On Christmas morning as I was enjoying opening presents with my family, it occurred to me that President Trump’s suggestion that the tax bill was a big Christmas present for Americans must be very painful for the poor to hear. This bill puts much of their “safety net” in jeopardy in the very near future. The truth is the tax bill was a big present for himself and other favored members of his base. Like many other bait and switch strategies there was an appearance of benefit for most of the middle class, but those relatively scanty benefits stay in place just long enough to get past the next few elections.  

There are many middle class Americans, like the homeowners and taxpayers in “Blue States” like California, New York, New Jersey, parts of Virginia and Massachusetts who would like to have been able to take their “gift” back on the 26th for an exchange or credit, just like a sweater that did not fit or a book that they had already read. The biggest losers are always the ones excluded from the conversation or whose advocates either abandon them for their own benefit or just don’t hold the power to protect them.

When the dust settles on this shabby era of American history it will be the poor who will lose once again because to pay for this gift for the well to do Paul Ryan and Mitch McConnell are looking forward to “entitlement reform.” That will mean cutting many of the “welfare” programs like Medicaid, food stamps, housing assistance, and all the other programs that marginally benefit the poor who live on the edge of our national banquet.  Republicans strategists and authors of the party’s orthodoxy have loathed entitlements since the New Deal and have plotted for a reversal since the sixties. Ronald Reagan popularized “Welfare Queen” as a way of turning off rational discussion about publicly funded assistance programs during his first bid for the presidency in 1976. Entitlements have been an itch they have wanted to scratch for many decades and now facing 1.5 trillion dollars of deficits, they have manufactured a necessity to act.

In my heart I have known for a few weeks that a miracle would not emerge and the tax bill would pass. I guess that even divine intervention can’t balance a situation where the driving motivation is to pay off donors. Senators who are willing to make deals, or pull off the appearance of making deals for the benefit of their constituencies, or are pursuing personal interest to the detriment of those dependent on the mercy of public support to healthcare, are low on my list of those due for respect. Put Lisa Murkowski and Bob Corker on that list.

Poor John McCain gets a bye. He was not physically able to vote; so, there would be no thumbs down on tax reform to match his performance on the repeal and replacement of the ACA. Susan Collins deserves special consideration. She voted for the tax bill based on nothing but “assurances” from Mitch McConnell that he would get her concerns for healthcare turned into law that would protect the poor from some of the losses engendered by the bill. How naive is that? Did she not remember that the Senate alone does not make laws, and that Paul Ryan was saying, “No way!” David Leonhardt of the New York Times postulates that she is too smart and experienced for her story of a deal to fly. He thinks she voted for the bill because she liked something about it even though over the next ten years many of Maine’s citizens will lose, big time.

The whole process has left me weak and weary, and I was just a spectator. I do not know if I, as a private citizen, will be a winner or a loser when the dust settles. That is not the origin of my disgust. I am most certain that my country will lose. The individuals who will lose the most are the ones who always lose. The poor who have very little left to lose will see the meager supports that provide them minimal assistance converted to payments for the very wealthy. The  large majority of the 1.5 trillion dollars of the deficit that is generated by the bill will be new debt as resources are transferred from public coffers to corporate assets and the personal bank accounts of those who are the financially most fortunate among us.

Martin Luther King, Jr.’s message was larger than a discussion of the issues of racism and the injustices that it perpetuated. He understood that those injustices perpetrated poverty and that poverty was the product of economic inequities that existed for the poor of all races. In his 1964 speech when he accepted the Nobel Prize he said:

“A second evil which plagues the modern world is that of poverty. Like a monstrous octopus, it projects its nagging, prehensile tentacles in lands and villages all over the world. Almost two-thirds of the peoples of the world go to bed hungry at night. They are undernourished, ill-housed, and shabbily clad. Many of them have no houses or beds to sleep in. Their only beds are the sidewalks of the cities and the dusty roads of the villages. Most of these poverty-stricken children of God have never seen a physician or a dentist.”

Dr. King, Nobel Peace Prize address, 1964

You may say, “That was a picture of the third world in 1964 and not a fair representation of America in 2017. We are past that.” I am not so sure, and think what he said in 1963 is appropriate to this moment.

“God never intended for one group of people to live in superfluous inordinate wealth, while others live in abject deadening poverty.”

