Medicaid cuts are likely to worsen mental health care in rural America
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Diverging Reports Breakdown
When Medicaid Disappears: How Cuts Could Devastate Behavioral Health Care in Rural America
South Dakota-based Sanford Health is the largest rural health system in the United States. Yet even with its size and resources, there are many challenges to delivering the care that patients need, especially regarding behavioral health services and the threats to care posed by cutbacks to Medicaid. Dr. Jon Ulven, Ph.D. talks about the challenges and solutions he’s had to come up with to meet the mental health needs of rural Americans. Tom Haederle: Let’s hear from you, Dr. Ulven and Rebecca Chickey, the senior director of behavioral health at the American Hospital Association. They talk about what it’s like to live in a rural community and how they’ve dealt with the challenges of providing mental health care in rural areas. They also talk about the solutions they’ve had tocome up with but help the listeners understand the barriers they’ve faced. They’ll be on next week’s episode of Advancing Health at 10 p.m. ET on CNN.com/ HLN. For more, go to www.advancinghealth.com.
00:00:01:04 – 00:00:25:09
Tom Haederle
Welcome to Advancing Health. South Dakota-based Sanford Health is the largest rural health system in the United States. Yet even with its size and resources, there are many challenges to delivering the care that patients need, especially regarding behavioral health services and the threats to care posed by cutbacks to Medicaid.
00:00:25:12 – 00:00:51:27
Rebecca Chickey
Hello, I’m Rebecca Chickey. I’m the senior director of behavioral health at the American Hospital Association. And is my great honor to be here today with Dr. Jon Ulven, who is chair of psychology of Sanford Health, which is the largest rural health system in the country and covers North Dakota, South Dakota, Minnesota, and probably parts of the country that are very small and rural surrounding those states.
00:00:51:29 – 00:01:20:25
Rebecca Chickey
So, Dr. Ulven, thank you so much for joining us today for this very important topic: serving and meeting the mental health needs of rural Americans. And particularly the intersection of that with patients who are covered by Medicaid. So to set the stage, I’d love to have you share a little bit about Sanford Health, what it’s like to really – I say rural – but you’re in frontier states for the most part.
00:01:20:28 – 00:01:35:05
Rebecca Chickey
So the vastness of North and South Dakota and what that does to create challenges in terms of access and, the solutions that you’ve had to come up with but help the listeners understand the barriers.
00:01:35:07 – 00:02:01:07
Jon Ulven, Ph.D.
Yeah. So first of all, just thanks for having me. And I really appreciate the attention to this really important topic. You mentioned a few states, but I’m just going to mention a few more states that we cover, Rebecca, because we’re also in Wyoming, Iowa, Wisconsin and then the Upper Peninsula of Michigan. We have a very, very large footprint for our organization, and we serve about 2 million patients in that area.
00:02:01:09 – 00:02:26:05
Jon Ulven, Ph.D.
We do a lot of work with very rural areas, as you were mentioning, frontier type states. And North Dakota and South Dakota, most of those counties are known as behavioral health shortage areas. I practice primarily in Moorhead, Minnesota. And in the state of Minnesota about 80% – 80 to 85% – of our counties are known as a behavioral health shortage areas.
00:02:26:07 – 00:02:49:24
Jon Ulven, Ph.D.
So we have, just a very unique set of challenges when it comes to the trying to provide world class health care and behavioral health care to a footprint that size. And when we look at the rurality of the folks we serve. And so things that we often encounter, we counter pretty much persistent challenges with provider shortages.
00:02:50:01 – 00:03:14:10
Jon Ulven, Ph.D.
It’s hard to recruit to this part of the country. We’re in a perpetual state of recruitment. And we also know that a couple of unique things that happen with rural areas. We have people who can travel for literally some of…I’ve seen patients who travel across the state of North Dakota to come to an appointment on the eastern side of the state.
00:03:14:15 – 00:03:31:21
Jon Ulven, Ph.D.
So there are sometimes some very legitimate transportation challenges. And then, and then also, I think one of the things that is – when you are in a small rural community, and I know because I grew up in one, I actually grew up about 25 miles from where I am right here in Moorhead. I grew up on a farm.
00:03:31:24 – 00:03:50:22
Jon Ulven, Ph.D.
There’s some nice opportunities for connectivity in a rural setting, but there’s also you lose anonymity. So you have you have challenges with people who, might need behavioral health services. But, everybody knows everybody’s business. So it makes it really hard to reach out and seek care.
00:03:50:24 – 00:04:10:09
Rebecca Chickey
I hear you, I grew up in rural Alabama. And it took 20 minutes to get to the closest gas station, and 20 more minutes from that to get to the closest hospital. So, perhaps not quite as rural as yours, but you got the fact and everyone in the little community I grew up in knew everyone else’s business.
00:04:10:09 – 00:04:21:00
Rebecca Chickey
And with that comes the stigma of seeking care. It’s incredible. That’s one of the things we’ve been working on. So glad you’re working on it, too. What about broadband? Can you speak to that for just a minute?
00:04:21:02 – 00:04:45:23
Jon Ulven, Ph.D.
Yeah. So to try to meet this behavioral health need, Sanford has invested a tremendous amount of infrastructure and time into a virtual care platform that we offer for this footprint, an area that I described a little bit earlier, where currently we have about 1 in 5 of our behavioral health visits are virtual at this time.
