"It was the best of times, it was the worst of times": Threats to the public's health from Medicaid cuts, MAHA, and others

“It was the best of times, it was the worst of times…” begins Dickens’ “A Tale of Two Cities”, and people have used that phrase to describe all kinds of times in the 150+ years since it was published in 1859. But maybe not today. In some ways, I guess, it could be the best of times for some privileged people in wealthy countries; never in history have so many people been able to enjoy things like enough food to eat, shelter, air that is breathable, water that is clean, heat in the winter, A/C in the summer, travel for long distances by plane, for many distances by private car, etc., etc. In every way, often ones that seem to us to be mundane, a lot of us enjoy a standard of living that could not be imagined even by the wealthy of Dickens’ time or earlier. Of course, that is only for some of us in the world, it is likely the majority in wealthy countries, even those working people living paycheck to paycheck.

But even in those wealthy countries we see too many who do not enjoy those benefits, who are living on the streets, who sleep in shelters or sewer grates or parks, who are freezing in winter and roasting in summer, who do not have enough to eat, who cannot get basic health care for their needs, and often have additional needs related to mental health or alcohol or drug use. We see children being abused and neglected by parents who do not have the wherewithal or support they need. We are, some of us, outraged and angry, some of us at them, and others of us at the system in which they live. Because we have a society that actively chooses to make the lives of many people worse so that the most privileged can have more.

And, once we leave wealthy countries such as the US, it becomes phenomenally worse. The number of people starving or suffering in wars and armed conflicts is incredible. Gaza is one obvious example, and it is horrific – the government of Israel using the all too real fact of centuries of oppression and anti-Semitism to destroy another people, the Palestinians, killing tens of thousands, displacing millions from their homes, destroying what infrastructure they had stingily allowed to be built – this is not wrongly called genocide. And there is Somalia and South Sudan and Ukraine in wars, and whole continents of people whose best days are the ones on which they get something to eat.

So, is it the worst of times? The policies being followed by the US government under President Trump and the bootlicking GOP Congress and the Supreme Court to which he appointed a disproportionate number of members, are leading us steadily downhill in virtually every part of the public arena. But the fact that they keep getting worse indicates that we have not yet reached bottom, we are not yet in the Europe of the late 1930s and 1940s even. But it does keep getting worse, in the US and across the world. It hits on so many fronts – the economy, basic human rights, climate, war – that it is difficult to even keep up.

And health and health care? The focus of this blog? Still lots of bad things, starting with the cynical, opportunistic, and dangerous policies being implemented by the Secretary of Health and Human Services (HHS), Robert F. Kennedy, Jr., the director of the Centers for Medicare and Medicaid Services (CMS), Dr. Mehmet Oz, and others in the administration, which become more and more outrageous. And, of course, the negative impact of the President’s “Big, Beautiful Bill” on those dependent on Medicare and Medicaid will be dramatic. STAT News recently reported that the Congressional Budget Office (CBO) estimates 11 million people will lose their health coverage as a result of Medicaid cuts. That is a lot of people, and only a very tiny percentage are the “boogeymen” cited by the GOP as deadbeats, adults capable of working but not seeking work. In fact, most people on Medicaid are children and their mothers, and most Medicaid dollars are spent on caring for seniors and disabled people in long-term care, and most able-bodied adults receiving Medicaid are already working, sometimes at more than one job, but making less than the standard (often 138% of the Federal Poverty Level). In my state, Arizona, that is less than $22,000 a year for a single person, and it is similar for families and in other states. The outrage is not that there are people receiving Medicaid who should be able to work, but rather that people working full-time can be paid so little that they qualify for Medicaid and other federal benefits. Many of these folks are working for high-profile (and high-profit!) corporations such as Walmart and McDonald’s, as reported by CNBC in 2020 (and probably is worse now!) Medicaid, by the way, is not a benefit paid to individuals (such as welfare or SNAP) but rather is paid to medical facilities for providing care to eligible individuals. To the extent that there is fraud, it is more likely to be on the part of those providers than the individuals. And cutting Medicaid threatens the continued existence of many of those providers, particularly rural hospitals which are, because the population that they serve has a higher percent of poor, disabled, and elderly people, more dependent upon Medicaid payments.

Medicare is also being harmed, in less obvious ways than the cuts to Medicaid, largely by encouraging the movement of Medicare recipients into private, insurance company-run plans called Medicare Advantage. I have often discussed the details (e.g., Open Enrollment Season for Medicare and Medicare Advantage: What you should know, Oct 7, 2024) but, in brief, insurance companies get paid more than Medicare spends on “traditional Medicare” (TM) recipients, and use some of it to provide benefits that are attractive, especially if you are not really sick. Of course, it is not then Medicare, but an insurance package, a PPO or HMO paid for with Medicare dollars, and the insurance company can (and often does) deny claims, as they do for their non-Medicare insurance packages, which TM does not.

And what about RFK, Jr., and his MAHA (“Make America Healthy Again”) campaign, including his disparagement of vaccines and advocacy for unproven (and sometimes proven-to-be-dangerous) treatments such as unregulated use of stem cells, and other “alternative” treatments, including saying “‘Charlatans’ Are No Reason to Block Unproven Stem Cell Treatments” even though “some methods have resulted in blindness, tumors and other injuries”? I’d say there is great cause for concern, but would also recommend reading the sympathetic and balanced discussion of MAHA supporters by Katelyn Jetelina, “Your Local Epidemiologist”. She distinguishes between leaders of the movement, like RFK, Jr., about whom she says “I don’t believe RFK Jr. is acting in good faith. His record is riddled with contradictions and falsehoods. His tactics often erode trust under the guise of restoring it. Treating him as a serious partner would be a mistake,” and the grass-roots. Many of these people feel that they are not getting accurate information (often they are not), many (appropriately) distrust Big Pharma and associate the mainstream medical and public health disciplines with it, and some are advocates for the magic benefits of “alternative” treatments such as stem cells. But a big issue that she identifies is their desire for “autonomy”, to make their own decisions on health care (where to go and what to do, what treatments to use, etc.) rather than be forced into using vaccines, or taking pharmaceuticals when they don’t want to. This is a big issue. In many areas, particularly infectious disease, individual autonomy that says “we don’t want vaccines” can lead to big disease outbreaks (like the ones we’ve recently seen of measles, which include deaths of unvaccinated children). The issue of individual autonomy vs. the public good is a longstanding tension, and of particular potency in the US.

So, what is there to say? I say do get vaccinated. Vaccines do not cause autism. Childhood vaccines, as is often stated, cause adulthood – because children do not die of polio, measles, or influenza, or epiglottitis and meningitis from H. influenza B, and hepatitis, and all the other conditions which at best cause significant suffering even when they do not lead to permanent disability or death. Vaccines are a good thing.

Swimming in polluted water, as RFK, Jr., has done is a bad idea. Taking your grandchildren along with you, as he has also done, is a really bad idea.

And yes, cutting millions of people, most of whom are hard-working, off of Medicaid, is another really bad idea.

 

 

For a balanced description of the terrible abuses that were carried out in the name of medicine and public health by Nazis, Americans, and others, see the excellent podcast “Doctors Gone Bad: Physicians, Dictatorships, and Warrior Cultures” by Dr. Martin Donohoe, part of his outstanding podcast series “Prescription for Justice”.