July 18, 2025
Dear Interested Readers,
The Coming Healthcare Crisis in the Aftermath of the One Big Beautiful Bill, and Other Concerns
I suspect that it is very likely that long after Donald Trump shuffles off this mortal coil, historians will be debating whether the havoc he created in the lives of so many was the summation of random acts of lunacy from a narcissistic sociopath or the product of well-executed strategy and unusual genius. In a recent opinion piece by Lydia Polgreen in the New York Times about Trump’s recent tactics attempting to bend Brazil to his request not to prosecute former President Jair Bolsonaro, we read an analysis that can be generalized to almost everything our wannabe autocrat has done in terms of unusual political tactics:
The surreal first six months of Trump’s second stint as president have offered up endless drama, danger and intrigue…Trump offers threats, tantrums and tariffs, to the profound detriment of American interests…
…Trump… seems committed to domination and destruction, in what could prove to be the final nadir of American overreach.
What has made the last six months even more difficult to bear has been the complacency and compliance with his demands demonstrated by Congress and the Supreme Court. Josh Hawley, the senior senator from Missouri, exemplifies the two-faced nature of many legislators. On May 12th, he wrote a guest opinion piece in the Times describing the immense danger to the health of 20% of his constituents and all the rural hospitals in his state if the “One Big Beautiful Bill” (OBBB) were to pass. He then voted for the bill, and now he has introduced a new bill to reverse many of the changes to Medicaid and hospital finance in the bill that he voted to pass less than three weeks ago. His bill to reverse those changes is probably dead on arrival, but now he can claim that he tried to defend the health of more than a million of his constituents and the vulnerable rural hospitals in his state. He is having his cake and eating it, too.
Passage of the OBBB would have been blocked if only one more senator had voted against it. At one time, Senators Ron Johnson of Wisconsin, Ran Paul of Kentucky, Lisa Murkowski of Alaska, and Hawley had expressed opposition to the “OBBB”; only Tom Tillis of North Carolina and Susan Collins of Maine joined all the Democrats in opposition. As you probably know, the vote was a 50-50 tie that allowed Vice President Vance to cast the deciding vote that passed the bill.
In my mind, Lisa Murkowski deserves special castigation because she sold out the citizens of the other forty-nine states in a deal to mitigate the impact of “OBBB” on the residents of Alaska. It is fine to try to protect your constituents, but it is bad math to protect a few hundred thousand people at the expense and welfare of over 13 million people to whom you also have a Constitutional responsibility.
What galls me most was the cynicism expressed in the structure of the bill. Many of the cuts to Medicaid in the OBBB will not hit potential low-income voters, many of whom are MAGA enthusiasts and don’t pay much attention on a day-to-day basis to healthcare policy, until after the 2026 mid-term election.
That sort of legislative cynicism and deceptive use of power doesn’t seem consistent with what would make America great. Hubert Humphrey and Gandhi are both credited for espousing that a country’s greatness is measured by how well it cares for its most vulnerable citizens.
Trump’s approaches to almost every aspect of his responsibilities for domestic and foreign policy management seem designed to create chaos to support some darker motive. The confusion he has engendered with tariffs has led a financial pundit to invent the term “TACO’ which translates as “Trump Always Chickens Out” to explain his erratic actions and many reversals. I am afraid that at some future moment, he won’t remember to “chicken out” before a real disaster occurs.
Thinking about what seems at times to be our president’s satanic behavior, I am reminded of a few lines from Kris Kristofferson, who was both a Rhodes Scholar and a struggling poet and songwriter working as a janitor in Nashville while waiting to become a star. In the middle of the song, “The Silver Tongued Devil and I,” he sings:
…He’s everything that I ain’t
Hiding intentions of evil
Under the smile of a saint
All he’s good for is getting in trouble
And shiftin’ his share of the blame…
I know it’s a stretch. I have lifted the lines from Kristofferson’s song that sounds like the confession of a philanderer who preys on young women in bars, and is trying to distance himself from his bad behavior. That shows some self-awareness and remorse. To my ear, the president is far from self-awareness and remorse. He is also only “silver-tongued” to those who have much to gain in wealth or personal affirmation from his boring vocal palaver, but millions of the MAGA faithful do seem enthralled by his word salad of exaggerations and his self-congratulatory accolades. It’s my bias that, unlike Kristofferson’s character, who seems to be trying to distance himself from his boorish and predatory behavior, Trump relishes the damage he does to others as he pursues his self-interests. To me, that so many people, especially members of Congress and the Supreme Court, who are presumably intelligent, have fallen for or blythly dismissed his thousands of lies, insults, and exhortations of misinformation, is as amazing as he is bizarre. I keep hoping that our collective nightmare is about to change, but many fear that our experience with the president has been difficult to say the least and may get worse before it gets better.
