The next four years may have an unusually huge sway on the future of health care in the U.S.

Yes, but: If I learned anything from covering the first Trump presidency, it's that his approach to health care can be very unpredictable, and it's not one of his preferred topics, all things considered.

• Some of his strongest instincts run counter to Republican orthodoxy, but in his first term he often left policymaking to political appointees or members of Congress who held those more orthodox views.
• This time could be very different. The makeup of congressional Republicans is different, and Trump has vocally signaled the empowerment of a different kind of health care thinker.
• On the other hand, health care isn't most of the GOP's favorite topic, either, and whatever changes happen under Trump could end up being fairly modest. That would lead the sector to largely sort itself out as it undergoes some of the massive, inevitable changes that are on the horizon.
• Because of all the uncertainty, then, apologies in advance for all of the on-one-hand-on-the-other-hand hedging I have to do today.

Let's dive in...

Theme 1: The big insurance era

Health insurance is, unsurprisingly, one of Republicans' prime targets: They'd like to cut government spending on Affordable Care Act subsidies and Medicaid, and some have also proposed reducing Medicare Advantage spending in the name of fiscal responsibility.

• We recently talked in this newsletter about how a specific insurer fares under the next president depends a lot on which markets they're most active in. The Trump administration is expected to be much friendlier as a whole to MA plans than a Harris administration would have been.
• But there's a bigger picture here. Health insurance has changed since Trump's last inauguration; there have been mergers, the big players have gotten bigger, and several have become conglomerates that can no longer be described as just insurance companies.
• The Trump administration is expected to take a friendlier approach to mergers and deliver less heavy-handed antitrust scrutiny than the Biden administration has. That could be great news for CVS' Caremark Rx, Cigna's Express Scripts and UnitedHealth's Optum Rx, which are being sued by the FTC.
• On the other hand, the GOP as a whole are skeptical of PBMs, and they would have been big losers under the former Trump administration's rebate rule had it been finalized. And there's definitely a vein of Big Insurance skepticism running through the party, especially of how well the industry has done post-ACA.

Theme 2: The hospital squeeze

Whoever won the presidential election wasn't going to change hospitals' fundamental problem: Patients are getting more care outside of the hospital setting, especially the kinds of services that tend to be profitable.

• But that reality — plus the added pressures of an aging population and, as some experts argue, an undisciplined approach to costs — have led hospitals to maximize revenue where they can, and to warn that any clampdown on those opportunities will have devastating effects.
• A couple of examples of threats that could be heading their way: equalization of Medicare payment across sites of care, which would cut back what hospitals can make from outpatient centers, and more scrutiny of the 340B program, which has ballooned and allows some hospitals to purchase drugs at lower prices. Cuts to the ACA or Medicaid could also have a negative impact on hospitals.
• Again, there's a bigger picture at play here: The ever-increasing payment rates that hospitals receive from commercial insurers are multiples of what the government pays, and that gap continues to grow. The first Trump administration took a stab at this through its price transparency regulation, and while that's producing a lot of good data on how wild and all-over-the-place those prices are, prices are still high and going up.

Continued below ...

Theme 3: Medicine's enormous moment (we'll go a little deeper on this one)

We've made it so far without talking about Robert F. Kennedy Jr., but here's where Trump's embrace of him becomes a huge wildcard. He's openly critical of Big Pharma and has vowed to shake up the FDA and the NIH, including where it spends its research dollars.

• His most well-known ire is focused at vaccines, which could lead to more public mistrust and have devastating effects on infectious disease spread. (He recently said he's not going to take away vaccines from anyone who wants them.)
• But it's much harder to yank older drugs off the market than it is to change the regulatory processes and personnel for approving new drugs or devices, and those changes could happen just as the FDA is grappling with a large pipeline full of scientific and technological advancements.

What we're watching: There's no class of medication that could have a bigger impact than GLP-1s, which could not only revolutionize obesity care but may also improve treatment for a variety of other conditions. But Kennedy has voiced skepticism about them.

