Drug costs, abortion, Obamacare: How Trump and Harris could change U.S. health care

Prescription drug costs. Abortion rights. The future of Obamacare. 

The fast-approaching presidential election between Vice President Kamala Harris and former President Donald Trump could lead to a huge range of outcomes for patients on those issues and others in the sprawling U.S. health system.

Both candidates are pledging to make care more affordable in the U.S., an outlier in the developed world due to its higher health-care spending, worse patient outcomes and barriers to access. But the candidates appear to have different approaches to doing so if elected. 

The candidates have not yet released detailed proposals on health policy, which ranks slightly lower than other issues at the top of voters’ minds, such as the economy. But each candidate’s track record provides a glimpse of what drug costs, health care and reproductive rights could look like over the next several years. 

“A Trump administration will try to slash federal health spending to pay for tax cuts and reduce the role of the federal government in health,” Drew Altman, CEO and president of health policy research organization KFF, told CNBC. He said a Harris administration “will build on existing programs, increasing federal spending to make health care more affordable for people.”

It wouldn’t be easy for either administration to make sweeping changes: The U.S. has a complicated and entrenched health-care system of doctors, insurers, drug manufacturers and other middlemen, which costs the nation more than $4 trillion a year. Any overhaul of the U.S. health-care system would also depend on which party controls Congress, and on the policies state lawmakers pass.

Despite spending more on health care than any other high-income country, the U.S. has the lowest life expectancy at birth, the highest rate of people with multiple chronic diseases and the highest maternal and infant death rate among those nations, according to a 2023 report published by The Commonwealth Fund, an independent research group.

Around half of American adults say it is difficult to afford health care, which can drive some patients into debt or lead them to put off necessary care, according to a May poll conducted by KFF. 

Here’s how Harris and Trump differ in their approaches to key health-care issues. 

Both candidates have pledged to lower prescription drug costs in the U.S. as many Americans struggle to afford treatments. The nation’s medication costs are nearly three times higher than those in other countries, according to the nonprofit research firm RAND. 

About 1 in 5 adults say they have not filled a prescription in the last year because of the cost, while roughly 1 in 10 say they have cut pills in half or skipped doses, according to the March KFF survey.

Many of Trump’s efforts to rein in drug prices have either been temporary or not immediately effective, according to some health policy experts. On the campaign trail, the former president has also provided few specifics about his plans for lowering those costs. 

Some of Harris’ proposals are not fully fleshed out, but if elected she can build on the Biden administration’s efforts to save patients more money, experts said. 

Harris plans to expand certain provisions of President Joe Biden’s Inflation Reduction Act, part of which aims to lower health-care costs for seniors enrolled in Medicare. In 2022, she cast the tie-breaking Senate vote to pass the legislation. 

Harris’ campaign says she intends to extend two provisions to all Americans, not just older adults in Medicare: a $35 limit on monthly insulin costs and a $2,000 annual cap on out-of-pocket drug spending. 

She also plans to expand and speed up the pace of Medicare drug price negotiations with manufacturers to cover more expensive drugs. The landmark policy, passed as part of the IRA, has faced fierce opposition from the pharmaceutical industry, as some companies have challenged its constitutionality in court. 

Trump has not indicated what he intends to do about IRA provisions.

Many Republicans have been vocal critics of the drug pricing negotiations, claiming they harm innovation and will lead to fewer cures, according to Dr. Mariana Socal, a health policy professor at the Johns Hopkins Bloomberg School of Public Health. Trump made a similar argument in 2020 when he opposed a separate Democratic bill that would allow Medicare to negotiate drug prices. 

Still, Socal said a Trump administration wouldn’t have much flexibility to dismantle or scale back the law without change from Congress.

Some of Trump’s efforts to lower drug prices during his presidency “didn’t really come into fruition,” Socal added. 

In 2020, he signed an executive order to ensure Medicare didn’t pay more than the lowest price that select other developed countries pay for drugs. But the Biden administration ultimately rescinded that policy following a court order that blocked it. 

The Trump campaign this month said the former president would not try to renew the plan if reelected.

