MV TELEGRAPH

U.S. President-elect Donald Trump arrives on November 13, 2024 at Joint Base Andrews, Maryland. 

Andrew Harnik | Getty Images

President-elect Donald Trump’s return to the White House is poised to have big impacts on consumer health care.

Republicans may face few legislative roadblocks with their goals of reshaping health insurance in the U.S., experts said, after the party retained its slim majority in the House of Representatives and flipped the Senate, giving it control of both Congress and the presidency.

Households that get health insurance from Medicaid or an Affordable Care Act marketplace plan may see some of the biggest disruptions, due to reforms sought by Trump and Republican lawmakers, according to health policy experts.

Such reforms would free up federal funds that could be used to help pay for other Republican policy priorities like tax cuts, they said.

Just under 8% of the U.S. population is uninsured right now — the lowest rate in American history, said Michael Sparer, a professor at Columbia University and chair of its Department of Health Policy and Management. That figure was 17% when the Affordable Care Act was enacted more than a decade ago, he said.

“That rate will start going up again,” Sparer said.

Trump announced on Nov. 14 that he wants to tap Robert F. Kennedy Jr. to run the Department of Health and Human Services, which includes the Centers for Medicare & Medicaid Services. CMS, in turn, administers the Affordable Care Act marketplace and the Children’s Health Insurance Program, or CHIP, among other endeavors.

Robert F. Kennedy Jr. speaks with Republican presidential nominee former President Donald Trump at a Turning Point Action Rally in Duluth, GA on Wednesday, Oct. 23, 2024. 

The Washington Post | The Washington Post | Getty Images

Kennedy, a vaccine skeptic who’s been accused of spreading conspiracy theories, has vowed to make big changes to the U.S. health-care system.

A spokesperson for Trump’s transition team did not respond to a request from CNBC for comment about the president-elect’s health policy plans.

Here’s how health care could change for consumers during the incoming Trump administration, according to experts.

Affordable Care Act marketplace

A lab technician cares for a patient at Providence St. Mary Medical Center on March 11, 2022 in Apple Valley, California.

Mario Tama | Getty Images News | Getty Images

‘Betting’ premium subsidies will expire

Based on how the election went, the enhanced subsidies on the Affordable Care Act will likely not be renewed once they expire at the end of 2025, said Cynthia Cox, vice president and director of the ACA program at KFF, a health policy research organization.

“If I was going to place a bet on this, I’d be much more comfortable betting that they are going to expire,” Cox said.

More from Personal Finance:
What Trump’s tariff plan may mean for your wallet
What a Trump presidency could mean for your taxes
What Trump could mean for the housing market

That government-backed aid, originally passed during the pandemic under the American Rescue Plan in 2021, has significantly lowered the costs of coverage for people buying health insurance plans on the ACA marketplace. Those customers include anyone who doesn’t have access to a workplace plan, such as students, self-employed consumers and unemployed people, among others.

An individual earning $60,000 a year now has a monthly premium of $425, compared with $539 before the enhanced subsidies, according to a rough estimate provided by Cox. Meanwhile, a family of four making about $120,000 currently pays $850 a month instead of $1,649.

Permanently extending the enhanced ACA subsidies could cost around $335 billion over the next 10 years, according to an estimate by the Congressional Budget Office.

“They’re concerned about the cost, and they’re going to be cutting taxes next year likely,” Cox said, of Republicans.

Still, it’s a ‘big’ gamble to forgo health insurance

Around 3.8 million people will lose their health insurance if the subsidies expire, the Congressional Budget Office estimates. Those who maintain their coverage are likely to pay higher premiums.

“The bottom line is uncertainty,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy.

“The good news for marketplace consumers is that the enhanced [subsidies] will be available through 2025, so there should be no immediate changes,” Corlette added.

Even if the subsidies disappear, experts say it’s important to stay enrolled if you can, even if you have to make trade-offs on coverage to keep the costs within budget.

Enrolling in a plan, even a cheaper plan with a big annual deductible, can provide an important hedge against huge costs from unforeseen medical needs like surgery, said Carolyn McClanahan, a physician and certified financial planner based in Jacksonville, Florida.

“I can’t emphasize how big a gamble it is to go without health insurance,” said McClanahan, founder of Life Planning Partners and a member of the CNBC Financial Advisor Council.

