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For Better or For Worse: How Project 2025 Could Transform U.S. Healthcare
Jared Dashevsky, MD
November 10, 2024 • Estimated Reading Time: 8 minutes
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For Better or For Worse: How Project 2025 Could Transform U.S. Healthcare
What may healthcare look like under a second Trump presidency?
I looked closely at Project 2025, a detailed policy blueprint by the Heritage Foundation, a conservative think tank group. The blueprint outlines the healthcare goals and priorities for conservatives. While Trump has distanced himself from Project 2025, he will be surrounded by those who support the blueprint.
Therefore, it’s worth talking about and analyzing.
In this article, I’ll break down the key healthcare initiatives outlined in Project 2025, spotlight the most impactful plans and policies, and offer my perspective on what these changes might mean for patients, physicians, and the healthcare system as a whole.
Project 2025 Healthcare Goals
In Section 14, page 449, of Project 2025, you’ll find information on the healthcare goals and initiatives under a conservative Presidency. Five goals are highlighted right off the bat. These goals are written as “should” statements, recommending what the Department of Health and Human Services should do when Trump begins his second term.
Protecting Life, Conscience, and Bodily Integrity: emphasizes a commitment to safeguarding life from conception to natural death, saying that abortion and euthanasia are not healthcare.
Empowering Patient Choices and Provider Autonomy: advocates for a patient-centered, market-based healthcare system where individuals have greater control over their healthcare spending and decisions. It calls for reducing federal regulations, allowing states to lead in healthcare regulation, and promoting transparency and competition to drive down costs and enhance provider innovation.
Promoting Stable and Flourishing Married Families: supports policies that encourage the formation of traditional, married nuclear families, emphasizing the role of married fathers in children’s well-being.
Preparing for the Next Health Emergency: calls for a fundamental restructuring of the federal public health response to restore public trust and ensure future responses are transparent, science-based, and respect medical choice and the doctor–patient relationship.
Instituting Greater Transparency, Accountability, and Oversight: seeks to prevent regulatory capture of public health agencies by private interests, calling for funding exclusively from government sources and long cooling-off periods for regulators transitioning between government and industry.
Key Healthcare Initiatives
There are dozens of healthcare initiatives discussed in section 14 of the Project 2025 book. I broke down these initiatives into three discrete buckets:
Fiscal Responsibility and Spending Reforms: includes initiatives to control federal healthcare costs through tighter eligibility standards, reduced regulatory burdens, competitive bidding, and reshoring drug production.
Cultural and Ideological Healthcare Reforms: encompasses initiatives that align healthcare policy with conservative social values, focusing on restricting abortion access, limiting gender-affirming care, and protecting conscience rights.
Devolution of Healthcare Regulation to State and Community Control: includes policies aimed at shifting healthcare oversight from the federal level to state and local authorities, empowering communities to set healthcare standards, regulate telehealth, expand veterans’ access to local care, and direct public health responses.
I’ll break down several features of each bucket below. These features aren’t all-encompassing. Rather, I try to highlight what I think are the most important and controversial initiatives within each bucket.
Fiscal Responsibility and Spending Reforms
Medicaid Eligibility Restrictions and Work Requirements
This policy would add work requirements and introduce cost-sharing for Medicaid recipients, aiming to make Medicaid more of a temporary support rather than a long-term solution. It’s likely to reduce the number of people enrolled—much like we’ve already seen with recent “redetermination” efforts. The idea is controversial, though, because it could affect millions of low-income Americans who rely on Medicaid as their main source of health coverage.
Competitive Bidding for Medicare Advantage
Competitive bidding for Medicare Advantage could mean lower reimbursement rates for these plans and cost-cutting that trickles down to physicians. While it might help trim federal spending, it could also squeeze insurers’ profits and make things tough for providers, especially as Medicare Advantage continues to grow in popularity. This change could be controversial, as it risks shaking up MA rates and potentially impacting the quality and access to care for seniors who rely on these plans.
