February 28, 2025
Dear Interested Readers,
A Reverse Robin Hood? Will Cuts In Benefits For The Poor Finance Tax Cuts For The Rich?
Last week I had the revelation that I have a lot of conservative DNA that has been hiding within my desire to promote “progressive” social policies to improve the social determinants of health and continue on the very long road toward the elusive Triple Aim. I have long been frustrated by many of the obvious inefficiencies in our state and Federal bureaucracies. Unlike Donald Trump and Elon Musk, I don’t think the answer is to fire millions of employees and blow up initiatives like DEI efforts across the government, and cripple, destroy, or pervert departments and agencies like USAID, the Consumer Protection Agency, the EPA, the Department of Education, the FBI, the Justice Department, and the IRS.
In retrospect, since I spent my professional life in a large healthcare organization, there has always been a need for “‘improvement.” Our efforts to improve never involved the disruptive dramas that seem attractive to the president and his organizational guru, Elon Musk. I have favored utilizing the processes of “continuous improvement” and “best practices” in concerted efforts to improve the access, cost, quality, and patient-centeredness of care in an environment that simultaneously sought to improve the work experience of healthcare professionals.
It is chilling for me to imagine trying to improve the government by weaponizing the Department of Justice or reprograming the FBI to investigate those who have investigated the January 6, 2021 attack on the Capital and the felonies of the president. The recent announcement that the presidential press corps will be hand-picked by the president feels like we are being shoved step by step toward an even more obvious autocracy where oligarchs are advantaged, and the underserved are kept in their servitude. I don’t know if we are moving toward an autocracy, an oligarchy, or a kleptocracy, but it is feeling less and less like we are in a healthy constitutional democracy.
For me, the big event of the week has not been Trump’s attempt to extort the natural resources of Ukraine much like a mob boss selling “protection” or his announcement that an easy road for foreigners to emigrate to America is to pay $5,000,000 for a “gold” green card. My biggest disappointment was the passage of the tax and revenue bill in the House that suggests that Medicaid and other social programs like SNAP might eventually be gutted in favor of extending and perhaps expanding the tax law of 2017.
I will confess that I was hoping that far-right remnants of the libertarian Tea Party movement of fifteen years ago would create a division within MAGA world which would be a problem for Speaker Mike Johnson and be a speed bump for our reckless president. As late as Monday night it appeared that my hopes might be fulfilled, but then all but one of the holdouts, Representative Tom Massie of Kentucky, folded on Tuesday to pressure from Speaker Johnson and the president. The result was the passage of a bill that calls for 4.5 trillion in tax cuts balanced by 2 trillion in budget cuts over the next decade. Those 2 trillion in budget cuts may eventually lead to 880 billion in Medicaid and CHIPS cuts plus substantial reductions to SNAP (food stamp) allotments to needy families and individuals. Cutting Medicaid and the CHIPS healthcare coverage and perhaps subsidies to the ACA marketplace for health insurance could have a significant impact on almost 80 million Americans, but cutting Medicaid is seen as more politically acceptable than cutting Medicare and/or Social Security.
Drew Altman, the CEO of the Kaiser Family Fund published an editorial yesterday that further expanded my concept of my intersectionality and common ground with voices that before these crazy times I would have said had nothing in common with me. How could it be that I am on the same page as Steve Bannon concerning the actions taken by the House on Tuesday? Altman’s piece began in a way that surprised me:
The noted health policy expert Steve Bannon had a warning for Republicans interested in cutting federal Medicaid spending, saying: “A lot of MAGAs on Medicaid. If you don’t think so you are dead wrong. You can’t just take a meat axe to it.” Bannon was correct, there are more than 20 million Republicans on Medicaid, although I don’t know from our polling how many of them regard themselves as MAGA. We asked Trump voters about Medicaid in focus groups we just conducted in Arizona, Pennsylvania, Kentucky, Arizona, Nevada, North Carolina, Ohio, Missouri and Oklahoma with Democratic and Republican Medicaid beneficiaries. What we heard was that they were not expecting big Medicaid cuts from the Trump administration when they voted for President Trump and worry about what the impact of cuts in federal Medicaid spending will be.