“One heart attack easily costs $100,000” out of pocket for someone without insurance, she said. “Do you have that to pay?”

Medicaid

A ‘pretty big target’ for lawmakers

Medicaid is the third-largest program in the federal budget, accounting for $616 billion of spending in 2023, according to the Congressional Budget Office. Trump campaigned on a promise not to make cuts to the two largest programs: Social Security and Medicare.

That makes Medicaid the “obvious place” for Republicans to raise revenue to finance their agenda, said Larry Levitt, executive vice president for health policy at KFF.

“Medicaid will have a pretty big target on its back,” Levitt said.

The bottom line is uncertainty.

Sabrina Corlette

co-director of the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy

Cuts would “inevitably mean” fewer households would get benefits, Levitt said. Medicaid recipients tend to be lower-income households, people with disabilities and seniors in nursing homes, he said.

Medicaid cuts were a big part of the push among Trump and other Republican lawmakers to repeal and replace the Affordable Care Act, also known as Obamacare, in 2017, Levitt said.

Those efforts were ultimately unsuccessful.

How Medicaid might be curtailed

Maskot | Maskot | Getty Images

The new Medicaid cuts may take many forms, according to experts, who cite past proposals and remarks from the Trump administration, Republican lawmakers and the Project 2025 conservative policy blueprint.

For example, the Trump administration may try to add work requirements for Medicaid recipients, as it did during his first term, said Sparer of Columbia University.

Additionally, Republicans may try to cap federal Medicaid spending allocated to states, experts said.

The federal government matches a portion — generally 50% or more — of states’ Medicaid spending. That dollar sum is uncapped.

Republicans may try to covert Medicaid to a block grant, whereby a fixed amount of money is provided annually to each state, or institute a per-capita cap, whereby benefits are limited for each Medicaid enrollee, Levitt said.

Lawmakers may also try to roll back the Medicaid expansion under the Affordable Care Act, which broadened the pool of people who qualify for coverage, experts said.

They could do this by cutting federal financing to the 40 states, plus the District of Columbia, that have expanded Medicaid eligibility. That would shift “an enormous financial risk to states, and many states as a result would drop the Medicaid expansion,” Levitt said.

Short-term health insurance plans

Under the previous Trump administration, consumers saw an increase in the availability of non-ACA compliant health insurance options, including short-term plans, experts say. The same is likely to happen over the next four years.

Short-term health insurance plans offer coverage for limited amounts of time, and typically on fewer medical services than comprehensive coverage.

Proponents of these plans say they allow insurers to offer consumers lower monthly premiums because they’re not required to cover as many services. At the same time, the plans are able to reject people with preexisting conditions or charge them more. While Trump was in office, enrollment in short-term plans spiked.

The U.S. Capitol building in Washington, D.C., Oct. 4, 2023.

Yasin Ozturk | Anadolu Agency | Getty Images

“The previous Trump administration and many in the GOP have called for expanding the marketing and sale of short-term plans and other insurance products that do not have to satisfy the ACA’s pre-existing condition standards and other consumer protections,” said Georgetown University’s Corlette.

She said that consumers can be attracted to the plans for their low costs, but often learn too late how thin the coverage is.

Drug prices

It’s unclear if lawmakers would keep the drug policies intact, experts said. Trump signed executive orders in 2020 aimed at lowering costs for prescription medications, for example.

“It’s not at all clear Trump will be a friend of the pharma industry,” Sparer said.

For example, the Inflation Reduction Act gave the federal government — for the first time — the authority to negotiate prices with pharmaceutical companies over some drugs covered by Medicare.

That provision is slated to kick in for 10 drugs — some of Medicare’s “most costly and most used” medications, treating a variety of ailments like heart disease, diabetes, arthritis and cancer — in 2026, according to the Centers for Medicare & Medicaid Services.

The measure will save patients $1.5 billion in out-of-pocket costs in 2026, CMS estimates. The federal government would expand the list of medications in ensuing years.

The Inflation Reduction Act also capped Medicare copays for insulin at $35 a month. They were previously uncapped. The average Medicare Part D insulin user had paid $54 out of pocket a month per insulin prescription in 2020, according to KFF.

The law also capped out-of-pocket costs at $2,000 a year for prescription drugs covered by Medicare, starting in 2025. There was previously no cap.

