The Most Vulnerable Are At the Greatest Risk
The repeated theme in the uncertainties of federal spending is that Medicaid will have to suffer a huge hit to make the numbers work for Donald Trump’s visions about underwriting immigration and military programs and providing permanent tax cuts for the wealthy.
Primarily, those projected $880 billion in cuts over 10 years being required by recent House resolutions will hit at tens of millions of Americans with the most vulnerability.
But it’s become apparent that cutting Medicaid would also affect those beyond direct recipients, but those who rely on the medical facilities that are financially dependent on the program’s reimbursements. From all accounts, rural hospitals fear massive Medicaid cuts could decimate maternity services or close already struggling medical facilities.
Those hospitals disproportionately serve communities that overwhelmingly voted for Trump.
A recent analysis in JAMA Network Open warns that the country already may face a shortage of beds by 2032, the result of an aging population with more complex health problems, increasing chronic disease, labor shortages and hospital finances. It’s a trend building since 2009. exacerbated during Covid, but the point is that there already are issues for hospitals.
And, in a variety of ways, hospitals — urban and rural — increasingly are turning to corporate alliances and business practices based more on finance than health.
Nearly half of all rural hospitals nationwide, often small facilities, operate at a deficit, with Medicaid barely keeping them afloat. Almost 200 rural hospitals have closed over 20 years, according to the Cecil G. Sheps Center for Health Services Research, part of the University of North Carolina at Chapel Hill.
We’ve Known This
None of this is a secret, and little of it is new. But almost none of it is getting a full hearing as “populist” Republicans seeking to change federal spending, consider big cuts to Medicaid. Instead, they insist, as they do with other federal spending programs, that the differences can come from trimming fraud and waste in overpayments and striking ineligible patient reimbursements.
In scattered news articles and interviews, there are warnings about the effects that shutdowns of rural hospitals will mean. Longer transit to a regional hospital will mean more heart attacks and strokes will prove fatal or severe, for example. Rural nursing homes may vanish. Prenatal checkups will require long drives, and, well, we know that rural hospitals in red states are abandoning abortion and unrelated maternal health care, reimbursable or not.
Perception of Medicaid as primarily serving the urban poor but statistically, rural children and non-elderly adults are more likely to rely on Medicaid or the Children’s Health Insurance Program (CHIP) than those in metro areas, according to the Center for Children and Families at the McCourt School of Public Policy at Georgetown University.
More than 35 percent of U.S. counties don’t have birthing facilities or obstetric clinicians, according to a March of Dimes report. In Texas, that figure is closer to 50 percent. Cuts to Medicaid will prompt more decisions to shut down maternal health units.
Let’s throw in closing down services provided by the Veterans’ Administration by the 80,000 employees it wants to dismiss. Does anyone in the Trump administration coordinate among the departments about the ripples it is sending across the country?
The Politics
Seeing the writing on the wall, even some Republicans, including Sen. Josh Hawley. R-Mo., and Trump ally Stephen K. Bannon have advised against cuts to Medicaid. Trump says he will not touch Medicaid, even as he supported the bill to insist on them and is unleashing Elon Musk and his computer minions on health coverage.
We all understand that cutting federal spending means eventually having to consider cuts to Medicaid, Medicare and Social Security in one form or another, since they make up about 40 percent of federal spending.
The alternative, promoted over time by Democrats, is to tax the wealthy at a fair share of income, which will eliminate the financial pressure.
Trump wants the tax cuts.
KFF, which monitors health issues, has a recent poll showing three in four rural residents saying that Medicaid funding should increase or stay the same. Republicans promoted Medicaid cuts in 2018 and lost the elections.
Of course, Trump being Trump, we can expect that there will be exceptions to protect certain states or regions or some other political accommodation. Generally, Trump favors shifting federal costs to states altogether.
Apart from being health facilities, hospitals also are substantial employers, particularly in rural communities.
Republicans insist that tightening work requirements will reduce eligibly without changing reimbursements, an assertion belied by statistics that show that the vast majority of patients are working, looking for work, or disabled. Medicaid was extended through work stoppages during Covid, and millions were removed from Medicaid rolls as a result. Republicans also claim there is too much fraud and waste in the system, and there are occasional prosecutions for fraudulent billing. But the chances of that rolling up the hundreds of billions of cuts proposed is slim to none.
Health care is expensive, without question. America is aging and its rural counties are growing, without question. It would seem a rationale issue for the Trump administration to analyze, though these questions are not among the top 10 even getting a mention from Health and Human Services Secretary Robert F. Kennedy Jr.
Waving a magic wand isn’t going to provide good health care for all with no investment. It is a values question for America. Simply put, this administration values billionaires’ tax reductions over extension of health benefits.
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