A thank you to Robert Pearl M.D. for his assessment of Trump's effects on Healthcare
With a new administration set to take office next week, the healthcare landscape is fraught with uncertainty as big questions abound: Will Robert F. Kennedy Jr. lead HHS—and, if confirmed as secretary, will the nation’s vaccine policies see a 180-degree turn?
How will Elon Musk’s newly formed Department of Government Efficiency (DOGE) deliver on its pledge to cut $500 billion from the budget, and what impact will it have on healthcare?
Will Trump’s promises to tackle drug prices finally materialize, or will Congress focus on the chaos of the prior authorization process in the wake of the shocking murder of UnitedHealthcare’s CEO?
Of course, these questions aren’t just headline fodder. They’re pressing issues with big consequences for millions of Americans.
Musk’s DOGE Could Threaten The Health Of Millions Of Americans
Elon Musk, the world’s richest man, co-heads the Department of Government Efficiency, a non-government entity tasked with slashing government spending. The exact amount has been amorphous, starting with claims of cutting $2 trillion, since reduced to $1 trillion or, more modestly, “taking aim at the $500 billion-plus in annual federal expenditures that are unauthorized by Congress or being used in ways that Congress never intended.” Deleting Dollars From American Healthcare
Since Trump’s first term as president, the country’s economic outlook has worsened dramatically.
Back in 2016, the national debt was $19 trillion, with $430 billion spent annually on interest payments. By 2024, the debt had surged to $36 trillion, requiring $882 billion in debt service—13% of federal spending that DOGE cannot touch.
Medicare, the $850 billion program for Americans over 65, is untouchable. So, too, is the $300 billion in tax deductibility for employer-sponsored health insurance and $120 billion in expired health programs for veterans. Cutting either involves raising taxes for 160 million working Americans or risking the health of millions of veterans.
This leaves DOGE with few options but to scale back programs that serve low-income Americans: Medicaid and online health exchanges.
Here’s how these cuts would likely unfold and the impact they would have on the lives of over 20 million Americans:
1. Reduce ACA Exchange Funding
Since the Affordable Care Act became law in 2010, it has provided insurance-premium subsidies to Americans earning 100% to 400% of the federal poverty level.
For lower-income families enrolled in the online health exchanges, the ACA also includes Cost Sharing Reductions, which help offset deductibles and co-payments. These reductions, which average 30% of total premiums, make coverage more affordable for enrollees.
Without CSRs, a family of four earning $40,000 could face deductibles as high as $5,000 before their insurance benefits take effect. The result: 7 million would drop out of the exchanges, with an estimated 4 million families becoming uninsured altogether.
If Congress allows CSR payments to expire in 2026, federal expenses could drop by approximately $35 billion annually. As millions of individuals exit the exchanges and forgo re-enrollment due to unaffordable out-of-pocket costs, DOGE could also take credit for additional savings of up to $50 billion. While these cuts may help meet budgetary targets, the human cost is undeniable: millions of low-income American families would lose health insurance.
2. Slash Medicaid Coverage, Tighten Eligibility Requirements
To achieve $500 billion in annual savings, DOGE will almost certainly target Medicaid, which provides healthcare for over 90 million low-income Americans, including children, seniors, and individuals with disabilities.
Several cost-cutting strategies are on the table, including reducing federal payments to states, tightening eligibility criteria, and restructuring Medicaid into lower-cost block grants.
Recall that the Affordable Care Act expanded Medicaid eligibility to individuals earning up to 138% of the federal poverty level. While Medicaid expansion remains optional, 40 states adopted the program, helping cut the U.S. uninsured rate in half—from 16% (50 million people) to 8% (25 million). DOGE would need Congressional approval to reverse this expansion, stripping coverage from millions in participating states.
