With candidates and voters focused on the economy, immigration and abortion, the 2024 presidential election has been unusually light on health policy. But former President Donald J. Trump’s recent pledge to let Robert F. Kennedy Jr. “go wild on health” has put the issue front and center in the final days of the campaign.
With an assist from Mr. Kennedy — an environmental lawyer who has no medical or public health degrees — Mr. Trump put the spotlight on a trifecta of health policies: fluoridated water, vaccines and the Affordable Care Act, the program popularly known as Obamacare, which has provided health coverage to nearly 50 million Americans over the last 10 years.
As president, Mr. Trump would have only limited authority to make changes in these areas, even if Republicans won control of both houses of Congress. But he would have the bully pulpit. Here’s what you need to know about the three issues:
FLUORIDE
Over the weekend, Mr. Kennedy declared on social media that, if elected president, Mr. Trump would advise communities to stop adding fluoride to drinking water. Mr. Kennedy described the compound as “an industrial waste associated with arthritis, bone fractures, bone cancer, IQ loss, neurodevelopmental disorders and thyroid disease.” In an interview with NBC News on Sunday, Mr. Trump said the idea of doing away with fluoridation “sounds OK to me.”
What is fluoride and why is it in our drinking water? Fluoride is a mineral that occurs naturally in water, although it can also be a byproduct of industry. Adding fluoride to public water systems began as an experiment in Grand Rapids, Mich., in 1945, after a dentist at the National Institutes of Health theorized that it might prevent cavities in teeth. Over the next 11 years, tooth decay in Grand Rapids dropped by 60 percent.
Other communities quickly followed suit. As of 2022, more than 209 million people, or 72.3 percent of the U.S. population served by public water supplies, had access to fluoridated water, according to the Centers for Disease Control and Prevention, which lists fluoridation as one of the “10 great public health achievements of the 20th century.”
What do health experts say about fluoride? Experts agree that excessive exposure to fluoride over a long period of time can cause health problems. The risks include dental fluorosis, a condition that leaves the teeth looking pitted or brown; skeletal fluorosis, which can cause joint pain or osteoporosis; and lower I.Q. in children.
But the C.D.C. and the American Dental Association say that fluoridated water does not pose any of these risks at the level currently recommended by the Environmental Protection Agency, which sets the safe standard at 0.7 milligrams of fluoride per liter of drinking water. The federal Public Health Service recommends water fluoridation at that level. Municipalities that fluoridate their water typically follow the guidelines.
A recent analysis by the federal government’s National Toxicology Program found that fluoride levels at or above 1.5 milligrams per liter — more than twice the E.P.A. recommended level — are “consistently associated with lower I.Q. in children.” But, the report added, “more studies are needed to fully understand the potential for lower fluoride exposure to affect children’s I.Q.”
Why do we need fluoridated water when it is already in toothpaste and dentists give fluoride treatments? Critics of fluoridation say getting fluoride from toothpaste or the dentist makes fluoridated water unnecessary.
But public health experts, including the American Dental Association, see fluoridated water as an equalizer — a way for children and adults to get enough fluoride to prevent cavities even if they lack access to good dental care. A recent study in Canada found that removing fluoride from water was associated with an increase in tooth decay.
Why is there controversy about fluoride now? Fluoride has long generated controversy. In the 1950s conspiracy theorists thought it was a Communist plot to poison Americans’ brains — a notion that the filmmaker Stanley Kubrick ridiculed in his 1964 classic film “Dr. Strangelove.” But a court case has once again landed fluoridation in the news.
Last month, a federal judge in California sided with the anti-fluoridation movement in concluding that fluoridated water poses an “unreasonable risk of injury to health or the environment,” even at the E.P.A.-recommended levels. The judge ordered the agency to revise its regulations for fluoride; the government has not said whether it will appeal the decision.
Can the president ban fluoride in drinking water? No. Drinking water in the United States is a matter of local, not federal, control. The level of naturally occurring fluoride in drinking water differs around the country. Some cities and counties, notably Portland, Ore., do not fluoridate their water; the Fluoride Action Network, an anti-fluoridation group, reports that some communities have suspended fluoridation in the wake of the California judge’s ruling.
VACCINES
Mr. Kennedy is one of the nation’s leading vaccine skeptics, and Mr. Trump — who has expressed doubts about vaccination even though his administration was responsible for fast-tracking development of the Covid-19 vaccine — appears to embrace Mr. Kennedy’s views. During the NBC News interview on Sunday, Mr. Trump was asked if “banning certain vaccines might be on the table,” in light of Mr. Kennedy’s opinions on the subject.
The former president responded, “Well, I’m going to talk to him and talk to other people, and I’ll make a decision, but he’s a very talented guy and has strong views.”
Could Mr. Trump, as president, ban certain vaccines? The short answer is no. In the United States, public health is the province of the states, not the federal government. Also, vaccines are licensed by the Food and Drug Administration, and the president cannot unilaterally remove a lawful product from the market — at least not without a legal fight, said Lawrence O. Gostin, an expert in public health law at Georgetown University.
That said, a president could exert pressure on the F.D.A. to reverse its approval for a particular vaccine. Mr. Trump could also appoint judges predisposed to limiting the power of federal agencies, including the F.D.A. In a landmark decision earlier this year, the Supreme Court greatly reduced the power of federal agencies by overturning the case of Chevron v. Natural Resources Defense Council, one of the most cited in American law.
Mr. Trump may appoint health officials who publicly criticize vaccination, which is likely, given that he has said he expects to give Mr. Kennedy a big role in his administration. That would almost certainly have the effect of discouraging vaccination. “There’s a lot of mischief that can be done,” Mr. Gostin said. “But a flat out ban? No.”
THE AFFORDABLE CARE ACT
Mr. Trump insisted over the weekend he “never mentioned” ending the program popularly known as Obamacare, and “never even thought about such a thing.” That is news to those who recall his fervent effort in 2017 to get Congress to repeal the law — only to see Senator John McCain, Republican of Arizona, return to Washington after brain surgery to cast the deciding vote against the repeal.
What’s behind the conflicting messages? Mr. Trump was probably trying to distance himself from House Speaker Mike Johnson, who promised during a recent campaign swing through Pennsylvania that Republicans would embark on a “massive reform” of the Affordable Care Act if Mr. Trump was elected.
“No Obamacare?” a voter called out. “No Obamacare,” Mr. Johnson agreed.
Can the president undo Obamacare on his own? No. As Mr. Trump discovered in 2017, that would take an act of Congress. However, the president could use his executive authority in numerous ways to undercut the law or restrict access to the program.
He could, for example, cut back the budget for “navigators” — outreach professionals who help people find and enroll in health plans. In January 2021, President Biden issued an executive order aimed at strengthening Medicaid and the Affordable Care Act. Mr. Trump could easily reverse that.
If Congress were to repeal the Affordable Care Act, what would come next? When Mr. Trump was asked during his debate against Vice President Kamala Harris whether he had a replacement plan for the law, he said he had the “concepts of a plan.” Larry Levitt, the executive vice president for health policy at the Kaiser Family Foundation, has written that there is “some truth in that statement.”
In Mr. Trump’s 2020 budget, Mr. Levitt writes, Mr. Trump proposed repealing the expansion of Medicaid and the premium subsidies that, under the law, make insurance more affordable for low-income families; he would have replaced both with a block grant to the state. Mr. Trump also called for capping federal Medicaid spending.
All told, Mr. Trump’s plan would have cut mandatory spending on health care by $1.5 trillion over a decade, according to the Congressional Budget Office.
