Donald Trump’s return to the White House, coupled with Republican control of the Senate and possibly of the House could result in a far more limited government role in the care of frail older adults and younger people with disabilities.
Most immediately, Trump’s proposed mass deportations will make the current shortage of care workers much worse, increasing the burden on family caregivers.
Trump himself has shown relatively little interest in health-related issues. But he’s surrounded by past and current advisers who are deeply committed to making major changes in health and long-term care. For example, Project 2025, written by a group of first-term Trump advisers, would fundamentally restructure federal health policy.
Here’s a more detailed look at some key issues:
Social Security: Despite Social Security’s inexorable path towards insolvency within a decade, Trump has steadfastly opposed any benefit cuts or payroll tax increases. Instead, he proposed exempting Social Security benefits from income tax—effectively raising benefits for those higher-income retirees now subject to the levy.
My colleagues at the Tax Policy Center estimate the measure would boost after-tax incomes by an average of $3,400 for those who can take advantage of the tax cut. But low-income retirees would get no benefit since they already are exempt from the tax.
Since those taxes currently are poured back into the retirement system, repealing them would drain $1.5 trillion from the Social Security and Medicare trust funds over the next decade.
However, thanks to complicated congressional budget rules, Trump will struggle to win legislative approval of this idea, even with full GOP control of Congress.
Heath Care: Medicare Advantage managed care currently covers more than half of Medicare enrollees, but critics say the plans are overpaid. Some in the new administration and Congress may look to slow the growth of MA payments to lower Medicare costs. But others will push to increase payments and ease regulation to boost enrollment. Project 2025 proposed making MA the default option in Medicare.
In 2022, Congress opened the door for Medicare to negotiate prices for a limited number of drugs. Manufacturers are suing to block the initiative and Trump is likely to kill it. On the other hand, Trump may also ease access to generic drugs, which could lower some prices.
One huge uncertainty: Robert F. Kennedy Jr.’s role in health policy. In his victory speech, Trump said Kennedy “is going to help make America healthy again. And now he’s a great guy and he really means it. He wants to do some things, and we’re gonna let him go to it.”
Given the unpredictability of both men, it is hard to know what that means. Would Kennedy’s opposition to vaccines affect availability of jabs important to older adults for conditions such as flu, Covid-19, pneumonia, shingles, and RSV? Would Medicare continue to pay for them? In addition, Trump’s tariffs would increase the cost of many drugs, which are produced overseas.
Trump also is likely to make big changes at the National Institutes for Health, the Centers for Disease Control, and the Food and Drug Administration. One result: Quicker federal approval of new drugs, which may benefit some consumers but increase risks for others.
Long-term care financing. Vice-president Kamala Harris made expanding Medicare to include home-based long-term care a key plank in her campaign. President Biden tried, with limited success, to expand Medicaid’s home-based long-term care program. Washington State enacted a public long-term care insurance program and other states are mulling the idea.
While the Republican platform also endorsed expanding home-based care, it never said how. And Trump was silent on the issue throughout the campaign. It is certain, however, that the new administration will make no effort to expand long-term care financing through Medicare, Medicaid, or public insurance.
Caregiving. Trumps’ highest priority is deporting tens of millions of immigrants and closing the borders to new ones. If he does, he’ll place enormous pressure on the supply of nurses, nurses’ aides, and other health care workers, making an already severe labor shortage vastly worse. And that will only put more of a burden on family caregivers, especially for those older adults and younger people with disabilities living at home.
Democratic efforts to create a federal paid family leave program will die. Instead, Trump has proposed an unspecified tax credit for family caregivers.
The Older Americans Act, The broad-based law that provides a range of government services, from home-based meal delivery to falls prevention, also could face funding reductions. The Trump Administration may not take the lead in pursuing these cuts (it didn’t in his first term) but congressional Republicans, looking to slash government, might.
Nursing homes: This probably is the easiest call. The Trump Administration almost surely will kill Biden’s effort to impose minimum staffing standards on nursing homes. Trump could withdraw the rules or, even stop defending the government against industry lawsuits attempting to block them. But either way, he’ll block government efforts to increase staffing at nursing facilities.
Trump’s second term will be highly consequential for older adults, younger people with disabilities, and their families. Many of his initiatives will not be to their benefit.
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