Trump Aims to Overhaul the FDA. What Does That Mean for Public Health?

President Donald Trump and his right-wing allies have made it clear they intend to do as much damage to the federal government as possible. Trump has promised to diminish, defund and defang federal regulatory bodies — proposals that are echoed in Project 2025, the Heritage Foundation’s far right blueprint for the next four years. During his first week in office, Trump issued 70 executive orders, including freezing federal hiring, pausing all communications from health agencies and withdrawing from the World Health Organization (WHO).

While the public struggles to keep up with the onslaught of orders and controversial appointments, somewhat lost in the shuffle is Trump’s pick to run the Office of Management and Budget: Russell Vought, one of the main architects of Project 2025. Vought has outlined plans to put federal employees “in trauma,” defund the EPA and override funding approved by Congress.

Meanwhile, in an executive order, Trump created his long-discussed “Department of Government Efficiency,” to be led by Elon Musk, the world’s richest man. On paper, the department is tasked with modernizing federal technology and software; however, Trump and Musk have spent months boasting about how it will gut the federal government.

What does all this mean for the Food and Drug Administration (FDA), a massive agency within the Department of Health and Human Services (HHS), which is responsible for regulating drugs and medical devices, approving vaccines and ensuring food safety?

Firing, Threatening and Reshaping the Workforce

Trump has already taken steps to weaken federal agencies like the FDA and reshape the regulatory system. On his first day in office, Trump issued an executive order reclassifying thousands of federal employees as political hires. The order effectively reinstated his own October 2020 executive order, which created a new federal classification, “Schedule F,” that stripped many career civil servants of longstanding protections, making it easier for an administration to fire and replace them.

Back in 2020, the American Federation of Government Employees, a major federal worker union, called the order the “most profound undermining of the civil service in our lifetimes.” Incoming President Joe Biden rescinded the order before it took effect, and created new rules to slow its reinstatement under Trump. Now, Trump’s new order revokes the earlier Biden revocation.

Throughout his campaign, Trump vilified federal workers, promising not only to reinstitute Schedule F, but also to fire workers, noting: “I will wield that power very aggressively.” Vice President J.D. Vance has called for Trump to “fire every single mid-level bureaucrat, every civil servant in the administrative state, replace them with our people.”

“There are entire departments, like the nutrition departments at FDA, that have to go,” said Robert F. Kennedy Jr., Trump’s nominee for HHS secretary, in a much-cited MSNBC interview in November. Days before the election, Kennedy threatened on X: “If you work for the FDA and are part of this corrupt system, I have two messages for you: 1. Preserve your records, and 2. Pack your bags.”

In his first week in office, Trump took further steps to intimidate and demoralize federal workers. He implemented a federal hiring freeze, ordered all federal employees back to the office full-time and paused communications from health agencies. His executive orders align with Project 2025’s proposals, which call for the president to “dismantle the administrative state,” including by reclassifying and replacing employees.

Actually firing tens of thousands of workers would be difficult if not impossible, but just the threat could be enough to drive some employees to quit, or intimidate them into following unethical orders. Cheryl Monroe, an FDA chemist, told The Guardian she fears employees will be pressured to produce findings that favor the president’s preferred companies and donors, which could lead to unsafe food and drugs on shelves. “We need people in place based on merit and professionalism, not on the political situation,” she explained. “Or else this can cost lives.”

“Attacking and displacing FDA experts would be disastrous for millions of Americans,” agreed two medical professors in a Health Affairs op-ed. “The agency would struggle to spot manufacturing problems, respond to outbreaks, and support patients in need of the benefits of technological advances.”

“There are entire departments, like the nutrition departments at FDA, that have to go,” said Robert F. Kennedy Jr., Trump’s nominee for HHS secretary.

At a November event, FDA Commissioner Robert Califf warned that, “Not having experts, I think historically, in every society, has been a case for demise of that society.”

How Might FDA Policies Be Affected?

In addition to intimidating the workforce, Trump and Kennedy could theoretically influence FDA policies more directly. While it would be unprecedented, Califf noted that “it’s totally within the law for the president or the HHS secretary to overrule the entire FDA.”

