While his piece focuses specifically on how Project 2025 impacts Medicare, there are two claims about Project 2025 and the Affordable Care Act (ACA, also colloquially known as Obamacare) that we are hearing and reading that need some clarification:
Despite multiple attempts by the Trump Administration to eliminate the ACA and in his 2024 campaign Trump has vowed several times to try again to repeal and replace it, a detailed plan has never been put forth. Recent actions by Republicans in Congress should also be considered an indication of their desire to slash this and other critical parts of our social safety net.
The legislative proposals spelled out in Project 2025 relating to Medicare include:
Lacking support for their legislative agenda, there seems little doubt they are willing to manipulate any available levers of power to achieve their extremist goals. In their attempts to circumvent Congress they could:
Exclusive of any footnotes, what would be your guess for the longest chapter of Project 2025? Department of Education? Certainly these extremists would have a lot to say about a whole department of the federal government they propose to eliminate, right? Department of Homeland Security? How badly did Trump and those around him want to make immigration a major issue in this election? The Department of Justice? The Republicans are the “party of law and order”, right? It is none of those. It is Chapter 14: Department of Health and Human Services. (When you include footnotes, this chapter ties with Chapter 12: Department of Energy and Related Commissions.)
Few would argue with the statement that healthcare in the United States is an extremely complex issue, and while the Department of Health and Human Services (HHS) is a complex department of the federal government that addresses more than just healthcare, we are going continue our exploration of Project 2025 by looking at its possible impacts on healthcare. Previously we have focused on how a particular group of individuals will be affected by the proposals in Project 2025, but since it is an issue that touches all of us we thought a deeper look at the healthcare related proposals in Project 2025 would be helpful.
Because there is so much information in this Department of Health and Human Services (HHS) chapter of Project 2025, it will appear in our next few newsletters. As you can imagine, the authors of Project 2025 have a lot to say about reproductive healthcare. However, since we will be having a special event in September highlighting that specific area of healthcare, we will wait to explore that in a later newsletter. Here we will try to keep our focus to the impacts of the proposals of Project 2025 on other areas of healthcare though, in reality of course, they cannot truly be separated.
There is a statement near the beginning of the chapter where the authors present their goals for reform that seems to be a rather thorough summation of the outcomes they are hoping to achieve:
“The federal government should focus reform on reducing burdens of regulatory compliance, unleashing innovation in health care delivery, ceasing interference in the daily lives of patients and providers, allowing alternative insurance coverage options, and returning control of health care dollars to patients making decisions with their providers about their health care treatments and services.”(p.450, Project 2025) While some of these goals are laudable and others might sound so, the reality is that often the proposals do not actually align with the goals, the past actions of those behind Project 2025 (or those they support or are in other ways connected to them) belie their true desired outcome, or the statements themselves are merely dog whistles - i.e. coded language written for a particular audience.
Here is one relatively straightforward example: That first goal of “reducing burdens of regulatory compliance” - From the past actions by these extremists, it would seem obvious to us this is a dog whistle whose real meaning is removing regulations that protect everyday Americans but also hinder corporations from making massive profits. However, even if we did not have past actions that hint at true intent or we weren’t aware of the “coded language” that is often used, there are several other statements in this chapter that call for the exact opposite of “reducing burdens of regulatory compliance”. Here are some where the proposals call for additional oversight: “must come directly from the government with robust congressional oversight” (p. 452),”Conduct oversight and reform of managed care” (p.467), “the federal government’s role should be oversight” (p. 468), “oversight authority for implementation” (p.493), and “for better oversight and communication”(p. 493). It is also notable that the only other times the word “compliance” appears in this chapter is in the context of enforcing “compliance” with anti-abortion measures and proposing a policy “specifying that it [Office of Civil Rights] will not enforce any prohibition on sexual orientation and gender identity discrimination.” (p. 495) All this to say, while we need to take the dangerous proposals put forth in Project 2025 seriously, we cannot dismiss the ones that sound innocuous and should look at a variety of other sources of information when trying to critically evaluate any part of this document.
The Centers for Medicare & Medicaid Services(CMS) and the Medicare and Medicaid programs feature prominently in this chapter on HHS and will be a major focus of the Project 2025 sections of the next two newsletters.
For clarification, as the two programs are often confused:
Medicare is federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions.
Medicaid is a joint federal and state program that gives health coverage to some people with limited income and resources.
