or who do not conform to traditional sex stereotypes or could deny services to transgender people based on their gender identity. A recent Supreme Court decision and subsequent federal district court ruling calls these actions into question and other litigation is pending.
      • Issued executive order directing federal agencies to expand religious protections, potentially laying groundwork for denying care to LGBTQ individuals, couples, and families.
      • Created the Division of Conscience and Religious Freedom in the OCR at HHS and issued final regulation on “Conscience Rights in Health Care” which aims to protect health care entities from discrimination on the basis of conscience, potentially allowing for discrimination based on LGBTQ status.