• When asked about a finding that the drug may reduce opioid and alcohol abuse, along with other conditions, and whether it's going to "help make America healthy again," Kennedy replied, "No, this isn't."
• "I need to look at the methodology of that study, because I don't believe it," he added. "The EU is right now investigating Ozempic for suicidal ideation. But you know, it may be that the drug, because it suppresses all the reward pathways, so it makes you want to do everything less. And that may be part of the answer for this."
• Be smart: The European agency reviewing the drugs' connection to suicide announced earlier this year that it's found no evidence of such a link.

Making GLP-1s available to all overweight Americans would cost trillions every year, he added.

• "If we spend about one-fifth of that giving good food, three meals a day, to every man, woman and child, in our country, we could solve the obesity and diabetes epidemic overnight for a tiny fraction of the cost. ... In our country, they're counting on selling it to Americans because we're so stupid and so addicted to drugs."

More below ...

Theme 4: The health care casino

Here's a place where the election matters mostly on the margins: While plenty of insured Americans are struggling to access health care — either because their insurance is unaffordable or because they're having a hard time getting the appointments they need — it's not what the Make America Healthy Again movement tends to focus on.

• But that could always change. Trump and Kennedy have vowed to address chronic disease, and experts say access to care — especially primary care — can be part of the solution. Right now, Kennedy is focused on going a different direction.
• Then again, if policy changes result in more people becoming uninsured, that makes accessing care even harder for those people. And if Trump opens the door to skimpier health plans again, that could also amplify access issues.

Theme 5: The gray trap

America is still getting older at exactly the same rate. Managing that transition, at least for the next four years, is now in Trump's hands, both in terms of how the country pays for the care burden and what kind of care support it offers.

• Aging is intricately related to the country's chronic disease burden. People are living longer with more health conditions (which experts say is part of why the chronic disease burden is going up in the first place), and experts say there's a lot of work to be done figuring out how to keep people healthier for longer.
• Trump has sworn off Medicare cuts, despite projections that the program is set to balloon, and pledged to offer tax credits to unpaid caregivers.

Theme 6: The mental health crisis

Trump has a vision for a drastically different approach to severe mental illness and has called for the return of "mental institutions" as part of his plan "to get the homeless off our streets."

• Trump was interested in the topic during his first term, but plans were upended by the coronavirus pandemic, Joe Grogan, the former director of Trump's Domestic Policy Council, told me last year.
• "We were spending a lot of time on it, and we had plans for commissioned corps appointments, for intake at homeless encampments, we were trying to figure out where we could remove people to and give them shelter to get them off the city streets," he said.

Theme 7: The drug epidemic

It's pretty clear at this point that the window for "harm reduction" policies like decriminalizing drug use has closed, and California this week became the latest state to embrace a tougher-on-crime approach.

• Expect talk of the fentanyl crisis to, fairly or not, dovetail even more closely with Trump's immigration agenda.

Let's wrap up ...

Theme 8: Labor strife

Worker shortages and dissatisfaction stem from some very systemic issues, not any one specific policy. It's also hard to see any undoing of the rapid shift toward doctors being employed by hospitals, insurers or other groups versus self-employment.

• Conventional GOP positioning — including during Trump's first term — is generally hostile to unions, which have recently swelled in popularity among the health care workforce.

Theme 9: Tech fusion

Health care probably has two wild cards now: AI and an RFK-powered federal government health care approach, and they're not unrelated.

• As my colleagues have written, the election results mean that "artificial intelligence will grow up in a permissive, anything-goes household, rather than under the guidance of stricter parents."
• Figuring out how to regulate AI was already an enormous challenge for the FDA. That only becomes more true amid a potential radical transformation of the agency.

Theme 10: Inequality's long reach

Disparities have been baked into the health care system under decades of rule by both parties. But while equity was a central consideration of the Biden administration's, Trump's general antipathy toward DEI makes that unlikely to continue.

• Some policy measures could worsen disparities. For example, the enhanced ACA subsidies have disproportionately benefited people of color, meaning rolling them back could also impact them more.

The bottom line: There's a lot of unknowns here, especially regarding who will actually be in power over health care decisions once Trump takes office.

• But seismic change could be headed our way, and it's my goal to keep connecting the incremental stuff to the big picture.