Also in 2020, Trump issued a rule setting up a path to import prescription drugs from Canada, where medication prices are 44% of those in the U.S. But it took years for the measure to gain momentum. The Biden administration only in January approved Florida’s plan to import some prescription treatments from Canada. 

Trump also set a $35-per-month cap on some insulin products for seniors through a temporary program that Medicare prescription drug plans, also known as Part D plans, could choose to join. The program was in effect from 2021 to 2023, and less than half of all Part D plans opted to participate each year, according to KFF. 

But that measure was much more limited than the Biden administration’s insulin price cap, which requires all Part D plans to charge no more than $35 per month for all covered insulin products. It also limits cost-sharing for insulin covered by Medicare Part B plans. 

Both administrations would likely continue to scrutinize pharmacy benefit managers, the drug supply chain middlemen who negotiate rebates with manufacturers on behalf of insurance plans, according to Dr. Stephen Patrick, chair of the health policy and management department at Emory University.

Lawmakers and the Biden administration have recently ramped up pressure on PBMs, accusing them of raking in profits while inflating prescription medication prices and harming U.S. patients and pharmacies. 

Harris in her 2020 presidential primary run supported a version of a “Medicare for All” bill, which would put all Americans in Medicare and effectively eliminate private insurance. Her campaign has since indicated she would not back the program as president.

But Harris has supported the Affordable Care Act, also known as Obamacare, since she was a senator, consistently voting against bills to repeal the plan and reasserting her commitment to strengthen it during the presidential debate on Sept. 10.

The ACA was designed to extend health coverage to millions of uninsured Americans and implement reforms to the insurance market. The law expanded Medicaid eligibility, mandated that Americans purchase or otherwise obtain health insurance, and prohibited insurance companies from denying coverage due to preexisting conditions, among other provisions.

The IRA extended enhanced subsidies that made ACA health plans more affordable for millions of households through 2025 — a provision Harris plans to make permanent if elected, her campaign said. 

Harris may also work with Congress to try to extend Medicaid coverage in the 10 states that haven’t expanded it under the ACA, some experts said. Medicaid provides coverage for 81 million people, or more than 1 in 5 Americans, according to KFF.

The program is the largest source of federal funding to states. It covers low-income patients and families, as well as those with complex and costly needs, such as people with disabilities and individuals experiencing homelessness.

But if Republicans control even one branch of Congress, boosting Medicaid coverage will “be much tougher, if not impossible to do,” KFF’s Altman said.

Democrats face a difficult path to retaining their slim Senate majority, while Republicans are trying to cling to narrow control of the House.

Meanwhile, Trump led multiple failed crusades to repeal the ACA during his first term. In a campaign video in April, Trump said he was not running on terminating the law and would rather make it “much, much better and far less money,” though he has provided no specific plans. Many Republicans have abandoned their promises to repeal the law after it grew more popular in recent years.

During the Sept. 10 debate, Trump reiterated his belief that the ACA was “lousy health care.” But he did not offer a replacement for the law when asked, saying only that he has “concepts of a plan.” 

KFF noted that Trump’s previous replacement proposals would have made the ACA less expensive for the federal government but raise out-of-pocket premiums for patients, lead to more uninsured Americans and increase risks for states. 

A Trump administration would likely have major implications for Medicaid, Altman said.

Notably, Trump has said he would not cut spending for Medicare and Social Security. But that makes Medicaid, which costs the federal government more than $600 billion a year, a target for severe cuts, Altman noted.

He said Trump could make fundamental changes to the program to curtail enrollment, such as lifetime limits on how many years people can get Medicaid coverage. 

Trump could also revisit some of his earlier attempts to reduce spending on Medicaid. As president, he approved eligibility restrictions such as work requirements, and proposed changing the way the federal government gives money to states for Medicaid into a “block grant” program. 

That refers to the government providing states with a fixed amount of money to administer and provide Medicaid services in exchange for more flexibility and less oversight.

The Biden administration withdrew some of those restrictions and encouraged waivers that would expand Medicaid coverage and reduce health disparities, which Harris would likely pursue if elected, experts said.

A Democratic House or Senate would likely block any of Trump’s sweeping changes to Medicaid, according to Altman. 

