May 16, 2025
Dear Interested Readers,
The “One Big Beautiful Bill” and What It Might Do to Healthcare
It has been another week of surprises in our ongoing adventure of the second Trump presidency. Was it a miracle or the “art of the deal” that led to the 90 day hesitation in the destruction of the world’s economy? What we were expecting was so catastrophic that a difficult situation feels like relief.
Paul Krugman, the Nobel Prize-winning economist, no longer writes for The New York Times, but several times a week, he publishes on Substack. His letter on Monday was entitled “When an Arsonist Poses as a Firefighter-Tariffs: What the hell just happened?” Krugman was as shocked as everyone when the president announced that he was dropping the tariff on Chinese imports from 145% to 30% and that the Chinese were dropping their 125% tariff on American imports to 10%. The stock market went through the roof and recovered much of its losses of the last several weeks. People said that Christmas was saved, but Krugman raised a cautionary voice. He gave four reasons to remain concerned. I have bolded some key phrases.
Four points:
- A 30 percent tariff is still really, really high, especially combined with the 10 percent tariff we’re imposing on everyone else. The back of my envelope says that the average U.S. tariff rate will now be around 13 percent, up from around 3 percent when Trump began his trade war. Before all this drama that would have been seen as wildly protectionist.
- This wasn’t a case of both sides backing down. China only imposed its tariffs as a response to Trump’s gambit, and has reduced them only because he retreated. And retreat he did. This was basically Trump running away from the killer rabbit.
- The prohibitive tariff has been paused, not canceled. Nobody knows what will happen in 90 days. I’ve long argued that the uncertainty created by Trump’s arbitrary, ever-changing tariffs is at least as important as the level of those tariffs. Well, the uncertainty level has arguably gone up rather than down.
- This retreat probably hasn’t come soon enough to avoid high prices and empty shelves. Even if shipments from Shanghai to Los Angeles — which had come to a virtual halt — were to resume tomorrow, stuff wouldn’t arrive in time to avoid exhaustion of current inventories.
Krugman may be a party pooper, but his analysis makes sense to me. What I see as a huge positive is that Trump blinked in the face of a rapidly developing disaster. One recurrent question during the first one hundred days of the Trump Presidency was how to effectively resist his blitz of executive orders that threaten to unwind or negate positive programs and efforts across the “deep state.” Perhaps, the president is not deaf or blind to resistance. Krugman finishes his analysis with a warning:
I guess it’s good news that Trump slammed on the brakes before driving completely off the cliff. But if you think that rationality has returned to the policy process, that the days of government by ignorant whim are now behind us, you’ll be sorely disappointed.
One voice that the President should pay attention to is the voice of Josh Hawley, the senior senator from Missouri. You might remember that on January 6, 2021, Senator Hawley raised a fist in salute to the crowd that stormed the Capitol. There is no question that, at least on the surface, Hawley is a staunch supporter of the president and his policies, which is amazing when you consider the Opinion piece that he published in The New York Times this week, entitled “Josh Hawley: Don’t Cut Medicaid.” The timing was excellent since two key committees in the House just passed a bill that would drastically cut Medicaid and deny a minimum of 8 million Medicaid recipients access to care. If the rules that were approved during Biden’s administration are not renewed, over 5 million more Americans will lose their access to care, meaning that over 13 million Americans will be suddenly uninsured. The hospitals that serve them would also be financially damaged by a sudden loss of revenue. Hawley rightly argues that rural and small-town hospitals would be vulnerable to closing. That was the message that Senator Hawley delivered to any Republican who still reads “fake news” in The New York Times. After pointing out that there is tension between the president’s “one big, beautiful [tax] bill” and the Republican Party’s desire to be “the majority party of working people,” Hawley writes:
Let’s begin with the facts of the matter. Medicaid is a federal program that provides health care to low-income Americans in partnership with state governments. Today it serves over 70 million Americans, including well over one million residents of Missouri, the state I represent.
As for Missouri, it is one of 40 Medicaid expansion states — because our voters wanted it that way. In 2020, the same year Mr. Trump carried the Missouri popular vote by a decisive margin, voters mandated that the state expand Medicaid coverage to working-class individuals unable to afford health care elsewhere. Voters went so far as to inscribe that expansion in our state Constitution. Now some 21 percent of Missourians benefit from Medicaid or CHIP, the companion insurance program for lower-income children. And many of our rural hospitals and health providers depend on the funding from these programs to keep their doors open.
All of which means this: If Congress cuts funding for Medicaid benefits, Missouri workers and their children will lose their health care. And hospitals will close. It’s that simple. And that pattern will be replicated in states across the country.
