History > 2017 > USA > Health, Health care (I)
Cuts Deeply Into Medicaid
and Anti-Poverty Efforts
MAY 22, 2017
The New York Times
By JULIE HIRSCHFELD DAVIS
WASHINGTON — President Trump plans to unveil on Tuesday a $4.1
trillion budget for 2018 that would cut deeply into programs for the poor, from
health care and food stamps to student loans and disability payments, laying out
an austere vision for reordering the nation’s priorities.
The document, grandly titled “A New Foundation for American Greatness,”
encapsulates much of the “America first” message that powered Mr. Trump’s
campaign. It calls for an increase in military spending of 10 percent and
spending more than $2.6 billion for border security — including $1.6 billion to
begin work on a wall on the border with Mexico — as well as huge tax reductions
and an improbable promise of 3 percent economic growth.
The wildly optimistic projections balance Mr. Trump’s budget, at least on paper,
even though the proposal makes no changes to Social Security’s retirement
program or Medicare, the two largest drivers of the nation’s debt.
To compensate, the package contains deep cuts in entitlement programs that would
hit hardest many of the economically strained voters who propelled the president
into office. Over the next decade, it calls for slashing more than $800 billion
from Medicaid, the federal health program for the poor, while slicing $192
billion from nutritional assistance and $272 billion over all from welfare
programs. And domestic programs outside of military and homeland security whose
budgets are determined annually by Congress would also take a hit, their funding
falling by $57 billion, or 10.6 percent.
The plan would cut by more than $72 billion the disability benefits upon which
millions of Americans rely. It would eliminate loan programs that subsidize
college education for the poor and those who take jobs in government or
Mr. Trump’s advisers portrayed the steep reductions as necessary to balance the
nation’s budget while sparing taxpayers from shouldering the burden of programs
that do not work well.
“This is, I think, the first time in a long time that an administration has
written a budget through the eyes of the people who are actually paying the
taxes,” said Mick Mulvaney, Mr. Trump’s budget director.
“We’re not going to measure our success by how much money we spend, but by how
many people we actually help,” Mr. Mulvaney said as he outlined the proposal at
the White House on Monday before its formal presentation on Tuesday to Congress.
Among its innovations: Mr. Trump proposes saving $40 billion over a decade by
barring undocumented immigrants from collecting the Child Tax Credit and adding
additional measures to ensure they cannot collect the Earned Income Tax Credit.
He has also requested $19 billion over 10 years for a new program, spearheaded
by his daughter and senior adviser Ivanka Trump, to provide six weeks of paid
leave to new parents. The budget also includes a broad prohibition against money
for entities that provide abortions, including Planned Parenthood, blocking them
from receiving any federal health funding
The release of the document, an annual ritual in Washington that usually
constitutes a marquee event for a new president working to promote his vision,
unfolded under unusual circumstances. Mr. Trump is out of the country for his
first foreign trip, and his administration is enduring a near-daily drumbeat of
revelations about the investigation into his campaign’s possible links with
The president’s absence, which his aides dismissed as a mere coincidence of the
calendar, seemed to highlight the haphazard way in which his White House has
approached its dealings with Congress. It is just as much a sign of Mr. Trump’s
lack of enthusiasm for the policy detail and message discipline that is required
to marshal support to enact politically challenging changes.
“If the president is distancing himself from the budget, why on earth would
Republicans rally around tough choices that would have to be made?” said Robert
L. Bixby, the executive director of the Concord Coalition, a nonpartisan
organization that promotes deficit reduction. “If you want to make the political
case for the budget — and the budget is ultimately a political document — you
really need the president to do it. So, it does seem bizarre that the president
is out of the country.”
The president’s annual budget — more a message document than a practical set of
marching orders even in the best of times — routinely faces challenges on
Capitol Hill. Lawmakers jealously guard their prerogative to control federal
spending and shape government programs. But Mr. Trump’s wish list, in
particular, faces long odds, with Democrats uniformly opposed and Republicans
already showing themselves to be squeamish about some of the president’s plans.
“It probably is the most conservative budget that we’ve had under Republican or
Democrat administrations in decades,” said Representative Mark Meadows,
Republican of North Carolina and the chairman of the conservative House Freedom
But in a signal that some proposed cuts to domestic programs are likely to face
resistance even from conservatives, Mr. Meadows said he could not stomach the
idea of doing away with food assistance for older Americans.
