Can a new President make health policy changes on ‘Day One?’

How can a President start making changes on ‘Day One?’

An incoming President can sign executive orders, proclamations, and administrative orders starting on their first day in office.³ In January 2017, President Trump signed four executive orders during his first week in office,⁴ and in 2021, President Biden signed 24 executive orders during his first week in office.⁵

These documents do not require the support of Congress or federal agencies, but they can be blocked by the courts.⁶ Presidents often use these tools “to set a policy direction.”⁷ For example, President Trump issued an executive order in 2020 directing the Department of Health and Human Services (“HHS”) and Congress to reach a solution to protect consumers from surprise balance billing,⁸ and legislation addressing that matter was enacted later that year. But executive orders are also much easier to undo than legislation, since they can be reversed by an incoming president just as easily as they were implemented.⁷

An example of a health policy presidential proclamation is the immigrant health coverage proclamation that President Trump signed in 2019,⁹ although this was blocked by a court before it took effect¹⁰ and later revoked by President Biden.¹¹

Executive orders can be used to guide federal agencies, and are often cited by those agencies when they issue proposed rulemaking.¹²

How quickly can a President make policy changes through federal rulemaking?

A president’s administration may also make policy changes through federal rulemaking, which plays an important role in setting health policy in the United States. For example, numerous sections of the Affordable Care Act (ACA) direct the Secretary of Health & Human Services to set rules and guidelines for the implementation of its provisions.¹³ These rules can evolve over time, as we’ve seen with ACA Section 1557 implementation.

But federal rulemaking is not an overnight process. Federal agencies must publish proposed rulemaking in the Federal Register and accept public comments for at least 30 days before considering those comments and then publishing a final rule.¹⁴

The Centers for Medicare & Medicaid Services (CMS), which oversees Medicare, Medicaid, and Marketplace health coverage, typically keeps the comment period open for at least 60 days. And the effective dates for final rules must be at least 30 days after they’re finalized (at least 60 days after finalization for “significant” and “major” rules).¹⁵

This is why it’s not a quick process for administrations to make regulatory changes. For example, consider the changes we’ve seen over the years regarding short-term health insurance:

• The Obama administration proposed new short-term coverage rules in June 2016, finalized them in October 2016, and they took effect in January 2017, with enforcement delayed until April 2017 – more than 10 months after the proposal.¹⁶
• The Trump administration proposed new short-term coverage rules in February 2018, finalized them in August 2018, and they took effect in October 2018¹⁷ – more than seven months after they were proposed.
• The Biden administration proposed new short-term coverage rules in July 2023, finalized them in March 2024, and they took effect in September 2024 – over a year after the proposal.

What types of health insurance policy changes are possible via rulemaking?

One important aspect of federal rulemaking related to the ACA happens each year, with the annual Notice of Benefit and Payment Parameters (NBPP).

The NBPP, which is hundreds of pages long, can be used for a wide range of changes that affect the health insurance Marketplaces. These include the length of open enrollment, access to special enrollment periods, user fees that insurers are charged to offer coverage via HealthCare.gov, rules for enhanced direct enrollment entities, setting guidelines for 1332 waiver proposals, rules and duties for Navigators, and many others.

Here’s a summary of some of the changes implemented by the 2025 NBPP.

The Biden administration published the proposed 2026 NBPP in October 2024,¹⁸ and finalized it in January 2025, in the waning days of the administration.¹⁹ But the incoming administration may make additional changes.

We saw this in 2021, with the 2022 NBPP: The outgoing Trump administration published the 2022 NBPP in January, finalizing some aspects of their proposed rule.²⁰ Then the Biden administration issued a “Part Two” 2022 NBPP a few months later,²¹ and subsequently proposed additional rulemaking for 2022,²² which was finalized in September 2021.²³

Separate invoices for coverage of abortion. The federal rulemaking process could be used to require Marketplace insurers to issue separate premium invoices for abortion coverage. A rule requiring this was finalized under the first Trump administration,²⁴ but later overturned by a judge and repealed by the Biden administration.²⁵

DACA eligibility for Marketplace enrollment. The federal rulemaking process could also be used to make changes to the Biden administration’s May 2024 rule that allowed DACA recipients to begin using the health insurance Marketplace in November 2024. This rule has already been challenged in court and DACA recipients are unable to use the Marketplace in the 19 states that challenged the rule.²⁶

Additional legal challenges are possible, but a change to the federal rule itself is also possible under a new administration.

It’s also important to note that even after the federal rulemaking process is complete, the resulting rules can also be challenged in court. During the first Trump administration, there were 246 legal challenges to federal regulations, guidance documents, and agency memoranda. More than three-quarters of these cases resulted in either the court ruling against the federal agency, or the agency withdrawing the action due to the lawsuit.²⁷

Funding for cost-sharing reductions (CSR). In October 2017, the Trump administration announced that they were cutting off funding for Marketplace cost-sharing reductions (CSR), effective immediately. The immediate effective date was unusual, but this stemmed from a lawsuit in which GOP lawmakers had argued that Congress had never allocated CSR funding.²⁸

Federal funding for CSR did cease immediately, but eligible Marketplace enrollees continued to receive CSR benefits. Insurers in most states added the cost of CSR to the premiums for Silver plans (CSR benefits are only available on Silver plans). Premium subsidy amounts are based on the cost of the second-lowest-cost Silver plan, so the increased Silver plan premium resulted in larger premium subsidies for most enrollees, and this continues to be the case.²⁹

Medicaid waivers. Medicaid waivers, including 1115 waivers,³⁰ allow states to customize their Medicaid programs within various requirements and guardrails set by the federal government.

Medicaid waiver proposals are approved by CMS on a case-by-case basis, and the last two presidential administrations have taken very different approaches to this.³¹

Examples of Medicaid changes that could be made with a new administration’s approach to 1115 waivers include work requirements or premiums for some enrollees. But just like federal rule changes, the Medicaid waiver approval process includes a public comment period and a federal review period, so these are not changes that could be put into effect overnight.³²

Is it possible for Congress and a President to overturn a predecessor’s rule quickly?

In most cases, a new administration has to go through the regular notice-and-comment rulemaking process to undo a regulation put in place by a previous administration. As described above, the evolving rules for short-term health insurance are an example of this.

But the Congressional Review Act (CRA) gives Congress and the President the ability to overturn a rule within 60 days of it being published in the Federal Register.³³

So a CRA resolution passed by Congress and signed by the President could be used to overturn rules that were finalized in the last several weeks of the Biden administration. The CRA, enacted in 1996, has previously been used to overturn 20 rules.³³

How can one-party control of the White House and Congress speed policy changes?

With one-party control of the White House and Congress, legislative action on health policy is certainly possible. In addition to the aforementioned CRA process for overturning federal agency rules, the regular legislative process could be used to make changes to existing laws or enact new laws.

This would be necessary, for example, to make sweeping changes to the ACA (legislation to repeal the ACA was introduced in Congress in January 2025³⁴), or to change the Inflation Reduction Act’s provisions regarding Medicare drug coverage.