While in this chapter, both the Medicare and Medicaid programs are woven together we are going to try to tease them apart somewhat because the way Republicans (MAGA and otherwise), many conservatives, and others on the right talk about these two programs and, in particular, their related populations is often rather different. To give you a sense of the overall tone here though, Project 2025 characterizes Medicare and Medicaid “as runaway entitlements that stifle medical innovation, encourage fraud, and impede cost containment” (p.463) and that the two programs are largely responsible for our federal deficit specifically saying “In essence, our deficit problem is a Medicare and Medicaid problem.” (p.283, Project 2025)
You probably remember hearing various statements from Trump and others, even those connected with Project 2025, that they will protect Medicare and Social Security. They are often short on details about how they would actually do this, primarily because the math they’re trying to do really just doesn’t add up. The idea of any cuts to benefits for seniors and those with disabilities is extraordinarily unpopular with the American public, but the money to keep these programs solvent has to come from somewhere. (We’ll leave the other possibilities for sources of that money, other than cuts to the programs, for another time). While Project 2025 does not specifically call for cuts, let’s look at what Project 2025 actually says about Medicare.
Within the Project 2025 document the authors often try to assert a distinction between “Regulatory Reforms” and “Legislative Proposals” by the use of these terms as headings in different sections. In reality, this is likely a distinction without a difference. While many of Project 2025’s plans for Medicare and Medicaid would require congressional action and thus would likely be more difficult to achieve, they also encourage a future administration to circumvent legislative changes by working from within the CMS to alter these critical programs however they can. This could be accomplished, in part, with the realization of their plans to replace the non-partisan civil service workforce with partisan loyalists by reissuing the Trump administration’s Schedule F executive order or other such order. (We’ve explored this in previous newsletters, but if you want a refresher, this section of Democracy Forward’s The People’s Guide to Project 2025 is a good resource.) Additionally, with closer reading it becomes obvious the authors have not actually drawn a clear distinction between which changes would be regulatory (i.e. could be made within CMS) and which would be legislative (i.e. would require action in Congress) as they seem to offer proposals of both types in multiple sections.
A number of the policy changes proposed in Project 2025 are presented under the guise of increasing choice, but many push people toward private alternatives that are likely not in the best interest of the beneficiaries, and therefore, one could argue, not really “choices” at all. One such legislative proposal calls for the repeal of the Medicare restrictions on physician-owned and specialty hospitals that were put in place by the Affordable Care Act (ACA). (p. 464, Project 2025) These restrictions were put in place to combat facilities that supposedly admitted primarily healthier patients and only admitted patients on private insurance. There were also concerns about physician self-referral and over referral, where physicians would refer patients only to the hospitals in which they had an economic stake or would refer patients for unnecessary tests, treatment or care. Removing these restrictions could result in increased costs for Medicare and potentially lower quality care for patients, all while likely adding to the profit of these physician-owned facilities.
Another legislative proposal would make “Make Medicare Advantage the default enrollment option.” (p.465, Project 2025). While at this point there is no “default” option, what’s called “Original Medicare” is typically what is presented first. Medicare Advantage plans, the bundled alternative to Original Medicare (which is fragmented into Part A, Part B, and Part D), are offered by private insurers who are paid, via contracts with the federal government, to “manage” patient care. These plans, also known as Part C, allow private insurers to offer their own plans that provide Medicare benefits as well as some additional perks not available in the original Medicare program. The concerns raised by this proposal to make Medicare Advantage the default option include:
Federal audits have found some of the largest plans have submitted inflated bills to Medicare (i.e. these insurance companies are up-charging patient care, which ends up costing the government and taxpayers more than Original Medicare).
The Medicare Payment Advisory Commission, a non-partisan agency of Congress, said in a March 2023 report that it could not conclude Medicare Advantage plans “systematically provide better quality” over regular Medicare.
In 2022 an inquiry led by Senate Democrats investigated complaints about private sector marketing for Medicare Advantage plans. The report “collected information on marketing complaints from 14 states and found evidence that beneficiaries are being inundated with aggressive marketing tactics as well as false and misleading information” raising concerns about fraud and scams among private insurers offering Medicare Advantage plans.
The plans routinely deny coverage for necessary care which, among other consequences, threatens the ability of rural hospitals to keep their doors open. As the popularity of Medicare Advantage plans surge, the number of older Americans in rural communities that rely on them continues to increase. As the denials pile up, these hospitals are forced to eat the increasing costs of care, causing some to close operations and leave residents without access to treatment.
In traditional Medicare, patients can see almost any doctor and few services need prior authorization. Neither is true under Medicare Advantage.