Another possible strategy involves imposing work requirements on Medicaid recipients. While proponents argue this would spur employment, data show most Medicaid enrollees already work for employers that don’t provide insurance—or they are unable to work due to caregiving responsibilities or serious health conditions. In reality, work requirements would function primarily as bureaucratic hurdles, disqualifying or discouraging eligible individuals and driving up the uninsured rate.
Restructuring Medicaid funding into block grants is a final possibility. Unlike the current system, which adjusts funding based on need, block grants provide states with a fixed dollar amount. This would likely force states to cut services, further restrict eligibility or both. Though advocates claim block grants offer states greater flexibility, the primary result would be fewer medical services and fewer Medicaid beneficiaries.
In total, Medicaid currently costs $800 billion annually, with the federal government paying 70%. Cutting enrollment by 10% (9 million people) could save over $50 billion annually, while a 20% reduction (18 million people) could save $100 billion.
The consequences of such measures, however, would be devastating. Medicaid covers more than 40% of U.S. childbirths, ensuring healthier babies and protecting families from financial ruin. It funds routine checkups, vaccinations, and treatment for chronic conditions like asthma and diabetes for children. It also provides essential nursing home care and home health services for seniors and individuals with disabilities who cannot live independently.
But the fallout wouldn’t end with tens of millions of Americans losing healthcare coverage. If DOGE scales back Medicaid, states would be forced to absorb much of the financial burden. And since states are required to have a balanced budget, increased healthcare costs would likely lead to cuts in education funding, reduced infrastructure investments and the closure of community hospitals—many of which are already struggling to stay afloat—further straining local economies and leaving patients with nowhere to turn.
The First 100 Days
The numbers don’t lie: If DOGE is going to achieve Musk’s $500 billion pledge, it would have to slash Medicaid funding and ACA subsidies to reach its cost-cutting goal in year one.
Yet, this approach isn’t the only path to fiscal responsibility. There are long-term healthcare solutions that could reduce medical spending while preserving the nation’s health. These would require bold, systemic reforms but they are achievable.
They include shifting how doctors and hospitals are paid to reward superior clinical outcomes instead of higher volumes, capping drug prices at levels comparable to peer nations, and deploying generative AI to prevent and manage chronic diseases more effectively.
These strategies would drive down costs by improving quality and preventing heart attacks, strokes and kidney failure, not by rationing care. Unfortunately, neither Musk nor DOGE has championed these ideas.
For now, the healthcare of tens of millions of Americans hangs in the balance, seemingly collateral damage in politically and financially.
The murder of UnitedHealthcare CEO Brian Thompson represented a horrific and indefensible act of violence. His family deserves our deepest sympathy.
As a physician and healthcare leader, I initially declined to comment on the killing. I felt that speculating about the shooter's intent would only sensationalize a terrible act.
Regardless of the circumstances, vigilante violence has no place in a free and just society.
News analysts have attributed the social media response to America's "simmering anger" and "frustration" with a broken healthcare system, pointing to rising medical costs, insurance red tape, and time-consuming prior authorization requirements as justifications.
These are all, indeed, problems and may explain some of the public's reactions. Yet these descriptions grossly understate the lived reality for most of those affected. When I speak with individuals who have lost a child, parent, or spouse because of what they perceive as an unresponsive and uncaring system, their pain is raw and intense. What they feel isn't frustration-it's agony. By framing healthcare's failures in terms of statistical measures and policy snafus, we reduce a deeply personal crisis to an intellectual exercise. And it's this very detached, cognitive approach that has allowed our nation to disregard the emotional devastation endured by millions of patients and their families.
When journalists, healthcare leaders, and policymakers cite eye-popping statistics on healthcare expenditures, highlight exorbitant insurer profits, or deride the bloated salaries of executives, they leave out a vital part of the story. They omit the unbearable human suffering behind the numbers. And I fear that until we approach healthcare as a moral crisis-not merely an economic or political puzzle to solve nation will never act with the urgency required to relieve people's profound pain. As a clinician, I've seen life-destroying pain in my patients and even within my own family. When my cousin Alan died in his twenties from a then-incurable cancer, my aunt and uncle were powerless to save him. Their grief was profound, unrelenting, and eternal. They never recovered from the loss. But Alan's death, heartbreaking as it was, stemmed from the limits of science at the time.