One major question is the future of medical abortion pills. Since the Supreme Court’s Dobbs ruling overturned Roe v. Wade in 2022, Republicans have challenged the FDA’s decadeslong approval of mifepristone as a safe and effective medication for abortion.

Project 2025 proposes the FDA ban the prescription of mifepristone over telemedicine and its administration through the mail, and ultimately withdraw approval entirely. Whether Trump would push the FDA to pursue this is unclear: He has flip-flopped repeatedly on abortion, both celebrating restrictive state abortion laws, and claiming he won’t push for a congressional abortion ban.

On many issues, predicting what will happen at the FDA is difficult because “you have to deal with the conundrum that is RFK [Jr.],” Peter Lurie, president and executive director of the consumer advocacy organization Center for Science in the Public Interest, told Truthout. “And the very confused and confusing set of policies that he has — that are internally inconsistent, certainly inconsistent with good science in some instances, and inconsistent with the general orientation of the GOP.”

Lurie’s organization opposes Kennedy as HHS secretary for two key reasons. “The first is that you have to have some kind of experience in the area,” Lurie explained. What’s more, “the positions that he’s taken, for example, on pasteurized milk and vaccination, are just not consistent with science.… So that tells me this is not a person who knows how to make decisions in a thoughtful and evidence-based way.”

Kennedy, who chairs an anti-vaccine nonprofit, has falsely claimed that no vaccines are safe and effective, that the polio vaccine killed more people than it saved and that vaccines cause autism. He also advocates drinking “raw,” or unpasteurized milk that has not been heated to kill bacteria like E. coli, salmonella, listeria, and viruses like the bird flu. Although raw milk is legal in 30 states, the FDA has long warned against drinking it and bans its sale across state lines. Kennedy also defies science by calling for the removal of fluoride from municipal drinking water. Federal officials have encouraged water fluoridation since 1950, a practice that has significantly reduced tooth decay.

Crucially, the FDA does not have the power to ban vaccines and milk pasteurization, which are regulated at the state level, or fluoridated water, which is determined by municipalities. But if the FDA were to change its guidance on these issues, it could affect decision-making at lower levels of government.

Stoking fear can have deadly consequences. In 2018, after two babies in Samoa died from a vaccine that had been incorrectly mixed with muscle relaxant instead of water, the Samoan government shut down its vaccination program for a 10-month investigation. During this period, Kennedy visited the island nation, meeting with government officials and writing to the prime minister to suggest the vaccine itself had caused the deaths. Kennedy waged what health advocates called a “significant disinformation campaign” in the country, contributing to fear, mistrust and low vaccination uptake once the program restarted. Months later, in 2019, the country was decimated by a deadly measles outbreak that killed at least 83, mostly children and babies, and sent 1,867 to the hospital.

Deregulating Industry at the Expense of Public Health

Across the government, Trump will likely continue the anti-regulatory policies of his first term. In 2020, Trump’s HHS Secretary Alex Azar instituted a rule preventing the FDA from requiring premarket review for laboratory-developed tests (LDTs), or diagnostic tests that have been designed, manufactured and used within a single laboratory. Biden’s HHS Secretary Xavier Becerra reversed this policy in 2021, and the FDA took subsequent steps to secure this regulatory power, noting: “LDTs are being used more widely than ever before – for use in newborn screening, to help predict a person’s risk of cancer, or aid in diagnosing heart disease and Alzheimer’s. The agency cannot stand by while Americans continue to rely on results of these tests without assurance that they work.”

The FDA does not have the power to ban vaccines and milk pasteurization, which are regulated at the state level, or fluoridated water, which is determined by municipalities.

During Trump’s first term, the FDA sent significantly fewer “warning letters” and carried out fewer other enforcement actions than in the prior administration. And although it is impossible to trace as a direct cause, the Natural Resources Defense Council pointed out that a deadly 2018 outbreak of E. coli linked to romaine lettuce occurred after the Trump administration suspended enforcement of a rule banning the irrigation of vegetables with manure-contaminated water.

Kennedy may bring an anti-regulatory agenda to another industry: the murky and already loosely regulated world of dietary supplements. The CEO of a botanical plant testing company told a supplement trade journal in November that Kennedy has been receptive to his industry’s requests, saying: “I’ve been helping to connect our trade association leadership with RFK’s people to assemble a needs list for our industry from the FDA.”

