Project 2025 Could Become a ‘Political Reality That Would Upend Medical Practice’ | SPH

From unraveling the Affordable Care Act (ACA) to curtailing fertility care, Project 2025 fails to prioritize the health and well-being of all Americans, according to a new viewpoint in JAMA by researchers at the School of Public Health’s Center for Health Law, Bioethics & Human Rights.

Instead, the wide-ranging, conservative blueprint for the next Republican administration presents an “antiscience, antidata, and antimedicine agenda” that would have serious consequences for healthcare and public health, write Nicole Huberfeld, Edward R. Utley Professor of Health Law; Elizabeth McCuskey, professor of health law, policy & management; and Michael Ulrich, associate professor of health law, policy & management.

Led by The Heritage Foundation, the 922-page collection of policy proposals in Project 2025 details what a potential second Trump presidency could look like. The blueprint calls for a massive overhaul of the federal government, including health reforms that would deregulate health care, weaken the ACA, defund and privatize federal safety-net programs, and allow discrimination within (and beyond) healthcare settings, the authors write.

“The playbook is built on numerous falsehoods about government, including how Medicare and Medicaid work, how federal law preempts conflicting state laws, and how law interacts with healthcare more broadly,” the authors write. “Although many of the proposals are unlawful, this would not be likely to deter a second Trump administration from implementing such policies.”

The commentary identifies several priorities outlined in Project 2025, as well as the health consequences that would ensue if this vision becomes policy or law.

One major goal is to “return to the untenable pre-ACA status,” the authors write. The playbook details plans to achieve Republicans’ years-long goal to repeal the ACA, which would limit or remove health insurance coverage for millions of people and be replaced with insurance plans that lack many of the ACA’s signature protections, such as requiring coverage for essential health benefits, prohibiting exclusion based on preexisting conditions, and reducing prescription drug costs.

The authors also discuss how the playbook would privatize and defund aspects of the Medicare and Medicaid programs. Project 2025 proposes to deregulate Medicare Advantage—but also make it the default enrollment option—while also imposing block grants and work requirements for Medicaid, which would result in loss of coverage for many patients.

Consequently, “low-income people predictably would become uninsured, meaning they wait longer to receive care or seek none, their health deteriorates and thus becomes harder and more expensive to treat, they cannot afford necessary healthcare, and any costs accrued are passed on to insured patients through higher premiums,” the authors write.

Huberfeld, McCuskey, and Ulrich also emphasize the harms that Project 2025 could inflict on both patients and their healthcare providers with regard to sexual, gender, and reproductive healthcare. The playbook describes multiple antiabortion efforts that would allow states to exclude abortion providers from Medicaid participation, withdraw federal Medicaid funding for states that include abortion coverage in private insurance plans, and limit covering other contraceptive measures, such as condoms.

The authors note a number of proposals in Project 2025 that specifically threaten the health and rights of LGBTQ+ patients and their physicians, including scaling back laws that prohibit discrimination on the basis of sex, proposing a federal ban on care related to gender identity, and prioritizing religion-based objections to treating sexual and gender minority patients. The playbook also promotes heterosexual marriages and ends support for single parenthood or LGBTQ+ families, which it states would create a “right of children to be raised by the biological fathers and mothers who conceive them.” This move would deny single people and same-sex couples access to assisted reproductive technologies (ART), such as in vitro fertilization—and it also implies that the federal government would intervene in family law, “a traditionally state-regulated area of law,” the authors note.

Amid the blowback and growing unpopularity of Project 2025, Trump has sought to distance himself from the playbook, despite the fact that many of his allies and former members of his administration were involved in its development. Huberfeld, McCuskey, and Ulrich warn that a potential Republican administration could begin to implement many of these policies swiftly, should Trump win the November presidential election.

“Although the document has no formal legal value, it is a blueprint that would aid a Republican administration in starting the work of shifting policy priorities quickly,” the authors write. “…In other words, a to-do list is ready, and it is not far-fetched to understand that it could quickly become a political reality that would upend medical practice.”