Canvassers visit a neighborhood in Crete, Nebraska, in 2023 to raise support for paid sick leave for all employees in the state. The measure was on the ballot in November and was ratified by voters.
Photo by Joshua Lott, courtesy The Washington Post/Getty Images
“We reject the idea that the values, perspectives and guidance we have articulated for many years are wrong and that we should back off — I assure you, that’s not going to happen.”
— Georges Benjamin
With federal leadership now dominated by a single political party that has often been less-than-friendly to public health in recent years, forecasters are bracing for an onslaught of measures that are hostile to prevention, health promotion and equity.
The next four years could bring attempts to overhaul health insurance, civil rights, reproductive freedoms and more amid a restructuring of federal agencies and public health funding cuts, experts fear.
With Republicans controlling the White House and both chambers of Congress, health leaders are readying themselves for actions based on recommendations from the official party platform, previous policies under President Donald Trump and sources such as the Heritage Foundation’s Project 2025 policy document. Overall, the recommendations paint a troubling picture for the U.S. public health system.
One of the most immediate challenges ahead is leadership of federal health agencies, according to APHA Executive Director Georges Benjamin, MD. For example, pending Senate confirmation, Trump’s pick for the U.S. Department of Health and Human Services secretary is Robert F. Kennedy Jr., an environmental law attorney who has falsely linked childhood vaccines to autism, called for a removal of fluoride from drinking water and supported consumption of unpasteurized milk. Many of Trump’s choices for other leading positions also fall short on science-based expertise.
“We’re going to be having major debates over the personnel (Trump) is going to choose to run the various health departments and federal agencies,” Benjamin told The Nation’s Health. “Obviously, his first proposal for HHS secretary is someone that we would and have been vigorously opposing.”
The presidential administration’s choice of leaders would influence the way crucial public health agencies, such as the Centers for Disease Control and Prevention, function. Project 2025 calls for splitting CDC into one agency that focuses on data and another on policy, with a limited ability to make policy recommendations.
Such a move would make it harder for local health departments that rely on CDC funding to do their work, said Adriane Casalotti, MPH, MSW, chief of government and public affairs at the National Association of County and City Health Officials.
“An infectious disease is going to hit the individuals in (a) community a lot harder if they have high rates of chronic disease and other areas that haven’t been attended to,” Casalotti told The Nation’s Health. “It just makes the work more difficult if your overall population is less healthy from the start.”
People with high rates of chronic disease are in need of access to affordable health insurance, which was threatened by the first Trump administration’s attempts to repeal the Affordable Care Act. Public health leaders are concerned a Republican-led Congress may not vote to extend advanced premium tax credits that help Americans afford health insurance under the ACA. If they expire, 4 million Americans may lose their health care, especially in states that did not expand Medicaid under the ACA, according to Families USA Executive Director Anthony Wright.
Aiden Oliver receives an influenza vaccine via nasal spray during a doctor’s visit in Atlanta last year. While vaccination support was strong during the Biden presidential administration, there is concern it may erode under the new leadership.
Photo by Alyssa Pointer, courtesy The Washington Post/Getty Images
“Those who would experience particularly high sticker shock include the many voters who politicians said they care about and represent — rural voters in high-cost areas, older adults and couples that potentially would have to pay 15, 20, 30% of their income on coverage if these tax credits are not extended,” Wright said during a Nov. 14 press event.
Medicaid coverage for is also in the crosshairs, said Rachel Nuzum, MPH, senior vice president for policy at the Commonwealth Fund. Project 2025 calls for implementing work requirements for Medicaid eligibility, a position that has hurt health insurance coverage at the state level. The new administration may also revisit its past policies such as limits on how much money is spent on each Medicaid recipient.
Medicaid provides health coverage for more than 72 million people, including 10 million people with disabilities, and is the nation’s leading payer for childbirth health services.
“It is a really important part of the safety net in our rural areas,” Nuzum told The Nation’s Health. “It’s been taking a lot of steps to address racial and ethnic disparities and inequities. So, changes to that program in how it’s financed as well as who is eligible — and ultimately, how many people are enrolled and really successfully navigating that program — could have a real impact on our coverage numbers nationwide.”