I think that Altman had his tongue in his cheek when he referred to Bannon as a “noted healthcare policy expert,” but Bannon is an expert on the minds and emotions of MAGA voters. What is interesting in the blitzkrieg of the first month of the second Trump presidency is that with the exception of his early efforts to deport “illegals,” there is little that he is doing that seems aligned with the most critical issues facing a large swath of his constituency. He seems to have forgotten the little people as he caters to the desires of his billionaire buddies. In another article from KFF this week entitled “Republicans Once Wanted Government out of Health Care. Trump Voters See It Differently”, we read:
Like many Americans who voted for Donald Trump, Jason Rouse hopes the president’s return will mean lower prices for gas, groceries, and other essentials.
But Rouse is looking to the federal government for relief from one particular pain point: high health care costs. “The prices are just ridiculous,” said Rouse, 53, a retired Michigan firefighter and paramedic who has voted for Trump three times. “I’d like to see a lower cap on what I have to pay out-of-pocket.”
Government regulation of health care prices used to be heresy for most Republicans. GOP leaders fiercely opposed the 2010 Affordable Care Act, which included government limits on patients’ costs. More recently, the party fought legislation signed by former President Joe Biden to cap prescription drug prices.
But as Trump begins his second term, many of the voters who sent him back to the White House welcome more robust government action to rein in a health care system many Americans perceive as out of control, polls show.
Bannon understands the “MAGA mind” and appreciates the internal controversy that threatens the Trump circus. Altman continues with his analysis:
One implication: Trump built a populist base of working people formerly in the Democratic party, making it more difficult for him to support traditional conservative Republican efforts to cut federal programs that serve that population. That also makes it more likely for tension—if not a rift—to develop over spending cuts between Trump and Republicans on the Hill who want to cut entitlement programs that now serve a significant part of Trump’s base.
I hope the tensions that could threaten the president will build. It is almost impossible to see him preserving Medicaid, Medicare, and Social Security to keep the MAGA faithful comfortable while spending billions on deportations and the border, lowering taxes for the rich, introducing tariffs that worsen inflation, and increasing military spending as he turns Gaza into a Mediterranean playground for the rich while sucking up to Putin and raping Ukraine. I am hoping that the MAGA faithful and the former Democratic voters who were wooed into the MAGA camp by Trump with his lies will get pretty upset when the cost of eggs and beer (in aluminum cans) continues to rise while Jeff Bezos and Elon Musk get closer to being the world’s first trillionaires. Further on in his piece, Altman comments:
For Republican Trump voters on Medicaid, the election was about immigration and the economy, not Medicaid…
…In an especially relevant finding, Trump voters in the focus groups opposed cutting Medicaid to pay for tax cuts, because they do not see the tax cuts benefiting them. “I don’t make much money to get my taxes affected by that. It would hurt my Medicaid,” said a Trump voter in Nevada.
Overall, there are partisan and ideological differences between low-income Harris and Trump voters—that’s why they voted as they did—but in the end when it comes to health care, lower-income working people share common problems and needs. A Trump voter in Nevada summed it up: “Times are tough right now. You know everything is overpriced and no one is working and can’t afford anything, and my health is terrible, so it’s kind of tough times.” She was not expecting Medicaid to be cut.
Altman does raise the point that there is fraud and abuse in Medicaid. Will Trump find 880 billion in fraud and abuse when much of that largess is possibly coming from other MAGA enthusiasts? I can understand why many lower-income voters shifted their votes from Kamala Harris and other Democratic candidates to other faux Republicans and Trump who conned them like a carny barker at a county fair. I hope that these less affluent converts to the GOP from their traditional Democratic home will figure out in time that they are the victims of Trump’s attempt to solve simultaneous equations that don’t share a common solution. Once they understand the con, they may come home in 2026 and 2028 and allow another attempt to use government to improve everyone’s life experience. For that to happen, we will need elections in 2026 and 2028, and I am not certain that we will. Altman’s conclusion is:
Whatever happens in the short term in Congress, voter reaction will be somewhat muted until the congressional committees determine specific cuts that states and voters can react to, and we see how successful Republicans are at recasting spending cuts as eliminating fraud and abuse.
