THE SET-UP: It’s Obamacare. It’s always been Obamacare.
The well-regarded law is now more commonly referred to as “the ACA” or “the Affordable Care Act.” That transition seems to have followed Trump’s ultimate failure to overturn the law back in July of 2017 when Sen. John McCain (R-AZ) famously gave Trump the finger … his downward-facing thumb, to be exact.
Once the fight faded and the law grew in popularity, its critics suddenly seemed less motivated to tie it to the former President.
But the grudge against Obamacare is back, even if the name isn’t. And it’s being targeted by the ongoing work of DOGE and, as The Bulwark’s Jonathan Cohn explained over the weekend, by the House Republicans’ efforts to deliver Trump his “big, beautiful” budget and tax-cutting bill.
Everyone knows the GOP cannot come close to paying for its tax cuts without slashing Medicaid. The rub is that many of the GOP’s voters are on Medicaid … and they are getting healthcare thanks to the expansion of Medicaid under Obamacare. There are at least ten Republicans in the House and perhaps a handful in the Senate who indicate they will not vote for a reduction in benefits. Trump has also deemed it sacrosanct. That’s why they need to make cuts without it looking or sounding like they are making cuts.
Speaker Mike Johnson navigates those shoals by repeating the mantra of “waste, fraud and abuse” … and when he’s asked what else he’s going to cut from the program, he starts talking in thinly-veiled code about preserving it for “those who truly need it” and about the working age, able-bodied scofflaws who need to be pushed out of eligibility. They seem convinced a simple work requirement alone will force a legion of working-age men off the books.
No one mentions, though, that they are attempting to overturn a part of Obamacare. Speaker Johnson learned his lesson during the last election. He opined about rooting out the ACA and was quickly rebuked. It’s not quite Social Security, but touching it can give a politician a painful jolt. But that’s exactly what Johnson & Co are trying to do … they want to cut one of Obamacare’s most widely-used provisions.
Medicaid Expansion was meant to assist those who couldn’t afford to buy insurance under the mandate. To get there it commits the unforgivable sin of providing free healthcare to all poor people with “incomes up to 138% of the federal poverty level.” That means single adults and two-parent families get access to same healthcare Medicaid long reserved for poor single mothers and their kids. Expanded eligibility meant the uninsured rate fell “to a record low of 7.7%.” in 2023. A Kaiser Family Foundation study published in February found over 20 million Americans are currently covered by the ACA’s Medicaid Expansion. But if those states lost funding, it could very well leave 20 million Americans without health care.
If so, they’d join Americans in ten states the ACA never touched: Texas, Kansas, Wyoming, Wisconsin and the unsurprising cluster of Alabama, Georgia, Tennessee, South Carolina, Florida and the nation’s poorest state—Mississippi. Those states all refuse to accept billions of dollars they could use to expand Medicaid. The ACA wants to cover most of the cost. Their political leaders decline.
While they all have varying degrees of need, Mississippi’s recalcitrance seems both unusual and cruel. In addition to its leading rates of poverty across all age groups, the Commonwealth Fund ranks its healthcare system “last overall” and “47th for access and affordability, 47th for prevention and treatment, 37th for avoidable hospital use and costs, [and] 35th for income disparity.” And “14% of Mississippians…said they were unable to see a doctor at some point in the prior twelve months because of cost.”
With Medicaid Expansion, the state government could quickly cover many if not most Mississippians in need. And it’s a relative bargain. The state picks up 10% of the cost and Uncle Sam covers the remaining 90%. Then again, Mississippi kicked off 2024 by declining Federal food aid for children living in poverty. On the other hand, state officials infamously expanded welfare benefits to include former NFL Quarterback Bret Favre. Meanwhile, his buddy, GOP Governor Tate Reeves, still defies advocates of Medicaid Expansion in the legislature. Reeves, channeling his inner Reagan, derides “Medicaid as ‘welfare' and has frequently said he does not want more people to enroll” in the program. Then again, he also recently declared April 2025 “Confederate Heritage Month.”
Georgia took a different tack. Instead of taking the ACA’s Medicaid Expansion, they launched a state-level “expansion” alternative with prohibitive hurdles built into it, including a work requirement. That, among other obstacles, forced poor Georgians to jump through new hoops after the pandemic’s temporary expansion lapsed. It was, according to Kaiser Health News, a disaster. The reboot tripled the time it took to process applications. Within months Georgia was the second slowest in the nation. It also impacted applications for financial and food assistance.
Most problematic was the fact that it didn’t provide much healthcare. The Atlanta Journal-Constitution noted in October that Georgia Pathways to Coverage “doesn’t cover all poor adults,” it costs the state’s taxpayers more than it would with full Medicaid expansion and, because there are “fewer than 5,000 enrollees at last count,” the program’s “administrative costs per enrollee are heavier.”
It also sounds like a Byzantine model for denying coverage … one that may be replicated in some form by House Republicans.