Reshoring Generic Drug Production:
To combat rising drug costs and address shortages, Project 2025 suggests reshoring the production of generic drugs to the United States. This initiative aims to reduce dependency on foreign manufacturers, especially China, and improve the reliability of the domestic drug supply chain. While potentially beneficial for drug availability and cost stability, this plan involves significant infrastructure investment and might drive up prices in the short term as production shifts domestically. To this day, I’ll continue to advocate for a Cost Plus Drugs x CMS partnership to lower generic drug costs.
Cultural and Ideological Healthcare Reforms
Restrictions on Abortion Access and Services
Project 2025 strongly pushes to reduce federal support for abortion, aiming to reverse FDA approval for abortion pills like mifepristone, bring back in-person dispensing requirements, and ban abortion-related services within Veterans Health Administration facilities. This is one of the more controversial moves, as it aligns federal healthcare policy with a strict anti-abortion stance, ultimately restricting access for women across federally governed healthcare programs.
Limitations on Gender-Affirming Care
Project 2025 suggests blocking federal funding for gender-affirming surgeries and related healthcare services, particularly within the Veterans Health Administration. It also recommends ending gender-identity-focused initiatives in public health programs and withdrawing federal support for treatments related to gender transition.
Promoting Traditional Family Structures in Health Programs
Another major and controversial initiative aims to reshape health programs—especially those under the Department of Health and Human Services—to promote traditional family structures. This would include policies that prioritize marriage between men and women and emphasize abstinence-focused education, or “sexual risk avoidance,” over comprehensive sex education. This approach takes a strong ideological stance on family and sexuality, potentially steering federally funded programs away from more inclusive approaches.
Devolution of Healthcare Regulation to State and Community Control
Expanding Community Care for Veterans
Project 2025 focuses on expanding veterans’ access to Community Care programs, allowing them to seek care outside VA facilities when VA services aren’t available or convenient. This shift encourages local, non-VA providers to meet veterans’ healthcare needs, giving veterans more options. However, it also raises concerns about redirecting funding away from VA facilities and the potential impact on continuity of care for veterans.
Decentralizing Public Health Authority from the CDC
One of the most notable initiatives involves restructuring the CDC by separating it into two entities: one for epidemiological data collection and another for public health recommendations. This proposal aims to minimize conflict of interest between the entity that’s making public health recommendations based on the data it’s collecting and analyzing.
Elimination of Federal Oversight of Telehealth Licensure
The plan advocates for rolling back federal oversight of telehealth regulations, returning authority to states to set their own licensure and practice standards. This would allow states to manage interstate telehealth independently, potentially leading to a patchwork of regulations and access barriers.
Repeal of Federal Restrictions on Physician-Owned Hospitals
Project 2025 suggests repealing the Affordable Care Act’s prohibition on physician-owned hospitals, giving states the power to decide on the operation of these facilities.
FDA and Conflict of Interest
Project 2025 proposes some big changes to the FDA to tackle conflicts of interest and limit industry influence. The plan would stop the FDA from taking funding from pharmaceutical companies through user fees, which currently help fund the drug review process. It also suggests tougher rules on the “revolving door” between the FDA and pharma, requiring longer cooling-off periods before former FDA regulators can work for the companies they once oversaw. While these changes aim to make the FDA more independent, they could slow down drug approvals and reduce collaboration, raising questions about how to balance regulatory integrity with industry support best.
Dashevsky Dissection
Ok, that was a lot of information. Honestly, that’s not even half of the information provided in the Healthcare Project 2025 document. So, when you have time, read through it yourself to gain a better understanding of what may come in healthcare within the next four years.
Anyway, based on what I shared above, let me now share how some of the above plans will affect patients, physicians, and the health system.
Patients
The emphasis on restricting abortion access and limiting federal support for women’s health services goes against the broader push for comprehensive women’s health, which I’ve consistently advocated for. In previous articles, Nyoo Health’s Priya Bathija and I highlighted how women’s health encompasses so much more than reproductive care alone—it includes critical areas like mental health, autoimmune conditions, and maternal health disparities, all of which need continued support and funding.
The plans in Project 2025 narrow the scope of women’s health services, potentially reducing access to essential care options, from reproductive health to broader healthcare services that women rely on within federally governed programs. As a physician, I believe in the importance of maintaining autonomy over health choices and protecting the resources necessary for comprehensive care. Ironically, Goal #2 of Project 2025, Empowering Patient Choices and Provider Autonomy, contradicts the restrictive plans on women’s health.