00:04:45:26 – 00:05:08:16
Jon Ulven, Ph.D.
So people can access this through their phones, through their computers at home. And we offer a confidential service where we are able to with the technology throughout that footprint, be able to deliver that type of care. And it’s something that we are training our clinicians on a regular basis about, the effective ways to provide this modality of care.
00:05:08:21 – 00:05:17:06
Jon Ulven, Ph.D.
I think in all of our areas, this has just become a pretty common way of life for us to do care that we have a certain portion of it that’s virtual.
00:05:17:08 – 00:05:20:23
Rebecca Chickey
And so you complement that with in-person visits, I assume.
00:05:21:00 – 00:05:46:17
Jon Ulven, Ph.D.
We do. Like I said, about 1 in 5 of our visits are virtual. I really have appreciated, some of the innovative minds that we’ve had here at Sanford to do some unique things. Like, for example, we have a very small community. The name of the town is Lidgerwood , North Dakota. And in Lidgerwood, North Dakota, which is like I said, I grew up around here, so I remember playing basketball in Lidgerwood, just a very, very small community.
00:05:46:19 – 00:06:08:06
Jon Ulven, Ph.D.
And if you head to that town, what they have is they had a clinic setting there, but it was nearly impossible to keep that staffed. So now what we’ve done is we have some bare bones medical staff in that area. We have some imaging capabilities and we have people to check patients in as they come in, and then they can do virtual care from there.
00:06:08:08 – 00:06:31:16
Jon Ulven, Ph.D.
And so they can do all different types of virtual care. They could be there for a checkup with their primary care physician. They can be there for a specialty visit for one of our other departments, and they can do behavioral health care from there as well. So we’re trying to have both kind of this, this nice opportunity for people to have where they can go to a location if they need, if they have some difficulties with their technology
00:06:31:16 – 00:06:56:19
Jon Ulven, Ph.D.
and so they can’t do the virtual care themselves, that we offer that up to people. And in this building that I’m in right here in Moorhead, we have 17 psychologists and master’s level therapists. We have psychiatry here, social workers, nursing staff. And then within our building we have family medicine, internal medicine, women’s health, pediatrics. We have a lab here.
00:06:56:19 – 00:07:20:28
Jon Ulven, Ph.D.
We have a pharmacy here. So we have this nice opportunity to provide just a really well-rounded, amount of health care. To tie back into the, connecting with what we’re all here for, it’s talking about the, you know, our ability to do that type of care, to think that way and to provide this platform of care.
00:07:21:00 – 00:07:37:26
Jon Ulven, Ph.D.
A lot of it has to do with in our country the ways that we pay for health care. And that’s where we get into what has been a mainstay for health systems, and especially when we think about rural health systems is the services that are allowable by Medicaid.
00:07:37:28 – 00:08:04:18
Rebecca Chickey
I want to get back to that point. But before we go further about the devastating cuts that are being discussed right now, help the listeners with a couple of stories, if you can. What has been – so your ability to provide these services, your ability to provide access to care virtually or in person by being creative around that clinic that was probably on the verge of maybe closing and not being there in that community.
00:08:04:20 – 00:08:09:18
Rebecca Chickey
What are some of the personal stories you’ve seen that have impacted the lives and how?
00:08:09:20 – 00:08:30:08
Jon Ulven, Ph.D.
Many stories that that I could share around this. I’ve been here with, Sanford for 21 years. I’m a licensed psychologist, and as you were saying, I’m the department chair of our adult psychology group. So I often feel like, jack of all trades and a master of none. But what I do is I do some hospital based coverage from time to time.
00:08:30:08 – 00:08:56:24
Jon Ulven, Ph.D.
And so we have an inpatient psychiatric unit that I will occasionally provide care for. So a very common course that we would see would be somebody who is uninsured or underinsured. And they end up coming through our emergency department for a mental health crisis. And while they’re there, the team, with our emergency department determines that the patient needs hospitalization in our inpatient psychiatric unit.
00:08:56:26 – 00:09:23:18
Jon Ulven, Ph.D.
Patient is admitted there. While they’re there, we might uncover, for example, a first episode psychosis. So if you take someone who is a young individual in one of our communities who is having an onset that might lead to schizophrenia diagnosis, they’re having a first episode of psychosis. And so we have the opportunity to assess the person there, start the person on anti-psychotic medications.
00:09:23:18 – 00:09:42:21
Jon Ulven, Ph.D.
And then let’s say that we also uncover that this person has a substance use disorder. Well, we have had the opportunity to enroll this person in Medicaid. Perhaps this person is unemployed, underemployed, has a position where they just don’t have the benefits to have, that standard type of health care that a lot of us are able to have.
00:09:42:23 – 00:10:07:29
Jon Ulven, Ph.D.
And so we get this person on Medicaid, and what we’re able to do from our inpatient unit is set this person up with a primary care provider, a psychiatrist, a therapist, and we’re able to do things like get this person started on some medication that might help with cravings for substance use. And we can we can also work with some of our community partners to try to get this person engaged in that care.
00:10:08:02 – 00:10:27:16
Jon Ulven, Ph.D.
What I often think about is just that if that early intervention that we know that if we can help this person out at that point on an early basis, we are really and in some ways, we’re bending the trajectory for their health throughout the course of that person’s life. And it is such an important time.