“Meals on Wheels, even for some of us who are considered to be fiscal hawks, may
be a bridge too far,” Mr. Meadows said.
Republicans balked at Mr. Trump’s demand for money for the border wall in
negotiations over a spending package enacted last month. Many were deeply
conflicted over voting for a health care overhaul measure that included the
Medicaid cuts contained in the budget to be presented on Tuesday. Now the
president is proposing still deeper reductions to the federal health program for
the poor, as well as drastically scaling back a broad array of social safety net
programs that are certain to be unpopular with lawmakers.
“The politics of this make no sense to me whatsoever, in the sense that the
population that brought them to the dance are the populists out there in the
Midwest and South who rely on these programs that he’s talking about reducing,”
said G. William Hoagland, a former senior Republican congressional budget aide.
Referring to Representative Paul D. Ryan, he said: “I don’t see how Speaker Ryan
gets anywhere close to 218 votes in the House of Representatives if this is the
model. It’s an exercise in futility.”
Senator Chuck Schumer, Democrat of New York and the minority leader, said Monday
that the Medicaid cuts would “carry a staggering human cost” and violate Mr.
Trump’s campaign promise to address the opioid epidemic.
“Based on what we know about this budget, the good news — the only good news —
is that it was likely to be roundly rejected by members of both parties here in
the Senate, just as the last budget was,” Mr. Schumer said on the Senate floor.
The budget itself avoids some of the tough choices that would be required to
enact Mr. Trump’s fiscal vision. The huge tax cut was presented but without any
detail about its elements or cost. Mr. Mulvaney said the tax plan would not add
to the deficit, implying that its cost would be made up with other changes, such
as eliminating deductions.
To balance the budget, Mr. Trump’s budget relies on growth he argues will be
generated from the as-yet-unformed tax cut.
The blueprint also steers clear of changing Social Security’s retirement program
or Medicare, steps that Mr. Mulvaney, a former South Carolina congressman who
has backed entitlement cuts, said he had tried to persuade Mr. Trump to
“He said, ‘I promised people on the campaign trail I would not touch their
retirement and I would not touch Medicare,’ and we don’t do it,” Mr. Mulvaney
said. “I honestly was surprised that we could balance the budget without
changing those programs, but we managed to do that.”
But budget experts argued that was little more than fiction, and the plan could
never deliver the results it claims to.
“The central inconsistency is promoting a massive tax cut and spending increases
in some areas and leaving the major entitlement programs alone,” Mr. Bixby said.
“You don’t have to be an economist to know that that doesn’t add up, and that’s
why there’s a great deal of concern about the negative fiscal impact that this
budget will have.”
While past presidents have often launched a road show with stops around the
country to promote the components of their inaugural budgets, Mr. Trump is
spending the rest of the week overseas, leaving his staff to explain his plan
while Republicans prepare their own response.
“This budget is dead before arrival, so he might as well be out of town,” said
David A. Stockman, a former budget director under President Ronald Reagan.
Mr. Stockman said both political parties had grown comfortable with running
large annual budget deficits. “There’s not a snowball’s chance that most of this
deep deficit reduction will even be considered in a serious way.”
Correction: May 24, 2017
An article on Tuesday about President Trump’s budget proposals, using
information from Mick Mulvaney, the White House budget director, misstated a
proposal to bar undocumented immigrants from receiving certain tax credits. A
Social Security number is already required to claim the Earned Income Tax
Credit. The proposal would impose this requirement for the Child Tax Credit, and
the Child and Dependent Care Credit is not affected. The article also referred
incorrectly to one effect on Social Security. The budget proposes cutting Social
Security disability benefits, not reducing retirement benefits.
Binyamin Appelbaum and Thomas Kaplan
Trump’s Budget Cuts Deeply Into Medicaid and Anti-Poverty
May 22, 2017,
MARCH 18, 2017
The New York
Pages | Opinion
Last week the
nonpartisan Congressional Budget Office estimated that the new Republican health
plan would increase the number of uninsured Americans by 24 million people
within a decade, mostly because changes in regulations, subsidies and Medicaid
coverage would make insurance too expensive for them.