Senator Hawley is an educated man (Stanford BA, Yale JD) who may support Trump, but he can recognize a policy conundrum that could sink the MAGA ship. Our current national debt is 36 trillion dollars. The “big beautiful [tax] bill” that the president wants to pass will add another 4 trillion to our debt. It is not clear what the impact of that much debt will be on the interest rates that those “working class voters” will pay when they want a new car or a mortgage. Reality may have modified Trump’s tariffs, and we may be lucky enough to see reality save Medicaid. It seems that Senator Hawley is not the only Republican Senator to realize that this “beautiful bill” will ultimately be a political faux pas.
Further on in his opinion piece, Senator Hawley demonstrates that he fully recognizes the importance of preserving Medicaid if Republicans are going to be the party of the working class and remain in power or in his words, “Will Republicans be a majority party of working people or a permanent minority speaking only for the C-suite?
Senator Hawley and Republicans do have a big problem because there is no natural coalition between working-class people and the “C-suite.” It is very difficult to give wealthy people the tax cuts they demand as repayment for their support and simultaneously continue to enjoy the votes of working-class people in red states who, for whatever reason, voted against their own best interest when they believed the president’s claim that he would not touch Medicaid, Medicare, or Social Security. As Hawley writes:
Mr. Trump himself has been crystal clear on this point. Since taking office, he has repeatedly rejected calls for Medicaid benefit cuts. Just the other week, he said: “We are doing absolutely nothing to hurt Medicare, Medicaid or Social Security. Nothing at all.”
Increasing defense spending, spending billions to rid the country of migrants, giving outrageous tax cuts for the wealthiest one percent, and maintaining Medicaid, Medicare, and Social Security without adding huge amounts to the national debt is an impossibility, and Mr. Hawley knows it. It seems realistic to assume that Elon Musk’s attempt to gut so many public programs and services like the Department of Education, U.S.A.I.D., reducing the staff of Health and Human Services, and backing off from federal disaster relief are futile attempts to make the numbers work. They don’t, and they can’t without attacking Medicaid.
It is at moments like this that our politicians begin to play games with the lives of our most vulnerable citizens. I believe that it is possible for the government to say that it has not cut programs and simultaneously reduce its spending by eliminating fraud and sponsoring programs that eliminate waste by improvements in practice, but that is hard work. I know from personal experience that mining the 35% of waste in practice will be resisted by all of the parties for whom that waste is part of their necessary revenue and margins. What I expect will happen is that there will be an effort to technically leave benefits in place while making them harder to access. The tools will be denials, requirements for more frequent recertification, and cutting administrative budgets. Another option is to give the states lump sums of money and let them decide what to do. Ultimately, it will not be the first or the last time this president tells a lie or reneges on what he promised.
I began this discussion by referencing the president’s temporary reversal on tariffs, which was a response to the resistance and negative economic realities that were adding up to a lot more than a little “temporary pain” and the need for little girls to be happy with two dolls instead of thirty. I think that his reversal on tariffs could offer those who want to preserve the larger context of Medicaid and other social programs some reason for hope. Resistance and efforts to inform and enlist those who will be damaged or harmed by bad healthcare policies are critical to preserving access to care for as many people as possible. Pointing out the likely bad outcomes from terrible trade policy had some positive effect. Is it possible that if enough people who care about the poor who will lose coverage for care complain to their members of Congress about the losses that loom from bad healthcare policies, it might make a difference?
Back in 2020, I wrote about Rutger Bregman’s book, Humankind. This week, Bregman was interviewed on the Vox podcast “The Gray Area” by Vox journalist Sigal Samuel. Bregman has a new book entitled Moral Ambition. I was intrigued by their discussion since these times in which we live often seem like such a challenge to our established moral principles. It occurred to me that, in retrospect, my professional life and many of my activities in retirement could be categorized as driven by moral ambition or efforts to avoid moral injury for myself and my colleagues. I was eager to hear more about Bregman’s 3 S approach to moral ambition. Bregman believes that moral ambition is most effective when we focus our efforts on problems that are “sizable, solvable, and sorely overlooked.”
Google Chrome now will automatically give you an “AI Overview” when you use it to look up a subject. When I searched “the three S approach to Moral Ambition,” Chrome wrote:
The “Three S” approach to moral ambition, popularized by Rutger Bregman, suggests that moral ambition is most effective when focused on problems that are Sizable, Solvable, and Sorely Overlooked. This framework helps identify impactful areas where efforts can make a significant difference.
Elaboration:
- Sizable:
The problem should affect a large number of people or have a substantial impact on a significant aspect of society.
- Solvable:
The problem should be something that can be addressed with existing knowledge, resources, and effort.
- Sorely Overlooked:
The problem should be one that is not receiving enough attention, funding, or action despite its importance.
By focusing on these types of problems, individuals can channel their moral ambition into areas where they can make a real impact and help solve important challenges in the world. For example, the book “Moral Ambition” discusses using this framework to find meaningful work and contribute to positive change.