00:10:27:18 – 00:10:50:10
Rebecca Chickey
That’s phenomenal. For the listeners: Statistically, by the age of 14, probably about 50% of the population if you’re going to show or have a psychiatric or substance use disorder, those symptoms are showing by the age of 14. And correct me if I’m wrong here, keep me honest. But then by the time you’re 21 to 24, we’re up to 75%.
00:10:50:12 – 00:11:13:05
Rebecca Chickey
So that early identification and intervention and treatment, there’s so many opportunities to improve the long term health of the individual, the ability to have a joyful life, to engage and be productive and make the most of the resources around them. It’s just critically important. And you’re being there, is equally so.
00:11:13:07 – 00:11:33:12
Jon Ulven, Ph.D.
Thank you for that. You know, as we’re having this conversation that when we hear stories like this, sometimes the tendency as humans to just say, oh, that’s nice. And it’s important to hear about that. But we, it’s a bit abstracted from us. If we don’t have the ability to treat that type of individual, we see, as we see, diminishing services across the board.
00:11:33:14 – 00:12:02:13
Rebecca Chickey
Research shows that 50% of children and 18% of adults in rural communities are covered by Medicaid. Let that sink in, listeners. 50% of the kids in rural communities are covered by Medicaid and 18% of adults. Medicaid is also the largest payer for behavioral health. So speak a little bit more about the impact of these Medicaid cuts that are, currently being discussed in Congress and what that would mean for your community.
00:12:02:15 – 00:12:22:02
Jon Ulven, Ph.D.
Yeah, thank you for that. And just as you were saying that, just another I think another example just comes to mind for me, and that’s the that’s the example of that, something that I think a lot of people don’t think about. And that’s health care coverage for foster kids, for foster children. So, if you think about that for a moment, you’re a family who’s taking on a foster child.
00:12:22:05 – 00:12:46:25
Jon Ulven, Ph.D.
We don’t allow that those folks to go under the foster parents’ insurance. There’s a gap. There’s a gap in care that is consistently filled by Medicaid. And if we think about some of the folks and even if our, you know, listeners can think about some situations where they think a foster child would come from a situation if they’re obviously coming from a situation that is a distressing and challenging situation.
00:12:46:27 – 00:13:13:13
Jon Ulven, Ph.D.
Often there are there are lots of different health related issues, including mental health issues. Essentially, these folks would possibly be in a situation where they would have no care, no, no access to care. And we know some things about, looking at places, for example, where, Medicaid expansion has hit a certain area and we can we can take a look at some big numbers about like what’s the impact of that?
00:13:13:13 – 00:13:39:27
Jon Ulven, Ph.D.
And we know, for example, that in one study they, looked at suicide rates, of the rate of suicide. And it was over the course of many years and found that folks who had access to Medicaid expansion that suicide rates go down. In the study that they looked at over a series of years, literally thousands of lives, they can see a reduction in completed suicides, which would suggest that there were thousands of lives saved.
00:13:40:04 – 00:14:08:14
Jon Ulven, Ph.D.
I’ll also offer just a more pragmatic one. There was a study that was out of Montana that looked at a group of people who were participating in a tele-psychiatry practice. A large number of these folks were Medicaid recipients. And what they found was that, participating in this psychiatry practice, they had a 38% reduction in inpatient hospitalizations, 18% reduction in emergency department visits.
00:14:08:16 – 00:14:45:00
Jon Ulven, Ph.D.
So if you think about the higher cost elements of health care, when we can invest in ways that we know have evidence support, are effective, get the job done, we’re actually preventing some of that higher cost care that that truly is. But I would much rather work on preventing something from getting worse than what ends up happening when people are at that level of distress, when they make it to our emergency department, or when I’m covering on our inpatient unit and I can see that I’m working with someone who has gone without care for a significant amount of time.
00:14:45:02 – 00:15:09:13
Rebecca Chickey
Again, going upstream, early intervention prevention, treatment, rather than waiting for the crisis, which might not only just impact the individual, but others as well, depending upon what the crisis is and how many people show up to the emergency room. So, as we draw this podcast to a close, is there a call to action that you would share with the listeners?
00:15:09:13 – 00:15:19:23
Rebecca Chickey
If there’s something you would like to encourage them to do? Or, the last thing that you want to make sure that they that resonates as they click off to this podcast.
00:15:19:25 – 00:15:48:29
Jon Ulven, Ph.D.
My heart often goes to children. I only work with adults in my practice, but I but I mean, I’m a father myself. I think about that. Just that point you just made that earlier, we can intervene the better. And I think it’s important that one study found that there children who have Medicaid coverage, they’re four times more likely to have a regular visits with like, a pediatrician or get some of their health care needs met.
00:15:49:01 – 00:16:08:28
Jon Ulven, Ph.D.
And that that includes behavioral health and that they’re 2 to 3 times more likely to receive preventative care. And then we think about when it comes to, adults who are enrolled in Medicaid, that they’re five times more likely to have a regular source of health care and also receive preventative care. From the listening perspective
00:16:08:28 – 00:16:34:28
Jon Ulven, Ph.D.