All of the uncertainty and conjecture about what his tactics mean and their ultimate consequences is creating great dismay and concern among thoughtful people, as well as many of those now doomed to face great difficulties as supportive programs are withdrawn or reduced. Collectively, we stand to lose a lot more than healthcare and public broadcasting. I was not surprised to see a front-page article this week in my local newspaper about the mental anguish and fear that he has induced in my neighbors and the confusion and concern at the state level about how to proceed with critical programs designed to provide healthcare, education, and other benefits. The loss of federal support to many of these programs will create a challenge to maintaining efforts to improve the social determinants of health for many of our residents. The article in Tuesday’s Valley News was entitled ‘It feels like the Wild, Wild West’: How the federal spending bill will affect Granite Staters. It was written by William Skipworth of the New Hampshire Bulletin. Mr. Skipworth begins with the story of a frightened woman:
When Michelle Lawrence heard about the Medicaid cuts included in the Republican tax and spending bill signed into law on July 4, it felt like “a punch to the gut.”
“I laugh, because if I don’t laugh, I cry,” she said.
Lawrence, who lives in Henniker, N.H., was diagnosed with a chronic form of cancer called T-cell lymphocytic leukemia 16 years ago. She said she lost her job about five years ago because the cancer was making it too difficult for her to work. And in losing her job, she lost her health insurance because she couldn’t afford COBRA coverage or anything on the marketplace.
“So I applied for Medicaid, which has been a major lifeline for me,” she continued. “That has enabled me and a lot of other cancer patients like me to be able to access the treatment needed in the past few years. I’m here. I’m alive and a contributing member of society. … Without Medicaid, I wouldn’t be able to afford my treatments or go to the doctor.”
Lawrence works 40 hours a month at a nonprofit assisting people with disabilities. Between the symptoms of her cancer and the side effects of her treatment, she can’t work any more than that, she said. But the “big beautiful bill” adds a work requirement to Medicaid that requires people to work 80.
“Those 40 hours a month are hard for me to do. I have had cancer for 16 years,” she said. “I can’t create a healthier Michelle that’s going to be able to work 80 hours. If I could, I would have by now, because I’d rather be working. No one wants to be sick and no one wants to be unable to work.”
I am sure that there are many “Michelles” across the country who are frightened about what might happen to them. Who will be Michelle’s advocate? Who will decide who needs to work and who is too sick or physically compromised to work? Like many of the antiabortion bills passed in red states, which fail to describe what interventions doctors are allowed to perform, I would expect that there will be many similar ambiguities and much inequality in how decisions are made in individual lives. The potential for ambiguities and uneven application of the new law is obvious to Michelle as we learn as the article continues.
The bill includes exceptions to the work requirements for “serious and complex medical conditions,” but it’s still unclear if that exemption will apply to all cancer patients, just some cancer patients, or no cancer patients at all. Lawrence said she asked the New Hampshire Department of Health and Human Services, the agency responsible for administering Medicaid in the state, but officials there didn’t have an answer for her.
“And that’s the scary part,” Lawrence said. “It feels like the Wild, Wild West. So we passed this bill, and now it’s left up to interpretation, and I don’t think that’s reasonable, because what am I supposed to do? Like, just carry on and wait to find out if or if not I get kicked off? Should I be planning a funeral instead of my next doctor’s appointment?”
There is much more to be concerned about in the OBBB. We all have a lot to lose.