What millions of Americans endure today is different. Their loved ones die not because cures don't exist but because the healthcare system treats them like a number. Bureaucratic inefficiencies, profit-driven delays, and systemic indifference produce avoidable tragedies.
To appreciate this depth of pain, imagine standing behind a chain-link fence, watching someone you love being tortured. You scream and plead for help, but no one listens. That is what healthcare feels like for too many Americans. And until all of us acknowledge and feel their pain, little will improve.
Curing America's indifference
When we focus solely on cold numbers millions who've lost Medicaid coverage, the hundreds of thousands of avoidable deaths each year, or the life-expectancy gap between the U.S. and other nations-we strip healthcare of its humanity.
But once we stop framing these failures as bureaucratic inefficiencies or frustrations and, instead, focus on the devastation of having to watch a loved one suffer and die needlessly, we are forced to confront a moral imperative. Either we must act with urgency and resolve the problem or admit we simply don't care.
In the halls of Congress, lawmakers continue to weigh modest reforms to prior authorization requirements and Medicaid spending steps that won't fix a system in crisis. The truth is that without bold, transformative action, healthcare will remain unaffordable and inaccessible for millions of families whose anguish will grow. Here are three examples of the scale of transformation required:
- Reverse the obesity epidemic with a two-part strategy. Congress must tax ultra-processed, sugary foods that drive hundreds of billions of dollars in healthcare costs yearly. In parallel, lawmakers should cap the manufacturer-set price of weight-loss medications like Ozempic and Wegovy to be no higher than in peer nations.
- Change clinician payments from volume to value. Current fee-for-service payment systems incentivize unnecessary tests, treatments, and procedures rather than better health outcomes. Transitioning to pay-for-value would reward healthcare providers, specifically primary care physicians, who successfully prevent chronic diseases, better manage existing conditions, and reduce complications such as heart attacks, strokes, and kidney failure.
- Empower patients and save lives with generative AI. Tools like ChatGPT can help reduce the staggering 400,000 annual deaths from misdiagnoses and 250,000 more from preventable medical errors. Integrating AI into healthcare enables at-home care, continuous disease monitoring, and personalized treatment, making medical care safer, more accessible, and more efficient.
If elected officials, payers, and regulators fail to act, they will have chosen to perpetuate the unbearable pain and suffering patients and families endure daily. They need to hear people's cries. The time for transformative action is now.
One of his cabinet appointments is Robert F. Kennedy, Jr. a controversial figure who advocated healthy living and who raised serious questions about the number of vaccinations mandated for children (20).
A.I or artificial intelligence is being bandied about promising a revolution in diagnosis and enhancing physicians' work. Trump is proposing a "STARGATE" venture to promote the funding of artificial intelligence harnessing the use of clean energy. Three top tech firms on Tuesday announced that they will create a new company, called Stargate, to grow artificial intelligence infrastructure in the United States.
OpenAI CEO Sam Altm S OpenAI CEO Sam Altman, SoftBank CEO Masayoshi Son and Oracle Chairman Larry Ellison appeared at the White House Tuesday afternoon alongside President Donald Trump to announce the comTrump called the “largest AI infrastructure project in history.”
The companies will invest $100 billion in the project to start, with plans to pour up to $500 billion into Stargate in the coming years. The project is expected to create 100,000 US jobs, Trump said.
Stargate will build “the physical and virtual infrastructure to power the next generation of AI,” including data centers around the country, Trump said.
HELPFUL LINKS
https://app.flashissue.com/newsletters/f775ef5e1ef96c424df98621d24d97f86989c9bd