Not only does that not sound like real choice, but there are clear concerns that these proposals would favor private, worse-performing alternatives to Medicare. When I was chatting with one of the attendees of NOVA Blue Squad’s meeting about Project 2025, we were discussing how often “providing more choice” is code for “privatization” and she shared her word for it: “profit-ization”. Sounds about right.
Another key legislative change specifically called for in Project 2025 would repeal the portion of the Inflation Reduction Act (IRA), signed by Biden in 2022, whereby Medicare directly negotiates lower prescription drug prices. (p.465 Project 2025) Many of the drugs targeted for price negotiation are some of the most expensive drugs frequently used by seniors. These price negotiations are expected to save hundreds of thousands of dollars annually for the more than 67 million Americans currently enrolled in Medicare. According to the White House an HHS report showed that “9 million Medicare Part D enrollees took the drugs covered under Part D selected for negotiation and paid a total of $3.4 billion in out-of-pocket costs for these drugs in 2022. For enrollees without additional financial assistance, average annual out-of-pocket costs for these drugs were as high as $6,497 per enrollee in 2022.” These savings would be wiped out with this proposal under Project 2025.
The broader statement under which this proposal appears calls for the repeal of “harmful health policies” enacted “under the Biden Administration such as the Inflation Reduction Act.” (p.465 Project 2025), but the price negotiation program is the only item detailed under the Medicare heading in this section. It is unclear whether the rest of the Medicare drug reforms in the IRA would be repealed as well. These other reforms include:
Requirements for drug companies to pay rebates if their price increases exceed inflation
Caps on out-of-pocket costs for all Medicare Part D plans - beginning in 2024, HHS will effectively cap Part D out-of-pocket costs at $3,250 and in 2025, the cap will drop further to $2,000
Allowing enrollees to spread out their total annual Medicare Part D out-of-pocket costs over the course of the year
Limiting monthly insulin cost sharing to $35
Makes recommended vaccines free to beneficiaries
Extending cost-reduction subsidies to even more low-income seniors by expanding eligibility for the Part D Low-Income Subsidy ProgramAccording to americanprogress.org, about 18.5 million Medicare Part D enrollees could lose “much-needed out-of-pocket savings from [a repeal of] the Inflation Reduction Act’s full package of Medicare Part D redesign elements”
As we have seen in many instances, these extremists are also willing to use the power of our justice system to try to get the results they desire. While attempting to directly repeal the part of the IRA that allows for drug price negotiations, they could also “advise the Department of Justice (DOJ) to stop defending Medicare’s ability to negotiate drug prices in courts, where the program currently faces numerous challenges”. As noted above, while direct congressional action may be their desired path to change, there seems little doubt they are willing to manipulate any of the available levers of power to achieve their goals. (https://democracyforward.org/restrict-reproductive-rights-and-access-to-health-care/)
What else does Project 2025 say about the Affordable Care Act (ACA, also colloquially known as Obamacare)?
While our focus in this newsletter is Project 2025’s potential impact on Medicare, it’s worth addressing a couple oft-repeated assertions about Project 2025 and the ACA that would likely be of particular interest to beneficiaries of Medicare:
A common proclamation is that Project 2025 calls for the end of the ACA. There is no specific proposal in Project 2025 for repealing the ACA, though it does criticize the budget impact of the Affordable Care Act and calls for changes to the act or its implementation. However, we are all familiar with the multiple attempts by the Trump Administration to eliminate the ACA, and in his 2024 campaign, Trump has vowed several times to try again to repeal and replace the ACA, saying he would create a plan with “much better health care” though there has never been a detailed plan to replace it. We will try to explore the other potential impacts of Project 2025 on the ACA in greater detail in an upcoming newsletter.
Another common assertion that would be of particular concern for Medicare recipients is that Project 2025 calls for the removal of the protections the ACA provides for individuals with pre-existing conditions. While Project 2025 makes no mention of changes to ACA protections for people with pre-existing conditions, again since there has been no detailed healthcare policy put forward by Republicans, this would remain a concern. However, this part of the ACA is by far one of its most popular features so even many people connected with Project 2025 admit that removing such protections would be politically untenable.
Project 2025 does contain specific proposals for the Affordable Care Act which we will include in future newsletter.
~ Carrie Knapp
Additional Sources:
https://www.nbcnews.com/health/rejecting-claims-medicare-advantage-rural-hospitals-rcna121012
https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf
https://www.hhs.gov/about/news/2024/08/15/historic-first-bid...
https://www.cnn.com/2024/07/24/politics/fact-check-harris-project-2025-trump/index.html
https://www.nytimes.com/2022/11/03/upshot/private-medicare-misleading-marketing.html