The One Big Beautiful Bill Act affects …huge swaths of the federal government’s services, budget, and tax code. The bill extends a set of tax cuts…And it makes deep cuts to social services in order to partially pay for the tax breaks, though independent bipartisan analysis from the Congressional Budget Office still projects the bill will increase the federal deficit…
What is even more complicated is an analysis of how the OBBB will impact people in different states. As was true with the varied approval of the ACA, the final experience of the losses associated with the OBBB will vary by state. I would guess that states like Massachusetts, California, Minnesota, and other progressive states will try to mitigate the damage the bill does to vulnerable individuals. It will be a heavy lift in the “live free or die” state, where the culture of our voters is to proudly abhor taxes and prefer a loss of services for others over a larger personal tax bill.
The cuts will leave states with tough decisions about whether to cover the new funding holes with state money — a big challenge for states like New Hampshire that are in tight budget cycles of their own — or cut the programs.
Our politics are sort of weird. Our governor’s office and governor’s council, and both houses of the state legislature are controlled by Republicans. Both of our members of the House and both of our senators are Democrats. Our senior senator, Jean Shaheen, has been outspoken about the damage the OBBB will do to Granite Staters. Among several quotes from our state’s political leadership, I will offer comments from Chris Pappas, the Democratic Congressman for our first congressional district, who will be running against Scott Brown, formerly the last Republican senator from Massachusetts in 2026 for the senate seat being vacated by Jean Shaheen, who is retiring. Congressman Pappas said:
“It’s a cruel bill that contains deep cuts that are going to impact our families, our neighbors, all across the state of New Hampshire,” … “This is decidedly unpopular here in New Hampshire … But the fact is, our colleagues across the aisle, it’s not that they didn’t hear it, it’s that they didn’t listen to what people were actually saying.
Scott Brown is quoted:
“I proudly support President Trump’s Big Beautiful Bill because working families deserve a break,” Brown wrote in a separate post, pointing specifically to provisions that eliminate taxes on tips and overtime.
After a discussion of how the bill will greatly benefit the wealthiest residents of New Hampshire, compared to minuscule benefits like the tips cookie, that will accrue to our poorest residents, the discussion of the bill’s impact on healthcare comes to the center stage:
The biggest cut to Medicaid in U.S. history
The bill cuts Medicaid nearly $1 trillion over the next decade through a number of different provisions. In New Hampshire specifically, the bill is expected to revoke 18% of New Hampshire’s federal baseline spending for Medicaid, according to an analysis by the Kaiser Family Foundation. That’s $3 billion over 10 years. Medicaid, which is funded and operated jointly by state and federal governments, covers roughly 186,000 people in New Hampshire, according to the Centers for Medicare and Medicaid Services.
The work requirements will continue to be a confusing conundrum for clients and administrators.
Work requirements have been unsuccessfully attempted at the state level a few times, including in New Hampshire. In 2018, the state enacted a law mandating Medicaid enrollees work 100 hours a month to receive coverage. However, about one month after the rule went into effect in 2019, only about 8,000 of the 25,000 people subject to the requirement complied and documented their hours. At that point, then-Gov. Chris Sununu, a Republican, intervened and paused the new system before the remaining roughly 17,000 people lost coverage. The state had spent more than $130,000 in outreach efforts to inform recipients of the requirements and to teach them how to complete the eligibility paperwork. Arkansas and Georgia have also tried to implement work requirements. Arkansas had similar issues until a federal judge intervened and blocked the law.
The work requirements will definitely lead to substantial confusion and will probably exceed the state’s capacity to monitor and manage an onerous process, included in the OBBB, most likely to be a superhighway for denying Medicaid coverage because patients will find it hard to comply with the reporting requirements. Our legislature and governor have preempted the OBBB.
The cuts also come at the same time as a number of changes to Medicaid at the state level. The New Hampshire state budget signed into law in June increases prescription co-pays and charges some enrollees premiums. The budget, which was passed before the federal bill, also enacts work requirements. However, details on the state work requirements have yet to be ironed out… It’s also unclear how the state rule would work in relation to the new federal requirements.
And then there is SNAP, which will be zapped.
Cuts to SNAP
Laura Milliken, executive director of NH Hunger Solutions, a statewide advocacy group working to address hunger in New Hampshire, said the bill “is just a world of bad.”