About 1.4 million Medicare Part D enrollees paid more than $2,000 out of pocket for medications in 2020, KFF found. Those costs averaged $3,355 a person.

Don’t miss these insights from CNBC PRO

Independent presidential candidate Robert F. Kennedy Jr. makes an announcement on the future of his campaign in Phoenix, Arizona, U.S. August 23, 2024. 

Thomas Machowicz | Reuters

President-elect Donald Trump has tapped Robert F. Kennedy Jr. to lead the Department of Health and Human Services – a selection that is raising fears in the public health community and leaving the biotech and pharmaceutical industries bracing for disruptions to drug development.

Trump’s announcement on Thursday gives Kennedy, a notorious vaccine skeptic, a good chance of securing the nation’s top health-care job. The coming Republican-held Senate will ultimately decide whether to confirm him, though Trump has raised the prospect of sidestepping that process with recess appointments. 

If confirmed, Kennedy will take the reins of a $1.7 trillion agency that oversees vaccines and other medicines, scientific research, public health infrastructure, pandemic preparedness, food and tobacco products. HHS also manages government-funded health care for millions of Americans – including seniors, disabled people and lower-income patients who rely on Medicare, Medicaid, and the Affordable Care Act’s markets.

The heads of the Food and Drug Administration, Centers for Disease Control and Prevention, National Institutes of Health and Centers for Medicare and Medicaid Services all report to the HHS secretary, though Trump has yet to nominate them. Kennedy will likely have some influence over who the president-elect chooses for those roles, health policy experts said. 

Some health policy experts told CNBC that Kennedy could elevate vaccine skepticism and deter more Americans from taking recommended shots, attempt to cut funding or entire departments at different agencies and shift research and development toward more alternative treatments or disease areas of interest to him, among other efforts.

Kennedy’s so-called “Make America Healthy Again” platform argues a corrupt alliance of drug and food companies and the federal health agencies that regulate them are making Americans less healthy. Kennedy has long argued that the agencies that HHS oversees need reform or a sweeping overhaul, part which could mean cutting funding, purging staff and hiring new employees who share his often disproven views on health and science. 

He has also said he wants to remove fluoride from drinking water systems and target chronic diseases by cracking down on food and chemical additives, among other efforts.

But there will be some limits to Kennedy’s power – even with a Republican government trifecta. Some of his proposals, such as cutting funding, may not easily pass through Congress. Other efforts could spark expensive and prolonged litigation against the federal government. 

Spokespeople for Kennedy and Trump’s campaign did not immediately respond to requests for comment.

Here are some of the things that Kennedy may – or may not – be able to accomplish as HHS secretary. 

Vaccines

Brandon Guerrero, 34, of Compton, receives both a flu and COVID-19 vaccine at CVS in Huntington Park on August 28, 2024.

Christina House | Los Angeles Times | Getty Images

Kennedy is a staunch critic of vaccines, which have saved the lives of more than 1.1 million children in the U.S. and saved Americans $540 billion in direct health-care costs over the last three decades, according to CDC research released in August.

He has long made misleading and false statements about the safety of shots. He has claimed they are linked to autism despite decades of studies that debunk that association. Kennedy is also the founder of the nonprofit Children’s Health Defense, the most well-funded anti-vaccine organization in the U.S. 

Ultimately, Kennedy’s influence over immunization policy could lead to an increase in diseases preventable by vaccines, several health policy experts told CNBC. 

“He could create considerable distrust in vaccines and make some vaccines highly politicized, so in particularly red states, we could see outbreaks of fully preventable childhood diseases,” Gostin said. That includes measles, mumps, rubella and polio.

Despite his history, Kennedy told NBC News in early November that he isn’t planning to take anyone’s vaccines away in the U.S. 

That would be a difficult task, experts said. The FDA can pull a product from the market if further trials after approval fail to confirm that its clinical benefits outweigh its risks, or if unexpected risks are detected among patients. That has not been the case with the approved shots on the market. 

“It would be hard to imagine that a new HHS Secretary would be able to immediately remove vaccines that are already approved and already being used and recommended by the government from the market,” said Josh Michaud, associate director of global health policy at KFF, a health policy research organization. “He can’t just make that change with a simple wave of a wand.”

