How Trump’s Big Bad Bill Will Kill Americans

What research tells us about how Trump policies are bad for your health

When confronted by a constituent claiming that “people are going to die” from the massive Medicaid cuts in Trump’s just-passed Big Bad Bill, Iowa Senator Joni Ernst flippantly responded that “we are all going to die.”

Yes, we are all going to die, but most of us would prefer to avoid a preventable death, and collectively rely on public policy to improve our quality of life and extend longevity. On that count, the US is doing poorly given its wealth. Americans already die much younger, and suffer from worse health while alive, than people in every other wealthy country.

Americans experience lifespans similar to citizens of much poorer nations: U.S. life expectancy in 2023 was lower than Albania and Panama, but a little higher than Estonia. The Big Bad Bill ensures that the US will fall even further behind. We may all end up dead, but the GOP just ensured that it will happen much sooner for many Americans.

The Big Bad Bill will extend tax breaks that primarily benefit the richest Americans, cut over $1 trillion for health coverage and food aid for the poor and middle class, and increase the budget deficit by $3.2 trillion over 10 years. Estimates suggest that 17 million people will lose health insurance who previously received health care from Medicaid or Affordable Care Act (ACA) coverage. For the first time, most Medicaid enrollees will be required to comply with burdensome work requirements and subsidies for those enrolled in ACA coverage will be slashed.

Food aid through the Supplemental Nutrition Assistance Program (SNAP) will also be cut by capping future increases, expanding work requirements, reducing matching funds to states, and limiting immigrant eligibility. Support from both programs will be reduced by about 20%, which represents the largest cuts in their history.

This is not simply about resources. The bill will also significantly increase funding to Immigration and Customs Enforcement to build more detention and deportation capacity. Even as RFK Jr. promises to Make America Healthy Again by stoking vaccine skepticism, or getting people to drink sugary drinks, there is a wealth of credible health research that shows just how dangerous the Trump administration’s policies are for Americans.

Being American is bad for your health

Higher medical bills and worse health outcomes are not something that Americans can afford. Ranking lowest among high-income nations in average lifespan means that Americans live 4 fewer years than the average OECD country and 7 fewer years than countries like Japan and Switzerland. And in contrast to previous periods in modern history, U.S. life expectancy has not improved for almost two decades after rising steadily for the previous century.

A recent study used a different metric to represent these stark differences across countries. It asked: if we lived as long as our peers in other wealthy countries, how many more Americans would still be alive? The numbers are jarring. Starting in the 1980s, there were around 600,000 missing Americans each year. That is, the number of Americans that would have been alive if the U.S. performed like an average well-off nation.

During the COVID-19 pandemic, the number of missing Americans rose to over 1 million lives per year. Cumulatively, we lost about 10,000,000 Americans since the 1980s– effectively, this was as if we’d wiped out Los Angeles, Chicago, Houston, and Phoenix.

Missing Americans by Year 1933 to 2021

Source: Bor, J., Stokes, A. C., Raifman, J., Venkataramani, A., Bassett, M. T., Himmelstein, D., & Woolhandler, S. (2023). Missing Americans: early death in the United States—1933–2021. PNAS nexus, 2(6), pgad173.

Our short average lifespan compared to other wealthy nations masks even worse inequities within. Across any dimension - income, geography, or race - those with less, experience more death. These gaps have widened over time and the pandemic super-charged this trend.

One large-scale analysis using 1.4 billion tax returns found that the richest 1% of Americans live 12 more years than the poorest 1% of Americans. This gap steadily widened over the 21st century. Racial disparities in health and mortality in the United States are also stark, with Black Americans robbed of an additional four years of life expectancy compared to White Americans.

Note: AIAN refers to American Indian / Alaska Native people.

Both maternal and infant mortality rates are drastically higher for Black and Indigenous women– five and two times as high, respectively. Even Black women with college degrees experience almost twice the risk of pregnancy-related mortality compared to white women without high school degrees. Black and Native populations are also far more likely to die earlier in life from conditions that are treatable.

It’s not just income and race. Where you live also matters. People in rural communities face significantly higher mortality risk. The map below shows the rural concentration of mortality. Explanations for the rural disadvantage range from limited access to health care to high rates of ‘deaths of despair’ or hopelessness, reflected in epidemic levels of drug overdoses, alcohol-related deaths, and suicides.

How the Big Bad Bill will make all of this worse

The Big Bad Bill includes a range of provisions that will almost certainly steal more years of Americans’ lives, and will hit the poor and those in rural communities hardest.

F--king with Medicaid – and the ACA too

The most obvious killer in the bill is that it will dramatically increase the number of Americans without health insurance. By last count an estimated 11.8 million people will lose Medicaid or ACA coverage by 2034 because of cuts and another 4.2 million will lose ACA coverage because premium subsidies will expire.