When I consider Bregman’s process I realize that my concerns about universal access to care, healthcare equity, the social determinants of health, and the workplace challenges of healthcare professionals are all “sizeable” problems” and that our professional, political, and lay literatures are full of plausible solutions. They are not “sorely overlooked” but potential solutions are sorely resisted. I am reminded of the fact that Dr. Martin Luther King, Jr. saw connections between poverty and the social determinants that transcended issues of race. He stated in the mid-sixties that as a nation, we had the resources to abolish poverty worldwide. If you are a regular reader of these weekly letters, you know that I have held up Dr. King as morally ambitious. Continuing my fun and games with the AI overview in Google Chrome, when I type in the “search line” the declarative statement “MLK, Jr. believed in the mid-sixties that we could abolish poverty,” I get back an affirmative answer.
Yes, Martin Luther King Jr. believed that poverty could be abolished in the mid-1960s. In his 1967 book “Where Do We Go From Here: Chaos or Community?”, King advocated for a guaranteed annual income for all Americans, arguing that it would help eradicate poverty. He also envisioned the Poor People’s Campaign, a movement aimed at challenging income inequality and poverty through nonviolent direct action.
Here’s a more detailed look at King’s views on poverty:
Guaranteed Income:
King believed that the government should provide a guaranteed, livable income for every American, regardless of employment status. This was part of his broader vision for an “economic bill of rights” that would ensure jobs and income for all.
Poor People’s Campaign:
King’s Poor People’s Campaign was a direct response to the persistent poverty and inequality in the US. The campaign aimed to bring attention to these issues and demand government action, including a guaranteed income.
Economic Justice:
King understood that true equality required not only civil rights but also economic justice. He believed that poverty created a “lonely island of poverty in the midst of a vast ocean of material prosperity” that limited opportunities for individuals.
Beyond Self-Help:
While King recognized the importance of self-help and individual initiative, he also believed that systemic changes were necessary to address poverty. He argued that the government had a responsibility to provide resources and opportunities for all, rather than just relying on individuals to lift themselves out of poverty.
Given current events and the history of resistance to the improvement of poverty, the social determinants of health, and healthcare access, I would suggest to Bregman that his third “S” should be changed from “sorely overlooked” to “selfishly resisted,” or “stymied by the status quo.”
The driving questions of moral ambition during these continuing “Trump years” seem to be less about gaining new ground than a “war of attrition” with the hope of minimizing losses.
Like MLK, Jr, I am an advocate of universal basic income as a mechanism for improving poverty. During COVID, we dropped the number of children living in poverty by almost 4 million through enhancements of SNAP and the Child Tax Credit. When I checked this out with Google, the AI answer was again “yes”:
Yes, that’s true. Enhancements to the Supplemental Nutrition Assistance Program (SNAP) and the Child Tax Credit (CTC) during the COVID-19 pandemic significantly reduced child poverty.
Specifically, the American Rescue Plan‘s temporary expansion of the CTC, in combination with stimulus payments and other relief measures, led to a historic drop in child poverty in 2021. The expanded CTC, which included increased benefits and monthly payments, lifted millions of children out of poverty. Additionally, the expanded SNAP benefits helped ensure that families had access to food during a time of economic hardship.
While the impact of the COVID-19 pandemic and the relief measures on child poverty was significant in 2020 and 2021, the temporary nature of some of these measures also led to an increase in poverty in 2022 when they expired. The lapse of the expanded CTC, in particular, resulted in a significant increase in child poverty.
Even in its reduced form, the Child Tax Credit is touted as our most effective federal social investment. Reading the speculations about the future of Trump’s “big beautiful bill,” I am apprehensive about the future of SNAP. Currently, SNAP benefits are frequently recalculated, and all of the recipients that I know have already experienced increased administrative barriers and significant reductions in monthly payments.
Ironically, the title of Dr. King’s last book was Where Do We Go From Here: Chaos or Community? I don’t believe there is a better description for the last four months than “chaos.” My strategy until the mid-term election of 2026 is to help as many people in my community as possible and simultaneously hope for divine intervention or a series of “unforced errors” from our unhinged president and his supporters. Maybe Josh Hawley can turn some things around for us.
Spring Is Here, and Summer Is On The Way, Despite the Flies and Ticks
Some days, my wife wakes up early and decides to get up and read. One added benefit is that she gets to see the sun come up. She took today’s header early on Monday, which turned out to be a perfect late spring day and even warm enough to qualify as an early summer day. I knew it was not summer yet because after “mud season,” we have “bug season,” and the flies and ticks are currently active and ferocious.
I don’t know how I acquired it, but I have already discovered one tick crawling across the back of my neck, and I have several itchy fly bites on my arms. The ticks will be with us all summer, but the flies will back off soon. I hope.
Despite the bugs and the possibility of another rainy weekend, I am psyched for this weekend. We are headed to Maine to celebrate our youngest son’s fortieth birthday. I am grateful to him because he produces the header for these notes each week after I send him a picture. The added bonus for the weekend will be to see our youngest grandson, who has begun to walk and run since we last saw him in March.
I hope that your weekend is terrific, rain or shine.
Be well,
Gene