I hope that what this has done is just increased an awareness to truly wide reaching effects that a change in Medicaid is going to it’s going to have for the way that we deliver health. And I would say especially in rural health care. Rural health care systems are routinely much more impacted by non reimbursable care. And so you add to that, we’re going to see some pretty significant reduction in services
00:16:34:28 – 00:16:51:12
Jon Ulven, Ph.D.
would be I think a reasonable guess. The thing that like call to action? I think one of the things I’m so I feel so privileged about in, in that, in North Dakota. I’m a citizen of North Dakota, I practice in Minnesota, I’m right on the border. Because we’re in a small state of North Dakota,
00:16:51:15 – 00:17:30:05
Jon Ulven, Ph.D.
I have been able to work with our government support people and been able to testify. The last two legislative sessions, we have had laws changed in the state of North Dakota. That’s been a great opportunity through connections of – here’s me as a psychologist, working with our legislators. We all are responsible in a health care setting or our elected officials to improve the lives of the patients and the citizens of our states. And in a bipartisan way, when we can find some nice opportunities to get some things done that are truly meaningful for people in the states we serve, it’s a win for everybody.
00:17:30:08 – 00:17:49:16
Rebecca Chickey
That’s phenomenal. Thank you. Your passion for this work, both for the patients that you serve, for the organization that you work for and with, and for having an impact work globally. It resonates throughout this entire podcast. So thank you for that passion, for bringing it to the work that you do. And thank you for sharing it with the rest of the field.
00:17:49:18 – 00:17:51:13
Jon Ulven, Ph.D.
Well, thank you very much.
00:17:51:16 – 00:17:59:27
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.
West Virginia’s health care crisis is about to get worse
Republicans in Congress are closing in on the final passage of a funding bill that would drastically cut Medicaid. The cuts are part of far-reaching legislation to enact much of President Donald Trump’s domestic agenda. West Virginians already struggle to find the health care they need. The seven most at risk of closure are Logan Regional Medical Center, Welch Community Hospital, Broaddus Hospital Association, Minnie Hamilton Health Care Center, Grafton City Hospital, Jackson General Hospital and Montgomery General Hospital, according to researchers at the University of North Carolina. For hospitals that don’t close, services and treatments that rely on Medicaid the most are likely to be cut. The House of Representatives was moving toward a vote on Wednesday to meet Trump”s demand for approval before July 4.“We will see hospital closures,” said Rich Sutphin, executive director of the West Virginia Rural Health Association. “Imagine you’re having a heart attack, and you’re in one of those areas, “
Emergency rooms in West Virginia are overwhelmed with patients. Cots sit in hallways. Patients in waiting rooms scream in pain.
Many people who use drugs don’t have local treatment centers. Local doctors’ offices are in short supply.
West Virginians already struggle to find the health care they need. It’s about to get much, much worse.
Republicans in Congress are closing in on the final passage of a funding bill that would drastically cut Medicaid, which provides care for older, poor and disabled people, including more than 500,000 West Virginians. The cuts are part of far-reaching legislation to enact much of President Donald Trump’s domestic agenda.
Following the U.S. Senate’s passage of the bill Tuesday, the GOP-controlled U.S. House of Representatives was moving toward a vote on Wednesday to meet Trump’s demand for approval before July 4.
“We will see hospital closures,” said Rich Sutphin, executive director of the West Virginia Rural Health Association.
The seven most at risk of closure are Logan Regional Medical Center, Welch Community Hospital, Broaddus Hospital Association, Minnie Hamilton Health Care Center, Grafton City Hospital, Jackson General Hospital and Montgomery General Hospital, according to researchers at the University of North Carolina.
And for hospitals that don’t close, services and treatments that rely on Medicaid the most are likely to be cut. At the ERs, for example, people would have to wait longer to be seen with fewer doctors and nurses, and others would lose their regular doctor.
Montgomery General Hospital CEO Deborah Hill said it’s already stretched thin and would be likely to close. More than a quarter of its patients rely on Medicaid.
Small hospitals like Montgomery General are often one of the few places for people to see a doctor nearby. People from neighboring Clay and Nicholas counties often travel there.
“Imagine you’re having a heart attack, and you’re in one of those areas, “ Hill said. “You’re already 40 minutes from us, and it’s another 30 minutes to Charleston.”
Mothers and infants among the victims
In 90-degrees heat at a Huntington park, Christina Langley arrived early at a get-together for women in recovery.
With her 3-year-old daughter Magnolia, she put juice boxes, water bottles and ice in an inner tube as a make-shift cooler.
Sitting on towels in the grass and slathering on sunscreen, several women said Langley, who is also in recovery, has been a source of inspiration.
Cayla Watts and her daughter Caylee, 8 months, play at a splash pad in Huntington. The event was for mothers in recovery and their children to socialize. Similar programs are at risk of closure under Congress’ Medicaid plan. Photo by Erin Beck
At 15, Langley became pregnant. She said the town shamed her. Adults told their kids not to hang out with her.
Nothing helped until a dentist prescribed painkillers after removal of her wisdom teeth. For the first week, the pills numbed the pain. After that, they numbed the shame.
Through Medicaid, she got into addiction treatment and support groups.
Hospital workers showed her that what mattered was how she felt about herself.
“If I hadn’t gotten sober, I know I would be dead by now,” Langley said. “And without the treatment that I got, I know I wouldn’t be sober.”