The bill includes significant cuts to the Supplemental Nutrition Assistance Program, or SNAP, which helps low-income families pay for food. Those cuts are expected to cause 22.3 million families in the U.S. to lose some or all of their SNAP benefits…
…Milliken said. “People are having difficulty affording their housing, their child care, their medication. It seems like the moment to strengthen our programs that protect low-income folks and not to cut them, and this is such a drastic change in the program.”
The bill passes off much of the administrative cost of SNAP to states, which may or may not be willing or able to take on those costs. The bill also reduces benefits for some recipients by restricting what factors can be taken into account when deciding how much a family receives. The bill also caps future increases to SNAP at the rate of inflation. It bans many migrants (specifically refugees and asylees) from participating in the program (people in the country without legal status were already ineligible).
“People are scared,” Milliken said. “People are thinking, ‘Boy, I’m barely making ends meet right now, what am I going to do if my SNAP benefits are cut?’” Milliken said many of the food pantries in New Hampshire are afraid they won’t be able to keep up with the increased demand they expect to see as the provisions of the bill go into effect. She also noted that because SNAP automatically qualifies kids for free and reduced-price school meals, which in turn qualify schools for federal aid, the changes will likely impact other programs as well.
One of the activities that I do that gives me great pleasure is to deliver food from our local food bank to some home-bound recipients. I also help fill out applications for SNAP and SNAP renewals, Medicaid applications, and federal fuel assistance. Just keeping clients in line with benefits now is time-consuming and complicated. I shudder to think about the inevitable challenges that will now face us.
The OBBB is not the only Trump “strategy” that will impact my neighbors. We have yet to see what will happen to the economy as a result of the tariffs that are promised. They are a moving target daily. How will we get along without the benefits of PBS or a Department of Education? What will happen to FEMA? Will we be able to predict the weather? Where will all the unemployed scientists find work? What is the future of academic freedom?
Amid all the uncertainty about what is certain, like the OBBB, there are Trump-induced problems that have not yet occurred to most of us. One such issue was identified in a recent New England Journal Article entitled Who Will Care for America? Immigration Policy and the Coming Healthcare Workforce Crisis. It was written by Patricia Mae G. Santos, M.D. Reshma Jagsi, M.D., D.Phil., and Carlos Irwin A. Oronce, M.D., Ph.D.
Most of the time, when we think of immigrant labor, we are talking about farm laborers, construction workers, and a host of undocumented people who are providing essential services that most Americans don’t want to provide because of onerous working conditions and low pay. This article forces us to review how dependent healthcare is on “foreign” support.
After a brief description of President Trump’s effort to clear the country of illeagal aliens, the authors begin with a Socratic question, followed by an event that is a partial answer to the question.
But what happens when immigrants who work in the U.S. health care system are forced to leave? Just 4 days after the inauguration, 25 undocumented Filipino direct care workers were arrested in an ICE raid at a senior care facility in Chicago; at least 8 have since been deported. Weeks later, Dr. Rasha Alawieh, assistant professor of medicine at Brown University, was denied reentry after a return flight from Lebanon…Alawieh was one of only three transplant nephrologists in Rhode Island, and her forced departure left a critical gap in a highly technical specialty…
They want us to consider:
…the dangers that the current political climate pose to immigrants (whether documented or undocumented) who interact with the U.S. health care system. As the federal government seeks to curb immigration of all forms, immigrant health care workers and their patients will inevitably find themselves caught in the dragnet, which will have serious consequences for the system at large. The United States has already been grappling with severe health care worker shortages, which are projected to worsen over the next few years.
They give us very specific data about how patient care is dependent on immigrant labor, both legal and illegal. The situation for the elderly is particularly “dire.”
Current estimates suggest that the direct care worker shortage will grow to 860,000 by 2032. Factoring in turnover and retirement, one analysis suggests that 8.9 million positions will need to be filled over the next decade to meet demand.
It will probably be worse. The data that was used to calculate future needs came from before Trump began his deportation campaign. Partially because of ill-advised reductions in public funding over the last forty years, we have failed to adequately train the workforce across the entire spectrum of care providers from doctors and nurses to home health aides and medical assistants. The gap between what we need and what we train has been filled by dedicated people coming from other countries.
…immigrants are a vital part of the U.S. health care system: at least one in five U.S. health care workers is foreign-born, including 29% of physicians, 17% of nurses, and 24% of direct care workers.
