In the 1960’s, the Johnson Administration declared war on poverty. This was both a packaging of bills and a statement of values. Programs such as Head Start, the Job Corps, improved food stamp (SNAP) benefits, Medicare and Medicaid came out of this initiative. The programs were aimed at helping the poor access opportunities otherwise denied to them. Health care, food and employment – not only lifting up the impoverished, but also improving the community for everyone else. The current leadership in Washington, DC doesn’t have a nifty slogan to attach to their initiatives, and while many have called the current initiatives a war on poor people, the fiscal blueprint of the House-passed budget could more succinctly be labelled a war on healthcare.

Rates of health insurance have been on the rise since 2014, with insured rates increasing by over 6 percentage points in a decade. Between the ACA impacts on private insurance premiums, the increase in Medicaid coverage for individuals in the 41 states that have chosen to expand that coverage to the slightly less-poor population, and additional financial incentives to states to enroll more people during the pandemic, there has been an increase in access to healthcare in the US. The bill just passed by the House of Representatives (the OBBBA, as they call it) aims to reverse these trends, in the name of waste reduction. The CBO estimates that 10.3 million people will be denied Medicaid, with 7.6 million of those going uninsured (that is a 2 percentage point increase in the national uninsured rate) and the remaining population losing financial resources to take up plans they likely can’t afford. The claim is that this is simply to ensure that beneficiaries are working, but in fact the requirements simply add bureaucratic barriers for the poorest among us who often have unstable work situations, poor access to the internet to submit paperwork, and poor transportation to government offices, amongst other challenges. The OBBBA also reduced premium tax credits and cost sharing limits for those who purchase insurance, which the CBO projects will ultimately result in an additional 4.2 million uninsured.

Healthcare in the US is not simply a function of insurance though. There are a web of efforts that support American health, from Head Start (for pre-schoolers) to Meals-on-Wheels (for seniors) to NIH sponsored clinical trials and primary research. Among the largest programs that aim to maintain health is SNAP, a program relied upon by 41.7 million Americans to access food resources (a third of whom are children). Without SNAP, our nation’s network of not-for-profit food banks would become more overtaxed than they already are. Through a mind-bending array of bureaucratic changes in eligibility, the cuts in SNAP will touch a large segment of the beneficiaries (either through reduced/eliminated eligibility or reductions in funding per month). The knock-on impacts of these cuts are significant for American healthcare. Food insecurity has been shown in numerous studies to be associated with higher rates of obesity, diabetes, heart disease, and high blood pressure. When coupled with reduced access to healthcare, these individuals enter the nation’s healthcare system with higher levels of acuity than they would ordinarily experience.

Additional cuts to American health are scattered throughout the OBBBA. The NIH budget is to be cut by 40%. The CDC’s budget would be cut by 22% (including elimination of programs that focus on opioid prevention and use, drowning prevention, and firearm injuries/mortalities). The LIHEAP program (subsidizing low-income utility bills), has been zeroed out in the OBBBA, jeopardizing the health of nearly 6 million households. The logic behind the LIHEAP cuts are that energy costs will be coming down in the future, so the program is unnecessary. If they qualify for the program, they already struggle with paying for housing, food, healthcare – where they will find money for costly cold winters and hot summers is beyond me.

The final cut embedded in the OBBBA isn’t even explicitly stated in the bill. Because the deficits planned by the budget are so enormous (over $3 trillion in 10 years, according to the CBO and CFRB analysis), budget sequestration laws would be triggered. That means that automatic Medicare cuts would be implemented, without the Congress ever having to vote for them. Some might say that Congress could simply waive the trigger requirement, and they would be correct. But the House knew that their budget would exceed the the triggering mechanisms and yet did not include a provision in the bill that would waive sequestration. One could only conclude that their intention was to cut Medicare.

There are consequences for all of us when basic needs program funding is cut. When the health of the poorest Americans suffer, they use more healthcare resources – arriving at emergency rooms and clinics sicker than they would otherwise be. And without insurance, those health care providers will not be reaching into their pockets to pay for that care – they will be increasing the amount financed by the privately insured population. Medicaid insurance reimbursement rates are already less than the cost of care (as are Medicare rates), resulting in higher rates embedded in provider contracts with commercial insurers than would otherwise take place (to make up for their losses). Creating more uninsured and sicker patients will only drive up the cost of insurance premiums. For rural hospitals, experiencing higher proportions of Medicaid patients already and lower operating margins than their urban counterparts, the cuts will result in closures and bankruptcies. We will all pay the price for this penny-unwise and pound foolish approach to federal budget priorities.

And the national disgrace continues…