I fear that before 2026 there will be pain for many Americans who live in poverty or on its edge. Ironically, the pain is likely to be greatest in “red states.” Medicaid is a partnership between states and the Federal government which likely means that cutbacks in Medicaid funding will be experienced most severely in “red states.” Even now, there are ten “red states” that have not accepted the Medicaid expansion offered in the ACA. Trump may seek to “hide” the reductions in Medicaid by changes in payment methodologies to the states. How a state responds to the challenge will likely be dependent on which party controls the legislature and governor’s office.
I am sure that in states like Massachusetts, New York, Minnesota, and California, there are conversations in progress about what comes next. Perhaps prudent local healthcare leaders are getting together with state agencies and are asking “what if questions.” It would be prudent for organizations and state healthcare agencies to be doing some planning based on possible scenarios involving changes in the Federal government’s participation in healthcare finance. I can only hope that across the Southeast and in the Midwest the actions that are evolving in Washington have generated exercises in “planning for the worst” because their populations are facing the reduction in Federal support from more vulnerable positions. I hope that even in states with Republican legislatures and governors there is great concern for the health of their disadvantaged populations that have depended on Medicaid for their health, but I am not sure.
There have been many references to the benefits of reducing Medicaid and Medicare fraud and abuse, I wonder who will do that work after Elon Musk finishes decimating the Federal workforce in many of the places where those activities should occur. I doubt that the focus on Medicaid fraud and abuse referred to by Altman and others will generate 880 billion in savings, but what do I know for sure?
Unfortunately, I fear that not all patients and providers will benefit from forward-looking planning for the contingencies that might evolve as Medicaid is attacked. I would urge you, dear reader, to explore the plans that your organization is making to survive what may be an imminent political earthquake. Steve Bannon and I agree that there is likely to be growing tension in the fault lines of MAGA. I don’t know if Bannon would agree with me that the eruption that might occur would be a challenge to the health of all populations no matter what political “color” their state is.
My Grandsons Left Their Tracks
I had a great week with my grandsons. They wanted to do some ice fishing and we tried. I bought an “ice shelter” from Amazon that was easy to set up and stayed in place for several days without moving until we took it down. After setting up the shelter, I used a hand auger to cut through the ice which was three feet thick. Getting to and from the shelter required snow shoes because there were drifts of snow near the shoreline that were up to my thighs. At times in sunny areas, there was a slush down about two feet that must have been due to some strange solar phenomena because the temp was usually below twenty, way below twenty.
I had ordered ice fishing bait from Amazon, but it did not interest any fish even though we were fishing in exactly the same place where we catch a lot of “sunnies” and a few big basses every summer. The holes would freeze overnight and ultimately the end of our adventure coincided with the business end of the auger falling through the ice into deep water as I reopened one of the holes. I will need to wait until “ice-out” in April to “fish” out the auger.
What I did not anticipate, was just how much fun the boys would have walking in snow shoes. The header today shows some of the tracks that they left on the lake. Their uncle and aunt from Maine came down with their one-year-old cousin for the weekend. Having my three grandsons visit was a joy, but I was exhausted from all the fun by the time the week was over. I can hardly wait until they return in the summer. Before they left, we decided that next year the ice fishing would be better. A friend gave me an old power auger that I should have gotten serviced because it would not start. I have a year to get it ready. Cutting through three feet of ice with a hand auger is good exercise, but when I am over 80, it may be a challenge that I should avoid.
The week was a reminder of a life lesson that I won’t forget. You make your plans, and then you see what happens. I was very happy with our ice fishing adventures even though what I planned did not exactly happen. My son reminded me that “fishing” didn’t guarantee “catching,” but fishing, even without catching, can be a joy,
The temp rose into the warm thirties almost immediately after my grandsons boarded their flight to California with their father, but winter returned with more snow yesterday. A low of minus one and even more snow is predicted for this weekend. Winter persists. I hope that you find a way to enjoy it!
Be well,
Gene
