Trump’s One Big Beautiful Bill is said to reduce healthcare fraud and abuse, especially in the Medicaid population. It’s supposed to get able-bodied laggards back to work so only the ones who deserve Medicaid get it.
Certainly there’s some truth to that observation, just like the ICE activity we’ve seen in Southern California was supposed to go after just the criminal immigrants here illegally, but have somehow also picked up immigrants who have committed no crimes, based on skin color, language accent, and where they work, live, and shop.
The Medicaid population is easier to hit than Medicare, since Medicaid doesn’t have a powerful lobby like the older, wealthier gray panthers who also vote in droves. And Medicare associated provider lobbies (doctors, hospitals, pharmaceutical, equipment) are huge and well funded. Healthcare is the largest component of the federal budget, which consequently must be reduced in order to afford the huge tax cuts given the uber wealthy.
It will be hard enough to maintain clinical excellence when the cost of care keeps rising and fewer skilled clinicians will be available to deliver that care, now that DOGE and Robert F. Kennedy Jr. have undercut the foundational science and training pool of future clinicians. Creating novel and impactful medicines is not cheap, and although emerging technologies will make healthcare more efficient, they also have costs of development and deployment. The best we can hope for, assuming we don’t go backwards in quality of care, is a reduction in the rate of rise of healthcare costs,
The reality that all of us need to realize, regardless of your political preferences, is that eventually, each and every one of us will be a patient, assuming no catastrophic event intervenes. And not just us, but our families, parents, children, and grandchildren. You may have noticed that our local hospital just closed its pediatric unit, leaving only once pediatric hospital care facility in Ventura County. Illness does not care about your money, race, ethnicity, partner in life, or how important you think you are.
So what will Trump’s and the Congressional majorities (barely) legislation in the Big Beautiful Bill do to your healthcare, assuming you’re not paying cash?
Most Medicaid providers operate on a very thin profit edge. The further loss in Medicaid revenue ($960 billion, affecting 80 million Medicaid enrollees, half being children) has providers pondering what services will need to be cut and even which facilities will need to close. The prior bipartisan coalitions that protected rural and underserved populations collapsed, as targeted pressure from the White House and Congressional leaders gave them some things to take back to their constituents, but to sacrifice everyone else. Vocal GOP opponents folded.
The nonpartisan Congressional Budget Office that looks at the results of legislation gave estimates that at least 10 million more people will lose their health insurance, and that number may go up to 18 million when the full impact is eventually known. Adding $3.4 trillion to our national debt over the next decade is just another fact to be ignored by the White House. Of course, this particular Congress does not believe its own accountants, so it just pressed ahead.
Even health insurance companies, on no one’s Christmas list, are facing reduced revenue since their previously powerful lobbying efforts to protect their income have been largely ignored. Unless one is an investor or employee of these insurance companies, we can’t feel that bad for their loss of market valuation. But this will have the effect of raising premiums and providing fewer options even for those able to afford private insurance.
Doctor groups, opposed to cuts to the Medicaid population, were somewhat mollified by proposals to increase payments to Medicare. But instead of a multiyear bump, they got a one-year boost. A small rural hospital fund was put in, but is seriously underfunded compared to the massive losses this legislation will deliver. And children may be disproportionately impacted.
Most Americans do not realize that pediatric health care is largely dependent on Medicaid. About 40% of all children in this country, about 37 million, are covered by Medicaid or CHIP (Children’s Health Insurance Program). That includes getting preventive care and vaccinations. Think about it. Without insurance, children and families will likely delay getting care which raises the acuity level and increases complications when they eventually do see a clinician. Thanks to the vaccine hesitancy espoused by RFK Jr. and his handpicked inadequately credentialed members of the Advisory Committee on Immunization Practices, we will likely see a fall off in vaccination rates to below that which provides the herd immunity that protects all us. The measles outbreak that began in West Texas is exhibit A.
Moreover, when services are reduced, there is a tendency to regionalize the care to concentrate the expertise available to care for pediatric patients in need. These centers tend to be in urban centers or be more specialized like dedicated service hospitals. This geolocation only exacerbates the difficulties in traveling for care, much less acute emergency care. This stresses the availability of care even for those who have insurance, so being uninsured impacts everyone.
The same is true, of course, for adults without insurance. So being uninsured worsens outcomes and raises the eventual cost of care, which then impacts all of us. That’s one of the reasons why every other civilized country has universal healthcare coverage; it reduces the total cost of care. That’s a topic I’ve covered many times in prior columns over the years. That’s also why the prior efforts to expand coverage of previously uninsured people has always been so important.
During the pandemic, the Congress in a bipartisan fashion, and the Biden White House, forbade states from removing people from health insurance plans and pumped money into Medicaid to provide people with healthcare when it was needed. And there indeed was improper and fraudulent sign-ups by unscrupulous brokers, and the Biden administration began cracking down. But potential abuse was not wholesale, and certainly not warranting the massive cuts that Trump is implementing. No previous American Congress has ever written legislation that knowingly cuts millions of people from health coverage. So, incredibly and obscenely, we are now going backwards. Hardly making America great in the eyes of the civilized world, and likely leading developing countries to look elsewhere for aspirational leadership.
Cleverly, the GOP has staggered to impact of this bill. The tax benefits accrue immediately. But the cuts to healthcare phase in after the 2026 midterm elections so the victims of this BBB won’t feel the pain until after the House and Senate elections. The GOP is banking on their belief that the electorate has the memory of a goldfish. Make sure they’re wrong.
Irving Kent Loh, M.D., is a preventive cardiologist and the director of the Ventura Heart Institute in Thousand Oaks. Email him at drloh@venturaheart.com.
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