While abortion access has already been dealt serious blows since the Supreme Court overturned Roe v. Wade, public health advocates expect a multipronged attack. Project 2025 recommends ending U.S. Food and Drug Administration approval of abortion-inducing drugs such as mifepristone, banning the ability to receive mifepristone in the mail and requiring states to report abortions.
Another concern is the reinstatement of a domestic gag rule that shuttered Title X funded family planning services, said Amy Friedrich-Karnik, MPP, director of federal policy at the Guttmacher Institute. While President Joe Biden reversed the rule, it took years to restore services that serve millions of people.
“Any attack on one piece of reproductive health care impacts all aspects of reproductive health care,” Friedrich-Karnik told The Nation’s Health. “Even if you think you’re just going after an abortion-related provision in Title X, that has ripple effects on people’s access to contraception, to people’s broader access to reproductive health care. You can’t silo these things out because our lives are not siloed that way and our health care is not siloed that way.”
A gutting of Title X protections would also slow the progress the U.S. has made in reducing rates of sexually transmitted infections such as syphilis and gonorrhea, said Scott Bertani, director of advocacy of the National Coalition for LGBTQ Health. Bertani said the coalition is also concerned about the future of Title IX protections that shield LGBTQ+ people from sex discrimination, as well as a Project 2025 proposal to end access to gender-affirming care for adolescents and an end to CDC data collection on gender identity.
“Congressional dynamics alone is a concern, and I think that will affect the advancement or obstruction of LGBTQ+ health protections,” Bertani told The Nation’s Health. “There’s legal scrutiny on issues like gender identity and marriage equality and potential judicial shifts in the coming administration that can influence actions around this care and workplace discrimination, Title IX and broader LGBTQ+ rights.”
Health successes achieved in states
While concerns remain about what will happen with public health on the federal level, many state-level ballot initiatives during the Nov. 5 election were a step in the right direction for public health.
Lidia Vilorio, a home health aide, gives patient Martina Negron her medicine in Haverstraw, New York in 2021. New restrictions on Medicaid, which pays for home health care for millions, could be ahead under the new presidential administration. Public health leaders are bracing for funding cuts or limits on how much is spent on individual Medicaid beneficiaries.
Photo by Michael M. Santiago, courtesy Getty Images
Voters in Alaska, Missouri and Nebraska approved ballot measures on paid sick leave, joining more than a dozen states and the District of Columbia with similar laws. Additionally, out of 10 states with abortion rights on the ballot, seven — Arizona, Colorado, Maryland, Missouri, Montana, Nevada and New York — voted in favor of widening abortion rights or making abortion a constitutional right.
The successful abortion rights measures show there is a way to combat restrictions, even if it does take time to rebuild a network of abortion access where there have been total bans, said Kimya Forouzan, JD, MPH, principal state policy advisor at the Guttmacher Institute.
“They are really, really incredible feats,” Forouzan told The Nation’s Health. “(Such measures) are an avenue to get rid of these bans and restrictions that we know are so harmful.”
Public health remains nonpartisan, meaning there is hope in moving the needle at the state level, Casalotti said. In Indiana, a state with a long history of supporting Republican presidential candidates, state officials sidestepped politics to fund local health departments and support coalitions that strengthen public health.
“They saw that investing in prevention is really the best approach fiscally and for people’s health and worked together to identify ways to make that work for their state,” Casalotti said.
Many public health organizations said they are undeterred in their quest for better health. APHA’s Benjamin said the organization will continue to work for evidence- and science-based policies and “champion efforts for optimal, equitable health and well-being for all.”
“We reject the idea that the values, perspectives and guidance we have articulated for many years are wrong and that we should back off — I assure you, that’s not going to happen,” he said in a Nov. 13 statement shared with Association members and the public. “We will continue to work on behalf of the American people to improve their health.”
For more information, visit www.apha.org/project2025.
- Copyright The Nation’s Health, American Public Health Association