Still, Kennedy has repeatedly argued that there is not enough data on vaccines and their effects. He told NPR earlier this month that the Trump administration is going to “make sure those scientific studies are done and that people can make informed choices about their vaccinations and their children’s vaccinations.” 

As HHS secretary, Kennedy could “cherry pick” data from additional government studies and release misleading results that undermine trust in the safety and efficacy of vaccines, said Lawrence Gostin, a health law and policy expert at Georgetown University.

That misinformation could deter some Americans from receiving certain shots. Michaud added vaccine misinformation could push health officials on the state and local level to “perhaps allow for more individual choice rather than mandating routine vaccination” for certain diseases. 

Many state health departments and clinicians rely on vaccine recommendations from an advisory committee to the CDC. Those include who should get what shots and at what age. 

Those guidelines have broader implications for public health. Vaccines recommended by that advisory panel and approved by the CDC director are covered under the Affordable Care Act. The agency also administers the Vaccines for Children program, which provides free vaccines for children in low-income families.

Kennedy could attempt to influence that CDC advisory committee and a similar panel linked to the FDA by stacking them with people who hold anti-vaccine views, Gostin said. The HHS secretary has the power to form an advisory committee, remove members and set the terms and qualifications for them.

That could produce more limited vaccine recommendations that aren’t firmly rooted in science, he added. It could also translate to a “fragmentation of vaccine policy” across the U.S. if only some states accept recommendations from advisors selected by Kennedy. 

Federal agency funding, staffing

Kennedy in recent weeks has pledged to end what he calls “corporate corruption” at federal health agencies and purge staff when he steps into his role in the Trump administration. 

He has said he would clear out “entire departments” at the FDA, saying that workers who stand in the way of approval of several controversial or dubious treatments should prepare to “pack their bags.”

Kennedy, before dropping out of the presidential race, also said he wanted to shift NIH’s focus away from infectious disease and toward chronic diseases like obesity for eight years. In September, Kennedy said half of the NIH’s $48 billion budget should go toward “preventive, alternative and holistic approaches to health.” 

A shakeup at the NIH – the largest public funder of biomedical research in the U.S. – could have major implications for research and the pharmaceutical industry. The NIH funds and conducts research on everything from vaccines and cancer to new drug targets, laying the groundwork for treatments that companies can develop.

“He could certainly allocate funding away from drugs that he’s not interested in and more towards maybe areas that are more speculative,” said Genevieve Kanter, associate professor of public policy at the University of Southern California.

Kanter pointed to his long history of embracing disproven treatments, such as claiming that hydroxychloroquine and ivermectin work against Covid, even though several studies say they do not. Hydroxychloroquine is an immunosuppressive drug, while ivermectin is used to treat infections caused by parasites.

Major changes or funding cuts at the NIH, FDA and CDC would require congressional approval. Federal employees are also protected against arbitrary or politically-motivated firing. 

FDA staff are further shielded because Congress does not fully fund their salaries. Nearly half of the agency’s $7.2 billion budget this year came from so-called “user fees,” or payments made by drug and medical device manufacturers to fund the staff resources needed to quickly review their products, conduct inspections and ensure the safety of clinical studies.

It seems “unlikely” that Kennedy would be able to end that user fee program, according to Richard Frank, director of the Brookings Schaeffer Initiative on Health Policy. But he may attempt to influence negotiations around how the program is implemented when Congress decides whether to reauthorize it after 2027, Frank said.

Gostin said other “cuts across the board” at the three agencies are possible, especially in areas that are “part of the culture wars.” The CDC could see funding reduced for key functions related to vaccines, chronic disease, sexual and reproductive health and firearm injury and prevention, according to Gostin. 

He added that the FDA’s nutrition departments could also see cuts or be “on the chopping block” altogether, given Kennedy’s intent to change what he calls the “broken” U.S. food system. 

Cracking down on pharma

Some Wall Street analysts are less concerned about Kennedy stifling drug approvals and regulation. 

“We anticipate RFK to focus on U.S. food policy and its relationship to chronic illness, not medicine,” BMO Capital Markets analyst Evan Seigerman said in a note last week.

Investors are already bracing for a crackdown on food policy, with shares of processed food companies, such as Pepsi and Coca-Cola, falling on Friday.