From left, Christina Langley, a mother in recovery, and her daughters Magnolia and McKayla visited Washington, D.C to tell members of Congress that Medicaid cuts would hurt families like their own. Courtesy photo
She could lose her job due to Medicaid cuts.
Hospital officials confirmed that programs like the moms’ group there, and other services for families harmed by problematic substance use, would be among the most at risk.
During a recent visit to Washington, D.C., Langley and hospital leaders from around the state warned cuts could devastate them.
She tried to help West Virginia’s members of Congress understand people don’t have to use Medicaid forever.
Now 42, she gets private insurance through the hospital.
“There are people out here breaking those generational bonds and chains,” she said.
Langley said she didn’t get any promises.
WV’s representatives praise hospitals, vote against then
As governor in 2017, Sen. Jim Justice said “any cut” to Medicaid would “cripple” the state.
Last year, he signed a bill to increase how much hospitals can get from Medicaid.
But earlier this week, he voted to pass the federal legislation, which sets new limits on the amount and makes other cuts to Medicaid.
Kaiser Family Foundation reports that cuts would reduce federal Medicaid spending by $1 trillion and increase the number of uninsured people by 11.8 million, making nearly 8 million people lose coverage by 2034.
Last month, he said changes to hospital payments would “hurt our rural hospitals and hurt them in a big way, and I don’t want to see that at all.”
Friday, his spokesperson sent an email saying Justice believes the legislation strikes a good balance between running the program efficiently and protecting the most vulnerable.
Sen. Shelley Moore Capito has said the goal “is to root the waste, fraud, and abuse out of the program,” but she’s said she didn’t know the extent of fraud, waste and abuse in West Virginia.
And in a news release Tuesday, she said the bill ensures Medicaid is sustainable long-term and touted other provisions of the bill
In May, when West Virginia Rep. Carol Miller, a Republican, voted for the similar version of the bill, she said it would improve the life of the average American and promoted tax cuts that predominantly benefit the wealthy and businesses.
Last month on social media, she posted a photo with hospital representatives and praised the West Virginia Hospital Association for doing “incredible work as the voice of the state’s hospital community.”
Miller wouldn’t speak to her stance this week.
Rep. Riley Moore, also a Republican, praised the bill for similar reasons as Miller and for helping build a border wall.
Margaret Hensley, of Logan County, said her entire community would suffer if their hospital closes. Photo by Kat Ramkumar Hensley and her nephew, who suffers from multiple health conditions, in the hospital. Photo by Kat Ramkumar
In Logan County, Margaret Hensley’s family knows the value of the local hospital. Hensley is Christina Langley’s mother.
Angel sculptures and family photos surround Hensley’s office.
Her nephew is in recovery and has mental illnesses, learning disabilities and diabetes.
“If he loses his benefits, I’m probably gonna have to bury him,” she said.
Her mother-in-law’s life was saved at the hospital after she developed a blood clot.
“I’m praying it doesn’t shut down,” said Hensley, a pastor’s wife. “It’s going to cost people their lives.”
Margaret Hensley points at a family photo while she talks about how Medicaid cuts could devastate them. Photo by Kat Ramkumar
Clarification, July 9, 2025: This story has been updated to clarify a paraphrased comment in which the CEO of Montgomery General Hospital said the Medicaid cuts would likely cause that facility to close.
Medicare and Medicaid cuts are big but not beautiful – The Washington Post
At least 17 million Americans will lose their Medicaid and Affordable Care Act coverage. People in vulnerable populations are more likely to go to the emergency room for nonemergency care. In rural areas where hospitals rely heavily on Medicaid dollars to continue operating, facilities might close and exacerbate the problem. States will also have the unfunded burden of dealing with all of the additional vetting of the Medicaid expansion population. They have a fiduciary duty to act in the best interests of the country, which includes its viability for future generations of Americans. They front-loaded tax cuts to provide benefits to many Americans before the midterm elections while back-loading some cuts until after the elections. They seem to have designed the “One Big Beautiful Bill” to ensure some benefits to some people before the midterms. They also have written the bill so that some benefits will be available after the election, ensuring their own political fortunes. It’s a mistake to say, “We all going to die.” The same is not necessarily true of corporations or countries.
People in vulnerable populations, including those who lack health insurance, are more likely to go to the emergency room for nonemergency care. The article stated that 40 percent of D.C. residents are covered by Medicaid. What will happen when some of them lose that coverage? In rural areas where hospitals rely heavily on Medicaid dollars to continue operating, facilities might close and exacerbate the problem. The patients left behind might crowd the hospitals that remain, or they might be forced to forgo medical care altogether.
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Make America healthy again indeed.
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Randy Rosso, Arlington
Cuts will increase cost
One of the sections of the “One Big Beautiful Bill” is intended to rationalize Medicaid and save money, resulting in at least 17 million Americans losing their health coverage.
However, the cuts to Medicaid will actually increase spending on health care for two reasons. First, studies have shown that uninsured people are less likely to seek preventative care, and are also more likely to delay or go without receiving the care they need because of the expense. But as a result of the delay or loss of care, the conditions of those who are ill or injured will probably worsen, requiring more intensive and costlier treatment.
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Second, as their conditions worsen, those affected will predictably seek care at community hospital emergency rooms, which are required to provide treatment for patients regardless of whether they have insurance. This is one of the most expensive avenues for medical care, far exceeding the cost of a visit to a doctor’s office. So, the combination of the higher cost for a more advanced disease, combined with a very expensive venue for treatment, will drive overall health care costs even higher.