To understand the scope of these cuts, over 83 million people in the U.S. - about 1 in 4 - are covered by Medicaid and a closely related program called the Children’s Health Insurance Program (CHIP). Medicaid/CHIP pays for almost half of all births, covers over 40% of children, and pays for more than 60% of long-term care for the elderly at home, in nursing homes, and in assisted living facilities. It also supports services for over half of all children with disabilities and pays for insurance premiums and drug costs for low-income Medicare recipients. Medicaid/CHIP in total provides 20% of all U.S. health care spending. It is hard to overstate how central the program is to the well-being of a huge number of Americans.

President Trump told Republicans in Congress not to “F around with Medicaid.” The bill actually F’s with Medicaid quite a lot. For the first time nationally, it requires all adults ages 19 to 64 to demonstrate that they have performed 80 hours per month of work, volunteering, work-related training, or be in school at least half time. The bill also requires that states verify eligibility at least twice a year for all adults receiving Medicaid through the ACA expansion.

These new paperwork requirements will mostly lead to eligible people losing coverage. Because virtually all people on Medicaid already either work, go to school, or take care of others, these new regulations will simply withhold care from those that should be receiving it. This is of course the point - these changes are designed to reduce spending.

We know what will happen because this strategy has been tried before. When paperwork requirements were imposed in Arkansas in 2018, 25% of enrollees lost Medicaid coverage in 6 months, while no job gains were observed. Instead of expanding Medicaid, a program in Georgia called “Pathways to Coverage” currently offers insurance while imposing work requirements. Program enrollment was under 5,000 people as of last year even though 360,000 Georgians would be eligible for expanded Medicaid. Meanwhile, millions in program funds have been spent on expensive consultants such as Deloitte.

The work requirements are so onerous and frustrating that the spokesperson for the Georgia program was kicked off insurance twice in a year and now denounces it. To make matters worse, these requirements will also force states to build data systems without providing money, sufficient time, or the staff to execute them - setting states up for failure. With less administrative capacity, there will be less help for Medicaid recipients to manage these new burdens.

Once individuals lose coverage, there is overwhelming evidence that health insurance reduces mortality. A comprehensive analysis from the University of Pennsylvania (UPenn) and Yale School of Public Health (YSPH) found that the budget bill will cause 51,000 preventable deaths per year.

The estimated additional deaths generated by the bill come from four sources:

1. 11,300 deaths from loss of Medicaid or ACA marketplace coverage,

2. 18,200 deaths from losses to Medicaid coverage among Medicare enrollees, which would mean losing access to low-income prescription drug subsidies,

3. 13,000 deaths from the law delaying for 10 years a lower federal minimum staffing mandate for nursing homes that was to take effect in 2026, and

4. 8,800 deaths from letting the enhanced ACA marketplace premium tax credits lapse, which heavily subsidized premiums for people making up to $60,240.

Worse health outcomes, and defunding community health care systems

There are multiple ways in which these mortality estimates underestimate the bill’s potential health harm. Lost insurance means that more babies will be born with low birth weight because of missed prenatal care appointments, foregone asthma medication will induce asthma attacks that produce long-lasting lung damage, and foot amputations will be required by uncontrolled diabetes. The UPenn / YSPH analysis projects that work requirements will lead to almost 140,000 additional cases of uncontrolled diabetes, 165,000 uncontrolled cases of hypertension, and 46,000 of uncontrolled high cholesterol annually.

In addition to decreasing mortality, Medicaid reduces household out-of-pocket expenses and medical debt, while improving self-reported health. Medicaid’s mental health benefits are particularly large. Medicaid reduces the prevalence of untreated depression by more than 60% through increased use of medications to treat depression and sleep disorders. It also decreased unmet need for mental health care by almost 40%, while screening positive for depression declined by 30%.

Medicaid access in childhood also improves later-life health and income. In particular, Medicaid expansions for children were found to raise earnings in adulthood, increase cumulative taxes paid, and reduce government earned income tax credit transfers. The benefits are large enough that the government recoups 58 cents for adults for every dollar invested in child Medicaid. These benefits would be about $1 in benefits for every $1 spent if Medicaid take-up was close to universal among the eligible.

The bill would also drain significant resources from the health care sector, reducing access to care for all. If uninsured patients use emergency services or do not pay their debt, hospitals must raise prices for everyone else. In response, medical debt financing companies are already offering their services to struggling rural hospitals by forcing “sub-prime patients” to pay more.