“My theory is that if the Democrats hold even one house in Congress, all of that will fail,” he said. “There’ll be a big debate, but it will fail. Medicaid is too big.”

Abortion is a pivotal issue that could drive many voters’ decisions in this election. The number of voters in swing states who name abortion as their top election issue has grown since the spring, according to a late August poll by The New York Times and Siena College. 

This is the first presidential election held since the Supreme Court overturned Roe v. Wade, the landmark ruling that established the constitutional right to abortion in the U.S. in 1973.

Abortion access in the U.S. has been in a state of flux in the roughly two years since the court’s decision, which has given conservative governors and legislatures the power to limit the procedure in their states. As of last year, more than 25 million women ages 15 to 44 lived in states where there are more restrictions on abortion than before the court’s ruling in 2022, PBS reported.

The future of abortion rights could look starkly different depending on which candidate holds office, according to Stacey Lee, professor of health law and ethics at the Johns Hopkins Carey Business School. That leaves the reproductive well-being of many women, especially lower-income people and people of color, hanging in the balance.

Harris has long been a staunch advocate of abortion access and has seized the opportunity to highlight what some health policy experts and voters consider the extreme and often inconsistent views of Trump and the broader Republican Party. 

She has blamed Trump, who appointed three members of the Supreme Court’s conservative majority, for the reversal of Roe v. Wade, and urged Congress to pass a national law codifying abortion rights. Democrats have not had enough votes in Congress to pass such protections under Biden.

Last month, Harris also said she supports eliminating the filibuster in the U.S. Senate to restore federal abortion protections as they existed under Roe v. Wade. The filibuster rule requires a 60-vote threshold for most legislation to pass, which makes it difficult for lawmakers to approve bills in a closely divided Senate.

Harris has also “been a firm proponent” of defending the availability of the abortion pill mifepristone, Lee said. Anti-abortion physicians squared off with the Food and Drug Administration in 2023 in an unprecedented legal battle over the agency’s more than two-decade-old approval of the medication. 

In June, the Supreme Court unanimously dismissed the challenge to mifepristone and sided with the Biden administration, meaning the commonly used medication could remain widely available. The administration’s FDA also revised restrictions on medication abortion, allowing certain certified retail pharmacies to dispense the pills. 

Meanwhile, Trump vaguely suggested in August that he would not rule out directing the FDA to revoke access to mifepristone. Just days later, his running mate, Sen. JD Vance, of Ohio, attempted to walk back those remarks. 

Trump’s comments appear to be a shift from his stance in June, when the former president said during a CNN debate that he “will not block” access to mifepristone.

During his time in office, Trump introduced several anti-abortion measures. That includes a “gag rule” that would have made clinics, such as Planned Parenthood, ineligible for federal health funds if they provided abortions or referrals for them. 

Vance this month also said a future Trump administration would defund Planned Parenthood.

But Trump has also waffled over the last few years on abortion policy, appearing to soften his stance on the issue to appeal to more moderate and independent voters.

He takes credit for Roe v. Wade’s demise since he reshaped the court, and his latest stance is that abortion policy should be set by the states. Earlier this year, however, Trump lamented that certain state laws go “too far.”

During a radio interview in March, Trump said he would consider a national ban on abortions around 15 weeks of pregnancy. 

But earlier this month, he said he would not support a federal abortion ban, writing in a post on X he would veto one. He added that he supports exceptions in cases of rape and incest and to save the life of a pregnant woman.

“It is difficult to find consistency within his policies, but that lack of consistency should amplify that perhaps anything is possible in terms of a more restrictive stance to abortion and reproductive rights,” Lee said. 

Meanwhile, both Harris and Trump have recently expressed their support for in vitro fertilization, a type of fertility treatment performed outside of the body in a lab. It accounts for roughly 2% of births in the U.S. but is extremely costly for many low- and middle-income people who need the technology to start families. 

It became a campaign issue after the Alabama Supreme Court ruled in February that frozen embryos created during the IVF process could be considered children, which threatened the availability of those services in the state. 

Trump has called for the government or private insurers to pay for IVF treatment. Harris has said she would defend the right to both IVF and contraception, but has not specified how she would do so.