Ken Lefkowitz, Medford, New Jersey
The writer is author of “Medicare for All: An Economic Rationale.”
In his July 7 op-ed, “Why the GOP’s Medicaid cuts are less than meets the eye,” Ramesh Ponnuru played down the loss of Medicaid coverage resulting from the Republican budget law. First, Ponnuru suggested states such as New York and California might subvert their work requirements without acknowledging the states that will implement the requirements to deny coverage. He also glossed over the tremendous impact that slashing the federal return from provider taxes will have on health care and state budgets.
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Ponnuru also did not mention that providers may be denied reimbursement that they might have been paid under prior law that provided a longer window for retroactive Medicaid coverage. Nor did he mention that the enormous deficit spending in the bill that will trigger massive Medicare cuts over time because of the Statutory Pay-As-You-Go Act of 2010. States will also have the unfunded burden of dealing with all of the additional vetting of the Medicaid expansion population. This work will fall to state agencies that are short-staffed and might have antiquated information technology systems.
My state of New Hampshire is among those that might lose over 7.5 percent of their federal Medicaid funding. Unfortunately, Ponnuru neglected to acknowledge the impact on human lives, including in my state, that are imperiled.
Brendan Williams, Pembroke, New Hampshire
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The writer is president and CEO of the New Hampshire Health Care Association, a long-term care trade association.
The dangers of kicking the can
Though Sen. Joni Ernst (R-Iowa) recently responded to the looming Medicaid cuts in the “One Big Beautiful Bill” by saying, “We all are going to die,” the same is not necessarily true of corporations or countries. Corporate boards have a fiduciary duty of loyalty, requiring them to act in the best interests of the corporation, including its solvency and continuity over time, not in their own personal interest. Similarly, the president and Congress have a fiduciary duty to act in the best interests of the country, which includes ensuring its viability for future generations of Americans.
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But the president and Republican legislators seem to have designed the “One Big Beautiful Bill” with their own political fortunes in mind. They have cynically front-loaded tax cuts to provide benefits to many Americans before the midterm elections while back-loading some benefit cuts until after the midterm elections. They have also written the bill so that some benefits to taxpayers, such as higher caps on state and local tax deductions, are set to expire after President Donald Trump leaves office so that another president will be under pressure to extend them or take the blame.
Since we are all going to die, while the country (hopefully) continues to exist, the president and Republican legislators should be thinking not only about their own personal interests in getting reelected but also about the interests of citizens who are not yet born. We should work to ensure our country is better, not worse, for our children. Future Americans deserve a country that is both fiscally solvent and environmentally sustainable. One searches in vain for provisions in this bill to meaningfully address these long-term crises. Rather, the bill is rapidly advancing both days of reckoning by expanding the federal deficit and cutting back support for green energy.
Chris Gerrard, Rockville
Threats to mental health care
I am a mental health therapist living and working in rural Maine. I’ve spent years helping families navigate a broken health care system, and I’ve seen firsthand what happens when access to care depends on Zip code or, worse, income. That’s why the recent proposals to slash funding for Medicaid aren’t just bad policy. They’re dangerous.
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That program is a lifeline. In my community, it covers everything from a child’s therapy to a senior’s insulin. About 1 in 5 Americans rely on Medicaid, and in the rural areas of my state, that percentage is even higher.
Many of my clients have no other form of insurance. Without Medicaid, they wouldn’t be able to walk into my office. Without Medicaid, their parents or grandparents wouldn’t afford the medication keeping them alive. These are not exaggerations; these are daily realities of our community members.
Supporters of the cuts argue they’re necessary to reduce the national debt. But we need to stop pretending that the burden of fiscal responsibility should fall on the backs of our most vulnerable citizens.
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Medicaid and Medicare are not just health programs; they keep small-town hospitals open. When we gut these programs, we’re not just cutting care; we’re threatening the livelihoods of health providers, closing clinics and driving our communities even further into crisis.
Also, we are experiencing a mental health emergency among young people. The Centers for Disease Control and Prevention has reported that suicide is the second-leading cause of death among people ages 10 to 34. Medicaid funds a significant share of youth mental health services. Stripping that support now would be like taking water away during a house fire.
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Some argue that charities could fill the gap. But they cannot replace coordinated, consistent care. We’re not talking about a gap to be filled; we’re talking about a canyon.
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So, what’s the alternative? Instead of cutting funding, invest those funds in smarter, more targeted ways. Close loopholes in Medicare Advantage plans that prioritize profits over care and health outcomes. Increase Medicaid eligibility in states that still haven’t opted in to the expansion. Boost funding for telehealth, which has proved especially effective in rural regions. These are policy moves that save lives and even money in the long run.
We can build a system that works — one that treats health care as a right, not a privilege reserved for the healthy and wealthy. But we can’t get there by ripping out the foundations that hold people up.
Our community members need us. Do not cut Medicare and Medicaid. Expand and protect them. When we protect health care, we protect dignity, safety and life itself.
Lisa Dezso, Pittsfield, Maine
The writer is a doctoral student in prevention science and a practicing mental health therapist.