Another provision of the bill cuts medical provider taxes from 6% to 3.5% over time. These taxes are initially levied on health facilities, but then states use that funding to unlock federal Medicaid matching funds, sending the money back to health facilities to support infrastructure like emergency rooms (ERs), hospital beds, and nursing homes. With the provider tax cap and the drop in payments from insurance cuts, health facilities, especially in rural areas, will be at higher risk of closing. According to a Brown University analysis, the cap in provider taxes could force 600 nursing homes to close. That would mean inundated ER facilities overwhelmed by former nursing home patients with nowhere to go.

The most vulnerable communities will be hit hardest

The map below shows the geography of Medicaid enrollment by Congressional District. Many House members represent districts where 30% or more of their constituents receive health care through Medicaid. Some are in blue areas such as the West Coast, New York, and New Mexico and purple states like Arizona and North Carolina. Many however are in deeply red districts in Louisiana, Kentucky, West Virginia, Arkansas, and Oklahoma - the same places with the lowest levels of life expectancy. Fundamentally, this bill represents a broken promise to those voters who believed President Trump’s assurances that Medicaid would be left alone.

It’s not just health insurance

A prodigious amount of ink and political capital has been spent over the last two decades debating whether and how to increase health insurance coverage. However, only part of the gap in life expectancy between the rich and the poor in the U.S. can be explained by differences in health coverage. One analysis estimates that health insurance explains between 5% and 25% of the mortality disparities between high- and low-income Americans. Other important factors are broadly summarized as the social determinants of health, including food security.

The bad news is that the Big Bad Bill will also increase food insecurity. SNAP provides food aid for more than 40 million people each year. Recipients now face expanded paperwork requirements for those aged 55-64, veterans, and people experiencing homelessness. It will also make states shoulder more SNAP administrative costs, reduce matching funds to states, and limit eligibility for some immigrant groups.

SNAP supports health by providing enough food to fight disease as well as freeing up money to improve health. For example, older adults with SNAP are less likely to forgo medical care or medicine because of cost. Adults on SNAP incur $1,400 (25%) lower medical costs per year as well. SNAP also generates direct health benefits by improving birth outcomes and reducing premature death for adults ages 40-64. SNAP eligibility for parents with young children improves health later in childhood, while SNAP for young children increases later educational attainment, economic self-sufficiency, and longevity. This means that SNAP - like Medicaid - is an investment in a better future for kids.

No way to prevent this, says only nation with health inequalities this wide

The damage will fall most heavily on people who have low incomes and those already in ill health such as the elderly. Government transfers represent a greater share of total economic activity in poor and rural areas, so more harm will be done to health and economic well-being in these communities as well. In addition, since Medicaid and SNAP for kids are investments that produce long-term benefits, these cuts - along with the budget deficit expansion - will fall most heavily on the younger generation.

The policy decisions that cause hundreds of thousands of ‘Missing Americans’ year after year are collective choices. And, the decision to pass this bill was also a choice - one that only succeeded by the narrowest of margins with Vice President Vance casting the tie-breaking vote. Most other wealthy nations have chosen differently.

America could address unequal access to health care the way almost all wealthy countries already do: eliminate administrative burdens by providing universal and automatic coverage for all people. The increase in economic precarity the bill will produce should also motivate a renewed push for comprehensive anti-poverty programs that are not conditional on work.

The action now shifts to how the bill is communicated to the public and how it is implemented. Given the legislation’s enormous size and importance, the bill passed very quickly, with debates and votes often happening in the dead of night, on weekends and holidays, and with limited drama or coverage.

This tactic may have been used because once people learn more about this bill, they seem to uniformly hate it. A survey found that many people are not aware of what the bill would do. But once told how much the bill would increase incomes for the rich and reduce it for the lower- and middle-class, support drops to 11%.

Because the law’s provisions are either phased in or vary in their start date, public response may be muted, especially before the 2026 midterms. Explaining the bill therefore is the responsibility of those that oppose it. Whether the public will become better informed or get distracted by other news is an open question.

The law’s ultimate impact will also still depend heavily on implementation decisions at the federal and state level. States must implement the onerous paperwork requirements by December 31, 2026, but can choose to move forward earlier. The expanded SNAP work requirements go into effect immediately, but states will still vary in how quickly they expand verification systems and how stringently they interpret the new rules. Sharply higher health insurance premiums for millions with ACA coverage will be sent out this Fall, since subsidies expire on December 31, 2025. And hospitals have to make resource allocation decisions today based on projected future revenue. Rural facilities in North Carolina and Nebraska have already announced they are either cutting services or closing due to the bill’s passage.

If the bill’s impact is clearly disseminated and its supporters pay a political price at each implementation step, there is real hope that the worst effects to the nation’s health may not come to pass. By organizing in response, based on evidence, a brighter future with better health and enhanced economic security can become reality.