The first Trump administration was of the COVID-19 pandemic and politicization of public health agencies. In 2020, Donald Trump's appointed HHS secretary demanded the right to review and change CDC's for health professionals. The administration under the Affordable Care Act (ACA) and approved waivers instituting Medicaid work requirements , both of which actions increased the number of . Meanwhile, Trump's appointments to the Supreme Court culminated in the reversal of Roe v. Wade.
With Trump's return to the White House, the future of U.S. health policy is again in the spotlight. Concerningly, he has nominated Robert F. Kennedy Jr. (RFK Jr.) for HHS secretary, a position that oversees , including the CDC, FDA, and NIH. A few days later, he nominated Mehmet Oz, MD, to lead CMS. Both nominees have a long history of ignoring scientific evidence.
Often viewed as the world's most influential anti-vaxxer, RFK Jr. recently threatened to get rid of FDA career scientists unless they ended the agency's "" of vitamins, raw milk, stem cells, and drugs like . "Dr. Oz," a TV personality, has been criticized for promoting baseless or incorrect medical advice on his show, including a green coffee extract "miracle" pill .
While the president and his political appointees would wield over the nation's venerable scientific agencies, there are constitutional and institutional guardrails against the most extreme anti-science policies. Understanding these safeguards will be crucial to effectively challenge harmful policies. So, let's review that both the president and his appointees hold and the restraints on those powers.
Banning Vaccines or Water Fluoridation
RFK. Jr. has peddled conspiracy theories about vaccines, especially COVID-19 vaccines and measles-mumps-rubella (MMR) vaccines, which he has . Although RFK Jr. has said to ban vaccines, the president-elect has this idea. RFK Jr. has also stated that he seeks to end the fluoridation of water nationwide.
As powerful as the president and his HHS secretary are, they do not have the authority to ban vaccines or water fluoridation. Under the Constitution and our system of federalism, public health powers are reserved to the states. All 50 states and Washington D.C. have laws requiring a for school attendance. Similarly, states and localities about adding fluoride to public water to promote dental health.
However, in determining which vaccines to include in the schedule of childhood immunizations, states rely on recommendations by CDC's (ACIP). ACIP members are nationally recognized experts in immunization science and serve staggered 4-year terms. ACIP members are appointed by the HHS secretary. A future secretary Kennedy, therefore, would be able to appoint virtually all ACIP members over the next 4 years, which could politically poison the well of objective scientific recommendations. RFK Jr. has also said he would and publicly disclose what he regards as unsafe vaccines. It is possible he could cherry-pick data, further undermining public trust in ACIP recommendations.
Beyond appointing ACIP members and putting out misleading information about vaccine safety, RFK Jr. could seek to interfere with FDA decisions on vaccine approvals. Suppose a future secretary overrode career FDA scientists or decided to put on a warning label on a vaccine. That is fully within the secretary's powers.
But there are guardrails. Decisions about drug and vaccine approvals are made at the FDA's "center director" levels, which are currently not politically appointed. Career FDA scientists would likely resist political interference in their decisions, and they have civil service and whistle-blower protections. (Of note, Trump has previously tried to for thousands of employees). Further, if the secretary overturned an FDA approval based on political preference and without scientific evidence, he could face a major legal challenge. Even a conservative Supreme Court is likely to think twice about going down the road of political interference in the FDA's scientific evaluations.
Healthcare Access and Affordability
During his first term, Trump attempted to the ACA several times but failed to gather . While a new Trump administration could try again, it is more likely it will reduce affordable access to ACA plans.
aim to significantly , reduce Medicaid funding, and to the insurance marketplace, raising costs for people with pre-existing conditions. If enacted, these changes could leave up to without affordable coverage. Many of these actions would be open to the president, the HHS secretary, and the CMS administrator without congressional approval. But since the GOP holds both chambers of Congress, it is feasible that more extreme cuts could come with congressional approval.
Meanwhile, RFK Jr. is reportedly exploring a proposal to reduce the role played by the American Medical Association (AMA) in for medical services, possibly . Besides leading to a major loss of revenue and influence for the AMA, upending the longstanding process for determining the medical billing code structure could affect Medicare reimbursement levels. If this leads to lower payments for medical services, fewer doctors may accept Medicare, reducing access and otherwise impacting care.
Political Appointments and Restructuring
The president wields tremendous influence over federal public health agencies, through appointments, restructuring of internal departments and agencies, and executive orders. The Trump administration may work with Congress to slash spending for key public health agencies (e.g., CDC, NIH, and FDA) and programs (Children's Health Insurance Program, Medicaid, and possibly Medicare).
In addition to the loss of vital funding, public health agencies might suffer reorganization or loss of key functions. Project 2025, for example, has proposed into two agencies, which could hinder the agency's ability to prevent or mitigate . RFK Jr. has also the FDA's Center for Food Safety and Applied Nutrition.
While control over the federal health workforce and key agency functions are held firmly by the president and HHS secretary, there are a few limits to plenary control. Political appointments often require Senate confirmation. Agencies must follow the Administrative Procedure Act, which requires a for significant regulatory changes; this takes time and creates an evidentiary record that the agency may not totally ignore. Additionally, of Chevron deference to agencies, courts can review and block agency actions that are deemed arbitrary or capricious.
Overall, if confirmed, RFK Jr. would have a sizable influence on budget, priorities, and staffing -- possibly remaking the federal health workforce with staff that distrust scientific research and evidence, and disempower career scientific experts.
Agency Orders and Control
Rescinding existing requires going through the notice-and-comment process, as well as a justification for the policy change. Courts may well not allow a rule or regulation to be overturned purely for political reasons, especially if it goes against the weight of scientific evidence.
Such a battle could be seen around FDA approval of mifepristone -- a pill used in a majority of abortion care in the U.S. are pressuring Trump to restrict access to the drug. This year, the Supreme Court to the FDA's original approval of mifepristone, but Trump has at times indicated an openness to . Rescinding approval would invite intense litigation.
The Trump administration will have the opportunity to influence public health and safety through enforcement discretion as well. Conservatives to direct the Department of Justice (DOJ) to enforce a radical interpretation of the Comstock Act to target the mailing of mifepristone and threaten criminal penalties against providers to discourage treatment. further calls for reinstating an in-person abortion medication dispensing requirement, which would effectively of mifepristone, which the FDA allowed in 2021.
RFK Jr. also seeks to undermine the FDA's schedule of safe pharmaceutical products to permit the use of . Approving psychedelic drugs for medical purposes, approving consumption of raw milk products, or green-lighting other untested or unsafe treatments would need to go through formal processes. However, the administration could still promote the use of these products through public recommendations or by directing the DOJ to stop enforcing rules that prevent companies from marketing unregulated and unproven health regimens.
Future Challenges
Robust U.S. institutions will protect the public from the most extreme health policies. Dedicated career public health professionals at HHS agencies will be a check on the secretary's power and influence. And these scientists, at least currently, hold both civil service and whistleblower protections. State governments can prioritize science and reinforce health policies that advance the public's health and safety. And even a highly conservative judiciary may serve as a check on federal actions that clearly overreach. The public health community will have to rely on these systems, processes, and guardrails to support health access, emergency preparedness, and the environment.
is distinguished university professor, the highest academic rank at Georgetown University, where he directs the O'Neill Institute for National & Global Health Law. He is also the director of the World Health Organization Collaborating Center on National & Global Health Law, and the author of . is a law fellow with the O'Neill Institute. is Global Health Justice Scholar at the O'Neill Institute.