Letter to U.S. House of Representatives: Vote NO on Harmful Reconciliation Bill and Medicaid Cuts
The Disability Rights Education and Defense Fund (DREDF) urges all members of the House to vote NO on the Senate amendment to H.R. 1. The Senate’s version of the budget bill targets at-risk communities and results in even deeper carve-outs to Medicaid and Medicare, with over $1 trillion in healthcare cuts. The proposed bill would lead to at least 17 million people losing healthcare coverage. People without healthcare coverage delay seeing the doctor or can’t afford treatment, they get sicker and miss work or risk being fired, or they go to work and potentially expose others to a virus. The budget bill is cruel. It jeopardizes our nation’s well-being and would harm disabled people and older adults. DREDF calls on all. members of Congress to defend the health and rights of our communities, and commit to ensuring Medicaid and. Medicare continue to provide reliable healthcare, including community-based supports and services for all. people in need. The bill is expected to reduce over a million jobs nationwide.
July 1, 2025
The Honorable Mike Johnson
Speaker
U.S. House of Representatives
Washington, DC 20510
The Honorable Hakeem Jeffries
Minority Leader
U.S. House of Representatives
Washington, DC 20510
RE: Vote NO on Harmful Reconciliation Bill and Medicaid Cuts
Dear Speaker Johnson, Leader Jeffries and Members of the House of Representatives:
The Disability Rights Education and Defense Fund (DREDF) urges all members of the House to vote NO on the Senate amendment to H.R. 1. The Senate’s version of the budget bill targets at-risk communities and results in even deeper carve-outs to Medicaid and Medicare, with over $1 trillion in healthcare cuts. The budget bill is cruel. It jeopardizes our nation’s well-being and would harm disabled people and older adults. DREDF calls on all members of Congress to defend the health and rights of our communities, and commit to ensuring Medicaid and Medicare continue to provide reliable healthcare, including community-based supports and services for all people in need.
The proposed bill would lead to at least 17 million people losing healthcare coverage.[1] People without healthcare coverage delay seeing the doctor or can’t afford treatment, they get sicker and miss work or risk being fired, or they go to work and potentially expose others to a virus. As a result of these healthcare coverage losses, an estimated 51,000 people will die every year.[2] When states have faced Medicaid budget cuts in the past, every state reduced its coverage of homecare services that people with disabilities need to stay out of costly institutions because federal law requires Medicaid to cover institutional care but not homecare.[3] The proposed budget targets low-income people, people with disabilities, students, immigrants and Black, Brown and Tribal communities.
Harmful parts of the bill affect disabled people, our neighbors, and our families by:
Making it much harder for people to stay enrolled in Medicaid by: forcing states to adopt job loss penalties, including for adults up to 64 years and parents with children older than 14; repealing simplified eligibility rules; and increasing the frequency of eligibility redeterminations to every 6 months.[4] At the same time, the bill is expected to reduce over a million jobs nationwide.[5] People with disabilities already face employment discrimination that means they are the last to be hired and the first to be fired, and barriers to employment such as limited transportation. Beginning in 2027, low-income people with disabilities who work less than 20 hours a week will not be permitted to enroll in Medicaid;
Creating so-called exemptions to job loss penalties that are difficult for people with disabilities to meet and apply for. Many people with disabilities that do not fit into Congress’s restrictive definition of disability could lose their care, including those who are not enrolled in very strict government programs under the Social Security Administration. People who don’t have a clearly defined diagnosis, who have disabilities that can worsen and improve over time, such as some mental health disabilities, or who experience periods of seasonal unemployment will all have trouble proving their eligibility for Medicaid;
Increasing the risk that people will also lose their care because of the difficulty of repeatedly proving that they are eligible. For example, some people with disabilities face barriers reading print or understanding their mail, making phone calls, having others understand their speech, or physically getting to a recertification office. States who want to give people a fair chance to stay enrolled will be forced to spend millions of dollars on keeping track of paperwork and eligibility, instead of spending money on providing care and services;[6]
Trapping low-income people who need insurance to be healthy enough to work into a terrible cycle due to the increased risk of healthcare coverage loss (including thousands of older women of color who work as both paid and unpaid caregivers for disabled people and seniors). If they fall off of Medicaid themselves, they will also be ineligible for Affordable Care Act (ACA) marketplace coverage,[7] and are likely to experience worse health, even as they are less and less likely to be able to find employment and get healthcare again;
Increasing out-of-pocket costs for adults who rely on Medicaid if they make over $15,650 a year for an individual or $32,150 for a household of four.[8] These fees could lead to fewer visits to the doctor and more unmet healthcare needs;
Limiting the income that states can raise to fill the budget gaps created by federal cuts. States will be forced to cut essential programs like homecare services instead of being able to raise revenue to prevent program cuts;
Denying future healthcare access to people living in states that have not expanded their Medicaid programs to more people;
Preventing a new rule from going into effect that would force nursing homes to have sufficient staff and help prevent abuse and neglect in long term care settings, thereby putting people with disabilities and older adults at risk;[9]
Banning Medicaid funding for community providers like Planned Parenthood that offer critical reproductive and preventive healthcare. This is effectively a back door abortion ban. If community providers lose funding, millions of low-income and uninsured people, including people with disabilities in rural areas, will lose access to vital health care such as mammograms, cancer screening, pap smears, sexually transmitted infection testing, birth control method counseling, and health care for pregnant people. People with disabilities often face significant transportation barriers and many will not be able to get to a provider that is further from their home;
Cutting access to Medicaid, Medicare, the Supplemental Nutrition Assistance Program (SNAP), the Children’s Health Insurance Program (CHIP), and the ACA for some immigrants including refugees, survivors of trafficking, and other humanitarian entrants who are here with legal status;
Increasing family detentions and deportations and eliminating baseline protections for immigrant children, including disabled children, in U.S. custody by removing state licensing requirements for facilities and maximum time in custody standards. The bill also allows officials to conduct invasive examinations of children’s bodies to search for tattoos or markings while they are in the custody of the Office of Refugee Resettlement;
Cutting nearly $300 billion from the SNAP, almost one-third of the entire program budget.[10] The Senate version of the bill shifts the costs of running the SNAP program to the states. Since SNAP benefits are technically optional for states to provide, some states might stop participating in the program altogether.[11] This would decrease access to food for millions of people. Students, single mothers and their families would be most affected, as would adults with disabilities who comprise 9% of SNAP beneficiaries; and
Repealing funding to address air pollution in schools which would disproportionately harm students with disabilities and chronic health conditions.