Dr. King, “Strength to Love”, 1963

Perhaps referring to what God wants is inappropriate, but the truth is that any law that aggravates poverty risks undermining the future of America no matter what you think about God. It is just destructive social policy. In the long run such moves are temporary wins for a minority flush with resources. In time these actions will assure that problems like increasing domestic violence, street crime, and substance abuse will be the opening act for a society in continuing decline.

Republicans say to just wait, everyone is going to love what happens to their paycheck and there will be lots of new jobs. I believe that there is a higher likelihood that the bill will be a burden on the underserved, and is more likely to aggravate poverty and reduce the health of the nation than create jobs. The perversity of this moment when the majority of our elected leaders pay off their donors is underlined by the quote of Dr. King that speaks most directly to me this week:

“There is nothing new about poverty. What is new, however, is that we have the resources to get rid of it.”

Dr. King, Nobel Peace Prize address, 1964

That is the point I want to make. We really did have a choice. I’ll accept that we needed a new tax bill, but not this one. The real issue was that a better bill might have improved the tax environment of business in a way that could have been a stimulus for employment, and our collective resources could have been allocated in such a way as to have improved the lives of the poor as well as the middle class.  We could have chosen policies that supported higher education, infrastructure improvement, housing and better healthcare that would have made us a greater and more equitable nation. It could have been done with collaboration, consultation, and creative problem solving, but that would have required different leadership. It is amazing that Republicans can joyfully pass a bill that has less than 40% support. Paul Ryan and Mitch McConnell deserve a release from the responsibilities that they clearly demonstrate they are not equipped to manage when they suggest that the over 60% of Americans who fear what will happen because of the bill, in time will come to like it.

Now that the bill is a reality, the obvious question is what is next? The best way to answer that question is to ask yourself what, after taxes, do Republicans hate most? The answer is entitlements and deficits. It appears to me that with their fuzzy thinking they see taxes, deficits and entitlements as an unholy trinity. I have been writing that the tax bill was best understood as the justification for cutting the expense of entitlements. Even before the tax bill is signed there is evidence that the deficits it will create will lead to an automatic cut of $25 billion in Medicare.

Every warm hearted Republican Senator claims to love children and yet the CHIP program that is currently dying for lack of renewal leaves 9 million children without access to the care they need. Their coverage is being used as a bargaining chip in the complex issues of the federal budget. This game is not over. It has just begun. Money is back in the pockets of those who do not need it, and now we are into deciding which programs for the poor and needy will be cut to pay for the transfer of capital. Look at any reputable newspaper of the last two weeks, or more practically copy and paste into your Internet browser: Programs and entitlements to be cut because of the tax reform law. You can pick your own favorite article. They all say the same thing; entitlements are next on the Republican “to do “ list. They are just beginning and the direct impact on healthcare finance will only be the tip of the iceberg. The huge piece of ice that will damage or delay our voyage toward the Triple Aim lies below the surface where efforts to improve the social determinants of health are vulnerable.

It is hard to calculate just how damaging this bill will be to the struggle to improve the social determinants of health which are the real drivers of cost to our fragile system of care, but rest assured the damage will be huge. At the individual level, before this is over, there will be children who needlessly die, mothers who will not get the support they need during pregnancy, and grandmothers and grandfathers who have strokes that could have been avoided. Poor and lower middle class Americans will pay a high price to increase the inheritances of people like the president’s children. We had made a little bit of progress, and now we will begin to see those gains lost to greed.

It will take decades for historians, social scientists, and economists to explain this moment. We did not get to where we are in the less than the two months it took to birth this awful bill. We will not get back on the path to a better and more equitable America just by electing Democrats in 2018 and 2020. There is much analysis and then work needed before the far reaching changes that must penetrate deeply into our communities can take hold. We need to continuously ask, “What part of the problem am I?” and, “What can I do differently?” There is much that needs evolution and transformation and those processes are dependent on the efforts of individuals, and individuals need the advice of wise and humble counselors and leaders. I believe that going forward an army of outraged healthcare professionals will step forward and join the majority of Americans who sense that this is an awful bill, and that many of the leaders in the movement to ameliorate its damage will base their actions on the realization that as long as poverty and economic inequity go unresolved, it will be hard to realize a healthier America.