Wall Street has fewer immediate concerns about pharmaceutical companies. Seigerman said “there is little precedent in recent history for HHS policy dictating or affecting FDA regulation or approval of drugs.” 

He added that the impact on the biotech and pharmaceutical industry is still unclear until Trump selects an FDA commissioner, and that the firm is more confident that he will tap a candidate with “robust medical background and ties to the industry.” 

Still, Kennedy appears to favor “tighter controls and intervening a bit more” in the biotech and pharmaceutical industry, according to Dave Latshaw, CEO and co-founder of AI drug development company BioPhy. 

That could bring some uncertainty to the drug development and approval process, which poses a greater risk to companies that primarily have products in the earlier stages of development than to large pharmaceutical companies, Latshaw added. 

Kennedy could attempt to crack down on the biotech and pharmaceutical industry in other ways – but they may not be successful. 

He has said he wants to ban direct-to-consumer television drug advertisements. In 2023, pharmaceutical companies spent nearly $3 billion on advertising for the 10 most promoted drugs.

Experts said the First Amendment, which guarantees freedom of speech, would make that an extremely difficult task. Trump also tried to take on pharmaceutical advertising during his first administration by requiring companies to disclose the list prices of products in their ads. Drugmakers sued the government, and a federal court blocked the rule. 

Kennedy’s position on the drug pricing provisions in the Inflation Reduction Act, President Joe Biden’s signature legislation, is unclear. That 2022 law gave Medicare the power to negotiate drug prices with manufacturers for the first time in history – a provision that the pharmaceutical industry is challenging in court. 

But the Trump administration won’t have much flexibility to dismantle or scale back the law without change from Congress. It also seems unlikely Kennedy would want to scrap efforts to lower drug prices, an issue top of mind for Americans, according to Amy Campbell, associate dean for law and health sciences at the University of Illinois Chicago School of Law.

Fluoride, food supply

Kennedy earlier this month proposed advising all U.S. water systems to remove fluoride from drinking water, falsely claiming that it is “an industrial waste” linked to several medical conditions, such as thyroid disease and neurodevelopmental disorders. Trump has since said that idea sounds “OK to me.”

But fluoride is a naturally occurring mineral found in soil, water and plants. Adding low levels of fluoride to drinking water is widely considered one of the greatest public health achievements of the 20th century for its role in preventing tooth decay. 

Campbell said the decision to add fluoride to water happens at the state and local level, so Kennedy could only advise its removal. But even that could eventually lead to certain states doing away with fluoridation, she noted.

Kennedy has been vocal about tackling the root causes of chronic diseases rather than spending resources on treating those conditions with drugs from the pharmaceutical industry. There are still few details on what exactly that would look like, but Kennedy is targeting a real issue in the U.S.

An increasing share of people in America are dealing with multiple chronic conditions, with roughly 42% having two or more, according to the CDC. More than 40% of school-aged children and adolescents have at least one. 

Some of Kennedy’s ideas, such as stripping ultra-processed food from school cafeterias and cracking down on food dye, have found public support on the right and left. But he has pushed misleading claims and comparisons related to food in the U.S. and how it is regulated, such as incorrectly claiming that Froot Loops cereal in Canada contains just two or three ingredients when it has 17. 

Some experts said Kennedy could pressure the FDA commissioner to scrap or cut down the agency’s Center for Food Safety and Applied Nutrition. But banning the use of already-approved food additives would require more rather than fewer resources, experts added. They said that the process would likely involve extensive reviews of data and real-time monitoring of the food supply, among other efforts. 

Other changes may need to be spearheaded by the U.S. Department of Agriculture, which does not fall under HHS. For example, the USDA sets guidelines that govern school lunch programs. 

President-elect Donald Trump said Thursday that he will nominate vaccine skeptic and conspiracy theorist Robert F. Kennedy Jr. as secretary of the Health and Human Services Department.

If the Senate approves Kennedy, the former independent presidential candidate will lead a sprawling department responsible for the huge Medicare and Medicaid health coverage programs, the Food and Drug Administration, the National Institutes of Health, and the Centers for Disease Control and Prevention.

HHS’s decisions on spending and policies have major effects on the U.S. health-care system and related businesses.