DREDF believes that health care and access to healthy and safe communities are human rights for all people. No matter our disability, race, gender, sexual orientation, citizenship status, income, or ZIP code – we all deserve to access the care and services we need to live. Without these services and programs, tens of thousands of people will die every year.
We call on all members of Congress to reject the harmful proposals and defend Medicaid and the programs people in all states need to live safe, healthy and fulfilling lives. Vote No on the Senate Amendment to H.R. 1. Please do not hesitate to reach out with any questions by contacting Carol Tyson, Government Affairs Liaison, ctyson@dredf.org, and Silvia Yee, Policy Director, syee@dredf.org.
Sincerely,
Michelle Uzeta
Interim Executive Director
[1] https://www.cbo.gov/publication/61535
[2] https://ldi.upenn.edu/our-work/research-updates/research-memo-projected-mortality-impacts-of-the-budget-reconciliation-bill/
[3] https://geigergibson.publichealth.gwu.edu/history-repeats-faced-medicaid-cuts-states-reduced-support-older-adults-and-disabled-people
[4] https://www.cbpp.org/blog/more-frequent-medicaid-renewals-would-increase-errors-and-lead-eligible-people-to-lose-health
[5] https://www.commonwealthfund.org/publications/issue-briefs/2025/jun/how-medicaid-snap-cutbacks-one-big-beautiful-bill-trigger-job-losses-states
[6] https://healthlaw.org/resource/top-10-reasons-why-house-republicans-work-requirement-proposal-will-harm-low-income-people/
[7] https://www.milbank.org/2025/06/lessons-learned-from-arkansas-experience-with-a-medicaid-work-requirement/
[8] https://www.kff.org/tracking-the-medicaid-provisions-in-the-2025-budget-bill/ and https://www.medicaidplanningassistance.org/federal-poverty-guidelines/
[9] https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid-0
[10] https://www.cbpp.org/research/food-assistance/house-reconciliation-bill-proposes-deepest-snap-cut-in-history-would-take and https://www.fns.usda.gov/data-research/data-visualization/snap/action
[11] https://www.cbpp.org/research/food-assistance/senate-republican-leaders-proposal-risks-deep-cuts-to-food-assistance-some
These 12 rural Indiana hospitals could be at risk under Trump’s ‘big, beautiful bill’
Four Democrat senators and at least one Republican have warned that many smaller hospitals throughout the country could be at risk under the proposed cuts. “Rural hospitals are going to be in bad shape,” U.S. Senator Josh Hawley (R-Missouri) said last week. The letter lists 12 Indiana hospitals that could potentially be impacted by the bill. To read a full copy of the letter and the list of potentially affected hospitals, click here.
Four Democrat senators and at least one Republican have warned that many smaller hospitals throughout the country could be at risk under the proposed cuts.
“Rural hospitals are going to be in bad shape,” U.S. Senator Josh Hawley (R-Missouri) said last week.
Four others sent a letter to Trump last week stating that 338 U.S. hospitals would be impacted by the Medicaid reductions as they currently stand.
U.S. Senators Edward Markey (D-Massachusetts), Ron Wyden (D-Oregon), Jeffrey Merkley (D-Oregon) and Charles Schumer (D-New York) cited research done by the University of North Carolina in their letter.
“Lack of health care access in rural America is contributing to worse health outcomes,” their letter reads. “Rural hospitals are often the largest employers in rural communities, and when a rural hospital closes or scales back its services, communities are not only forced to grapple with losing access to health care, but also with job loss and the resulting financial insecurity.”
The letter lists 12 Indiana hospitals that could potentially be impacted by the bill:
Daviess Community Hospital in Washington
Memorial Hospital Logansport in Logansport
Community Hospital of Bremen Inc. in Bremen
Ascension St. Vincent Randolph in Winchester
Ascension St. Vincent Jennings in North Vernon
Ascension St. Vincent Clay in Brazil
Ascension St. Vincent Salem in Salem
IU Health Jay Hospital in Portland
Franciscan Health Rensselaer in Rensselaer
Sullivan County Community Hospital in Sullivan
Adams Memorial Hospital in Decatur
Harrison County Hospital in Corydon
To read a full copy of the letter and the list of potentially affected hospitals, click here.