Republican leaders seem unfazed by this, perhaps because, in their minds,
deciding not to have health care because it’s too expensive is an exercise of
individual free will. As Representative Jason Chaffetz, Republican of Utah, put
it: “Americans have choices. And they’ve got to make a choice. And so maybe,
rather than getting that new iPhone that they just love, and they want to go
spend hundreds of dollars on that, maybe they should invest in their own health
There is an appealing logic to such thinking. The idea is that buying health
care is like buying anything else. The United States is home to some of the
world’s best medical schools, doctors, research institutes and hospitals, and if
you have the money for the coverage and procedures you want, you absolutely can
get top-notch care. This approach might result in extreme inequalities and it
might be expensive, but it definitely buys you the best medical treatment
anywhere. Such is the cost of freedom. As House Speaker Paul Ryan put it in a
tweet: “Freedom is the ability to buy what you want to fit what you need.” Vice
President Mike Pence picked up that baton: “Obamacare will be replaced with
something that actually works — bringing freedom and individual responsibility
back to American health care.”
In practice, though, this Republican notion is an awfully peculiar kind of
freedom. It requires most Americans to spend not just money, but also time and
energy agonizing over the bewildering logistics of coverage and treatment —
confusing plans, exorbitant premiums and deductibles, exclusive networks,
mysterious tests, outrageous drug prices. And more often than not, individual
choices are severely restricted by decisions made by employers, insurers,
doctors, pharmaceutical companies and other private players. Those interest
groups, not the consumer, decide which plans are available, what those plans
cover, which doctors patients can see and how much it will cost.
And I haven’t even mentioned the millions of Americans who don’t earn enough to
pay for insurance or a lifesaving treatment. If you can’t afford it, not buying
it is hardly a choice.
Eight years ago I moved to the United States from Finland, which like all the
Nordic nations is a wealthy capitalist economy, despite the stereotypes you may
have heard. And like all those countries, Finland has invested in a universal,
taxpayer-funded and publicly managed health care system. Finns constantly debate
the shortcomings of their system and are working to improve it, but in Finland I
never worried about where my medical care came from or whether I could afford
it. I paid my income taxes — which, again despite the stereotypes, were about
the same as what I pay in federal, state and local income taxes in New York City
— and if I needed to see a doctor, I had several options.
For minor medical matters, I could visit a private physician who was provided as
a perk by my employer. Or I could call the public clinic closest to my home. If
I saw the private doctor, my employer picked up the tab, with the help of public
subsidies. If I went to the public clinic, it might cost me a small co-payment,
usually around $20. Had I been pregnant, most care would have been free.
If I had wanted to, I also could have easily paid to see a private doctor on my
own, again with the help of public subsidies. All of this works without anyone
ever having to sign up for or buy health insurance unless he wants additional
coverage. I never had to worry whether I was covered. All Finns are covered for
all essential medical care automatically, regardless of employment or income.
Republicans are fond of criticizing this sort of European-style health care.
President Trump has called Canada’s national health care system “catastrophic.”
On CNN recently, Senator Ted Cruz gave multiple examples of how patients in
countries with universal, government-managed health care get less care than
In Europe, he said, elderly people facing life-threatening diseases are often
placed in palliative care and essentially told it’s their time to go. According
to the Republican orthodoxy, government always takes away not only people’s
freedom to choose their doctor, but also their doctor’s ability to choose the
correct care for patients. People are at the mercy of bureaucrats. Waiting times
are long. Quality of care is dismal.
But are Republicans right about this? Practically every wealthy capitalist
democracy in the world has decided that some form of government-managed
universal health care is the most sensible and effective option. According to
the latest report of the O.E.C.D. — an organization of mostly wealthy nations —
the United States as a whole does not actually outshine other countries in the
quality of care.
In fact, the United States has shorter life expectancy, higher infant mortality
and fewer doctors per capita than most other developed countries. When it comes
to outcomes in some illnesses, including cancer, the United States does have
some of the best survival rates in the world — but that’s barely ahead of, or
even slightly behind, the equivalent survival rates in other developed
countries. In breast cancer survival, for example, the United States comes in
second, after Sweden. Third-best is Norway, then Finland. All three countries
have universal, government-run health care systems.
For colorectal cancer, the five-year survival rate after diagnosis in the United
States brings it to a not very impressive ninth place in the O.E.C.D.
statistics. Ahead of the United States are South Korea, Israel, Australia,
Sweden and Finland, all with some form of government-managed universal health
care. And when it comes to cervical cancer, American women are at a significant
disadvantage: The United States comes in only 22nd. Meanwhile, life expectancy
at age 65 is higher in 24 other developed nations, including Canada, Britain and
most European nations.