Kennedy, 70, is the son of Robert F. Kennedy, the late U.S. attorney general and Democratic senator from New York who was assassinated in 1968 by a gunman in Los Angeles as he ran for president. He is the nephew of former President John Kennedy who was assassinated in 1963.

Trump said in October that if elected he would let Kennedy “go wild on health.”

“I am thrilled to announce Robert F. Kennedy Jr. as The United States Secretary of Health and Human Services,” Trump wrote in a post on his Truth Social site Thursday.

“For too long, Americans have been crushed by the industrial food complex and drug companies who have engaged in deception, misinformation, and disinformation when it comes to Public Health,” Trump wrote.

“The Safety and Health of all Americans is the most important role of any Administration, and HHS will play a big role in helping ensure that everybody will be protected from harmful chemicals, pollutants, pesticides, pharmaceutical products, and food additives that have contributed to the overwhelming Health Crisis in this Country.”

Kennedy told NBC News in a recent interview that Trump has said he wants Kennedy to “clean up corruption” at federal health agencies, return those agencies to science-based policies and “make America healthy again.” Kennedy said that “there are entire departments, like the nutrition department at the FDA, that have to go.”

Stock prices of vaccine makers fell earlier Thursday on reports that Trump would tap Kennedy for the HHS post.

Kennedy last year suggested that the Covid-19 virus, which CDC played a major role in combatting, was engineered to “attack Caucasians and Black people,” and to be less likely to harm “Ashkenazi Jews and Chinese” people.

He previously promoted theories that autism was linked to childhood vaccines, a connection that has been disproved.

Kennedy outraged many of his siblings by endorsing Trump in August after abandoning his long-short presidential candidacy.

Trump’s selection of Kennedy came a day after the Republican president-elect tapped Florida Rep. Matt Gaetz as attorney general.

Gaetz’s selection immediately sparked controversy due in large part to the fact that the Department of Justice, which he would lead as AG, previously investigated him for possible sex trafficking of a 17-year-old girl. Gaetz resigned from Congress effective Thursday, removing him from the jurisdiction of the House Ethics Committee, but a number of Republican senators have called on that panel to release a report of its investigation of the former lawmaker.

Kennedy last week reportedly suggested he would fire 600 NIH workers and replace them.

His “Make America Healthy” website has been seeking suggestions from the public for more than 4,000 appointee posts across the federal government to be filled by Trump.

Senate Finance Committee Chairman Ron Wyden, D-Ore., blasted Kennedy in a statement.

“Mr. Kennedy’s outlandish views on basic scientific facts are disturbing and should worry all parents who expect schools and other public spaces to be safe for their children,” Wyden said. “When Mr. Kennedy comes before the Finance Committee, it’s going to be very clear what Americans stand to lose under Trump and Republicans in Congress.” 

Another Democrat, Sen. Patty Murray of Washington, said “Donald Trump’s selection of a notorious anti-vaxxer to lead HHS could not be more dangerous — this is cause for deep concern for every American.”

“There is no telling how far a fringe conspiracy theorist like RFK Jr. could set back America in terms of public health, reproductive rights, research and innovation, and so much else.”

Sen. John Thune of South Dakota, who will become Senate majority leader in January when Republicans take control of the chamber, said he did not have any reaction to Kennedy being picked for the HHS job.

“Honestly, the entire nomination process is just getting started, so let’s, let’s give it a chance to see what happens,” Thune told reporters. “And these names, none of them have been formally submitted yet, so there’s going to be a vetting process. I’ve told people, these will be worked out under advise and consent, and we’ll make sure that we process them there.”

But other Republican senators, including Tommy Tubervilple of Alabama, Kentucky’s Rand Paul and Josh Hawley of Missouri, praised Kennedy’s selection.

“Bad day for Big Pharma,” Hawley tweeted.

Andrea Ducas, vice president of health policy for the advocacy group Center for American Progress, in a statement called Trump’s choice of Kennedy “would be nothing short of disastrous for the country.”

“His track record and open skepticism of longstanding medical science could jeopardize the incredible public health gains we’ve accomplished as a nation – including the gains we’ve made in combatting infectious disease through childhood vaccination programs and in making our food supply safer through pasteurization,” Ducas said.

“This pick is especially troubling coming at the heels of the COVID-19 pandemic, where lifesaving vaccines averted countless infections and deaths.”