Yet, Kennedy supports a strange mix of pro- and anti-regulatory policies, and if confirmed, will be at odds with others in the administration. Not only will he encounter disagreements over his vaccine conspiracy theories, but he will hit serious pushback in his plans to ban “ultra-processed food,” a somewhat vaguely defined category of foods that have been significantly altered from their original state and make up an estimated 70 percent of the U.S. food supply.

While Kennedy’s rhetoric lacks the specifics and scientific detail that are necessary when making FDA policy, his concerns over food additives and the American diet are well-founded. They are also out of step with the Republican Party.

“His best ideas are inconsistent with what the GOP believes,” Lurie told Truthout. “His best ideas are pro-regulatory in one way, shape or form. But this is an anti-regulatory party, and never more so than under Trump.… And similarly, many of the ideas that he has are things that industry will resist very, very strongly. And we also know that the GOP is highly receptive to the entreaties of industry.”

How Does This Fit Within the Conservative Agenda?

While Trump’s approach to the presidency is unprecedented in many ways, his anti-regulatory agenda fits within a decadeslong project.

Project 2025 is not the first presidential guide to come out of the Heritage Foundation. Heritage releases a new Mandate for Leadership with each incoming president, dating back to Ronald Regan’s election in 1980. As historian Kim Phillips-Fein outlined in The Nation last June, the first Heritage Mandate was effectively “a blueprint for how American government could work if many of the executive agencies that had been created during the New Deal and the Great Society were cut back or eliminated.” Like Project 2025, the 1980 Mandate called for a limited, dismantled federal government, as well as the elimination of entire departments.

The right has continued deregulation efforts through the first quarter of the 21st century. Each year since 2009, Republicans have introduced the REINS Act, which would hamstring agencies by requiring congressional approval for any rules with an economic impact of $100 million. In 2023, every House Republican voted for an even more extreme version of the legislation. In 2017, Trump issued an executive order requiring that for every federal regulation implemented, two others must be rescinded. And in 2024, the highly politicized Supreme Court stripped federal agencies of the power to interpret federal law, making it significantly harder to issue regulations.

During Trump’s first term, the FDA sent significantly fewer “warning letters” and carried out fewer other enforcement actions than in the prior administration.

Despite consistencies between the 1980 Mandate and Project 2025, Phillips-Fein does note a shift in tone and focus. The early version, writes Phillips-Fein, focused on government structure, mostly avoiding discussion of “abortion, family values, crime, religion, or sexuality.” In comparison, she notes Project 2025’s emotional, fearmongering language, in which the authors decry the “‘toxic normalization’ of transgenderism, ‘pornography invading’ school libraries, and most of all the ‘Great Awokening,’ which it likens to a ‘totalitarian cult.’”

Also writing in The Nation, historian Herbert J. Gans outlined a shift within the GOP as well. One month into Trump’s first term, in February 2017, Gans described what he called “The Overthrow Project.” While Republicans have always sought limited government, he wrote, now they were seeking “a radical shrinkage of the federal government that comes close to overthrowing it entirely.” He outlined a cohesive strategy — developed by think tanks and supported by wealthy donors and businesses — to lower taxes on the rich, reduce taxes and regulations on business, and privatize as much of government as possible.

What’s more, Gans argued, “the Overthrow Project also aims to obtain permanent control over all branches of the federal and state governments” by using an “increasingly aggressive and norm-violating form of hardball politics.” He was referring to Republican maneuvers like refusing to hold confirmation hearings for Obama’s 2016 Supreme Court nominee on the pretext that eight months out was too close to an election, only to push through Trump’s 2020 nominee less than one month before an election. Or how in 2022, after judges ruled that maps had been illegally gerrymandered in favor of Republicans in four red states, the states used the maps anyway.

Now in 2025, we are living through the continuation the far right’s full-on attack on the federal government. Trump’s initial blitz of executive orders advance the Project 2025 agenda, taking steps to dismantle and render ineffective federal agencies like the FDA, which have protected Americans’ health and safety for generations.