Americans might still assume that long waits for care are inevitable in a health
care system run by the government. But that’s not necessarily the case either. A
report in 2014 by the Commonwealth Fund, a private foundation specializing in
health care research, ranked the United States third in the world in access to
specialists. That’s a great achievement. But the Netherlands and Switzerland did
better. When it comes to nonemergency and elective surgery, patients in several
countries, including the Netherlands, Germany and Switzerland, all of which have
universal, government-guided health care systems, have faster access than the
It’s not just American patients who endure endless bureaucratic hassles.
American doctors were also significantly more likely to report as major problems
the amount of time they spent on dealing with administrative burdens related to
insurance and claims, as well as on getting patients medications or treatment
because of restrictions imposed by insurance companies, compared with doctors in
most of the other 10 countries studied — including Sweden and Britain.
Overall, Americans spend far more of their hard-earned money on health care than
citizens of any other country, by a very wide margin. This means that it is in
fact Americans who are getting a raw deal. Americans pay much more than people
in other countries but do not get significantly better results.
The trouble with a free-market approach is that health care is an immensely
complicated and expensive industry, in which the individual rarely has much
actual market power. It is not like buying a consumer product, where choosing
not to buy will not endanger one’s life. It’s also not like buying some other
service tailored to individual demands, because for the most part we can’t
predict our future health care needs.
The point of universal coverage is to pool risk, for the maximum benefit of the
individual when he or she needs care. And the point of having the government
manage this complicated service is not to take freedom away from the individual.
The point is the opposite: to give people more freedom. Arranging health care is
an overwhelming task, and having a specialized entity do the negotiating,
regulating and perhaps even much of the providing is just vastly more efficient
than forcing everyone to go it alone.
What passes for an American health care system today certainly has not made me
feel freer. Having to arrange so many aspects of care myself, while also having
to navigate the ever-changing maze of plans, prices and the scarcity of
appointments available with good doctors in my network, has thrown me, along
with huge numbers of Americans, into a state of constant stress. And I haven’t
even been seriously sick or injured yet.
As a United States citizen now, I wish Americans could experience the freedom of
knowing that the health care system will always be there for us regardless of
our employment status. I wish we were free to assume that our doctors get paid a
salary to look after our best interests, not to profit by generating billable
tests and procedures. I want the freedom to know that the system will
automatically take me and my family in, without my having to battle for care in
my moment of weakness and need. That is real freedom.
So is the freedom of knowing that none of it will bankrupt us. That is the
freedom I had back in Finland.
Here is my appeal to Republicans: If you really want to free Americans and
unburden American employers, why not try, or at least seriously consider, some
form of government-managed health care, like almost every other capitalist
democracy? There are many ways of giving people choice and excellent care under
government management. Universal publicly managed health coverage would even
free America’s corporations and businesses to streamline their operations,
releasing them from bureaucratic obligations that to me, coming from Finland, I
have to say look weirdly socialist. Would this mean they would have to pay more
in taxes? Possibly.
Many countries require employers and employees to contribute to the health care
system through payroll taxes, more than the United States does. But again,
Americans are paying far more for health care than anyone else, and America’s
businesses are stuck managing this mess. It’s true that in countries with
universal health care the cost of hiring a new employee can be significant,
especially for a small employer. Yet these countries still have plenty of
thriving businesses, with lower administrative burdens. It can be done.
In wealthy capitalist democracies all around the world the government itself
also has an essential kind of freedom. It’s a freedom that enables the
government to do work on behalf of the citizens who elect it, including
negotiating the prices of health care with providers and pharmaceutical
companies — a policy that has led to lower drug prices in those countries.
Americans today are paying vastly more in money, worry and hassle for the same,
and sometimes worse, care than people in other wealthy capitalist democracies.
Some Americans have coverage that serves them well, but judging by the current
mood, the number of Americans who think the system needs to change is growing.
No health care system is perfect. But in a nation that purports to champion
freedom, the outdated disaster that is the United States health care system is
taking that freedom away.
is the author of “The Nordic Theory of Everything: In Search of a Better Life.”
A version of this op-ed appears in print on March 19, 2017,
on Page SR1 of the New York edition with the headline:
The Fake Freedom of American Health Care.
Freedom of American Health Care,
MARCH 18, 2017,