Beyond women’s health, the focus on promoting traditional family structures could also limit access to certain healthcare resources for patients who don’t fit this model. By prioritizing policies that favor traditional, nuclear families, the initiatives may reduce support for single-parent households or LGBTQ+ families, which could lead to unequal access to health and welfare services. This shift risks creating a healthcare environment that doesn’t fully address the diverse needs of today’s patients.
I know that effective healthcare meets patients where they are—whether they come from traditional families, single-parent households, or other family structures. Policies that narrow the scope of “acceptable” family models may inadvertently marginalize patients, making it harder for them to access the services they need and increasing health disparities. In my view, supporting all family types ensures more inclusive, patient-centered care and leads to better health outcomes across the board.
Physicians
When it comes to physicians, Project 2025’s support for rolling back restrictions on physician-owned hospitals could be a monumental move. Physician-owned hospitals offer doctors autonomy and control over care, allowing them to focus on patient outcomes without navigating the bureaucratic and financial constraints typical of large hospital systems. In my previous analysis, I discussed how the Affordable Care Act effectively stymied the growth of POHs, largely due to pressure from larger hospital associations concerned about competition. Allowing physicians to establish and expand their own facilities again could empower them to provide more patient-centered, efficient care, unhindered by layers of corporate oversight.
However, as beneficial as this move could be for patient outcomes, it also raises concerns about potential market fragmentation and the impact on traditional hospitals that rely on high patient volumes. Moreover, ensuring high-quality, affordable care across a mix of provider types could become challenging if physicians prioritize certain profitable services over broader community needs.
Health System
Project 2025’s combined initiatives—like Medicaid work requirements, eligibility time limits, competitive bidding for Medicare Advantage, and site-neutral payments—present a complex picture for the health system, particularly regarding insured rates and care accessibility. With Medicaid reforms making coverage more conditional and temporary, we’re likely to see a decrease in insured rates as individuals who cannot meet the new requirements or who reach eligibility limits lose their coverage. This shift could drive more patients to seek care as uninsured individuals, increasing uncompensated care costs for hospitals and clinics.
Extended ACA subsidies have been a key policy that has maintained a relatively high insured rate despite Medicaid redeterminations. However, these subsidies are set to expire at the end of 2025, and the Trump administration may very well let them expire. This would further exacerbate the uninsured rate if Medicaid work requirements or eligibility time limits were put in place since those who’ve been booted off of Medicaid have found insurance through these extended ACA subsidies.
At the same time, the proposal for competitive bidding in Medicare Advantage aims to curb federal spending but may reduce reimbursement rates, which could discourage insurers or push additional costs onto providers. This could lead to narrowed provider networks and limited plan options, particularly for seniors who rely on these plans, thereby impacting access to affordable care. Coupled with site-neutral payments, which would cut hospital reimbursement rates for outpatient services to align with independent clinics, hospitals could face financial strain, potentially limiting services or access, particularly for low-income and complex patients.
Together, these reforms risk creating a fragmented system where fewer people are insured, healthcare access is uneven, and providers face heightened financial pressures. While these policies aim to control spending and promote efficiency, they could ultimately lead to higher system-wide costs and worse patient outcomes as hospitals and providers attempt to navigate the reduced coverage landscape.
I’ll note again that Project 2025 is not Trump’s healthcare agenda. He’s also tried removing his association with Project 2025. However, Project 2025 is the conservative agenda, and Trump will likely try to implement many of the items discussed.
In summary, Project 2025 outlines ambitious plans for reshaping healthcare under a conservative presidency, with initiatives focused on fiscal reform, cultural values, and local control. Key proposals include tighter Medicaid eligibility requirements, expanded options for physician-owned hospitals, and increased autonomy for states over healthcare regulation. While these changes aim to streamline spending and align healthcare with conservative principles, they also pose potential challenges, such as reduced access for vulnerable populations and added financial strain on hospitals. For physicians and patients alike, these policies could lead to a healthcare landscape with greater autonomy but also heightened disparities in care and coverage.
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