…37% of foreign-born direct care workers who are noncitizens, nearly half may be undocumented.
It is not a static picture:
As federal policies threaten to further destabilize the direct care workforce, nonimmigrants are unlikely to fill the resulting void. Direct care workers assist…frail, older adults and those with disabilities to live safely at home…The physically demanding nature of direct care work, combined with low pay and high susceptibility to exploitation, makes these roles unattractive to U.S.-born and highly skilled foreign-born workers. Health systems and the long-term care industry have therefore increasingly looked toward immigrants, particularly undocumented workers, to meet demand.
It is a sad reality that you can easily confirm by observation the next time you happen to be in a long-term care facility. After further description of the history and current status of the problem, the authors come to the only logical conclusion:
Though immigration reform must balance border security with economic priorities, indiscriminate mass-deportation policies not only infringe on basic civil liberties but may also exacerbate existing worker shortages, compromising care for older adults and the health care system at large. Even if domestic training programs were expanded today, the potential increase in workers would not be enough to meet current demand.
They recommend:
In the face of anti-immigrant rhetoric, health care leaders must find the courage to advocate for policies that support, rather than marginalize, immigrant health care workers…Immigration policy must therefore protect the dignity of people who dedicate their lives to caring for others. The recent deportation of immigrant health care workers is our canary in the coal mine: policymakers must act swiftly, or risk endangering the health of us all.
The systematic destruction of much of the critical infrastructure of our healthcare system, universities, research capabilities, emergency services, and social services will not make America great. Simultaneously, the president is pumping up cryptocurrency in a way that surely will make him, his family, and some cronies wealthier.
Greed is not a new reality. Cruelty is not a new reality. Disregard for the future in favor of the present isn’t new. It is rarely a long-term winning strategy, but immediate gratification has its fans. As tired as I am of talking about the threats to our future that this president represents, it feels to me that we must continue to have a vigorous conversation about the likely cruel impact of MAGA thinking on our collective future. I pray that we will soon find some way to stop our losses.
Visiting the Track On a Hazy Summer Day
I have spent many hours of my life running around in circles, or rather on oval tracks. I like quarter-mile loops. Many people have told me that running on a track was boring. I always found it to be easier and relaxing because they are flat, and you don’t have to be alert to traffic. I can be carried away by my thoughts when running on a track without the necessity of being alert to my surroundings.
In the past, when I was traveling, I would always try to locate the high school track. The condition of the track says a lot about the community’s commitment to its youth. A shabby track would be next to a run-down school. A terrific track was usually part of an impressive academic investment by the community.
When I first started running in junior high school, our track was made of brick cinders. Modern tracks are covered with a polyurethane compound made by 3M called “tartan.” The spongy surface can dry and crack, so it is not absolutely maintenance free although it requires less attention than a cinder track. Some towns will remove snow from the track so that runners can avoid running on streets in the winter when slush, ice, and snowbanks add to the potential peril. Again, the condition and winter availability of the track is a good index of a community’s commitment to its youth and the general health of its citizens.
When I moved to New London, it took me a while to locate a track near me. For a while, I did not put much effort into the search and assumed that, because we have a regional school district and the high school is about ten miles away, using its track would not be practical. Our local college, Colby-Sawyer, has a picturesque campus and an excellent gym that is available to all members of the community for a very reasonable fee. There is a large athletic field behind the dorms, but to my disappointment, when I first moved to town, I did not think there was a track. You can imagine my delight when I discovered that the college’s primary athletic fields were at a little distance across a road through some woods.
The track, a separate soccer field, and the baseball field all have spectacular views of Ragged Mountain to the east, as you can see from the picture that is today’s header, despite a little haze from our recent heat wave. With all my surgeries, it has been a while since I have been to the track.
Most of my recent walks have been on the lovely road around the lake where I live. I had my last PT appointment this week. After the appointment, I decided to drive over to the track to check it out. It was too hot to walk around the track, but the visit suggested to me that I am improved enough from my recent surgeries to return to the track soon. It is something to look forward to as a challenge that I can master in these very challenging times.
I hope that your summer is going well. If it is hot where you are, be prudent and take precautions, but if you are lucky enough to live near a high school track and it is not too hot or humid, give the track a try.
Be well,
Gene