Until then, DOGE is happy to do its part in making healthcare inaccessible again. - jp
TITLE: The Scramble to Save Rural Health Care From DOGE
https://www.theatlantic.com/ideas/archive/2025/04/doge-rural-health-trump-alabama/682513/
EXCERPTS: Traditionally, medical-school graduates complete their residencies at teaching hospitals in larger cities, places abounding with specialists, equipment, and nursing support. The idea behind the Teaching Health Centers Graduate Medical Education Program (THCGME) program was to establish residencies at health clinics in underserved areas where resources are scarce. The theory was that residents would not only gain confidence practicing medicine in a challenging context but develop a sense of mission about the work, and stay.
After an elaborate process of getting Cahaba accredited as a teaching health clinic, [Dr. John] Waits and [Dr. Lacy] Smith welcomed their first group of four residents in 2013. The initial funding allocated $150,000 per resident, enough to pay for their salaries and the support staff needed to retool Cahaba as an educational institution. Smith and Waits were not at all sure the plan would work. But out of the first group of residents, one decided to stay on at the Centreville clinic after she finished. Another one stayed from the second group of four, and out of the third group, all four stayed—a pattern that continued not only at Cahaba but at more than 80 other health clinics that became teaching health centers in other parts of the country. Out of the roughly 2,000 doctors who have graduated from rural residency programs, roughly 70 percent have continued to practice in underserved areas, according to program data.
As a practical matter, the $175 million federal program was creating a steady pipeline of doctors into some of the nation’s worst health-care deserts: places such as the Choctaw Nation in Oklahoma, inner-city Detroit, and southern West Virginia. And every year, the grant got renewed with bipartisan support, even as Republicans tried to repeal the Affordable Care Act dozens of times.
And that was how things had been going in Perry County, which struck Waits as an example of what government could be at its cost-efficient best, a version of American progress.
“This is working,” he would say to himself when he went over statistics showing improved health outcomes.
Then came the election, and DOGE, and a blizzard of executive orders, and an email that landed in Waits’s inbox: “Immediate Next Steps,” read the guidance sent to all THCGME grantees. “Carefully review policies, staffing plans, titles, roles and responsibilities, service offerings, etc., in the context of the related EOs. Consider immediate revisions and appropriate operational changes for compliance, particularly DEI.”
They reviewed their employment and promotion guidelines. Compliant. They considered Cahaba’s mission itself. Could DOGE possibly construe providing health care to their clientele as some sort of DEI program? No, they decided. As news reports emerged that certain words seemed to be triggering DOGE, Waits and Smith combed through their website and program materials for anything that might even remotely run the risk of making Cahaba seem noncompliant. Gone from their grant applications was the phrase health equity, which they had simply meant in the spirit of helping everybody. Gone, they decided, was a regular meeting they had implemented to talk about “cultural humility.”
Meanwhile, he was following the news closely. DOGE was starting to delete federal grants. For foreign food aid. For international nuclear inspectors. For programs across the country, including in Alabama. Gone was $10 million for a school food program. Gone was $22 million for the state’s department of mental health. Gone were millions of dollars for medical research at the University of Alabama at Birmingham.
Now it was March, and the federal budget deadline was looming, a moment when whatever DOGE cut could be enshrined. The uncertainty was such that two teaching-health-center programs in Arizona and Maryland dropped out, worried they would be unable to fulfill their commitments to residents if federal funding was cut.
[Eventually], the House of Representatives gathered to vote on a continuing resolution to keep the government running…and Waits got an email from a contact in Washington saying that THCGME funding had made it into the resolution.
When it was over, Waits felt momentarily relieved, but also something else.
There had been so much stress and confusion but no debate over policy. No discussion of health outcomes. No discussion about what would happen if THCGME and so many other grants got canceled, discussions he was more than willing to have, and now the questions were starting again. Why had this grant survived when so many others hadn’t? Was it because someone had asked a favor of Elon Musk? Was it because the grantees had complied with executive orders? Was it because Alabama was a red state? Or was it simply because DOGE had not gotten around to them yet? What would he have to do in September? How much more time would he have to spend defending a program that Republicans and Democrats agreed was working, instead of building upon progress? What was the point?
TITLE: Trump’s mental health and addiction problem
https://www.statnews.com/2025/04/21/samhsa-elimination-trump-kennedy-rfk-jr-substance-abuse-mental-health-aha/
EXCERPTS: The CDC reports that suicide is the second leading cause of death among those aged 10-34. More than 209,000 Americans die each year from alcohol, suicide and drug overdoses. One in four people will experience a mental health or substance use problem. These conditions account for some of the highest-cost drivers in health care, costing the U.S. economy an estimated $700 billion annually.
I was able to find recovery and turn my life around due to a small federal agency called the Substance Abuse and Mental Health Services Administration (SAMHSA). Through SAMHSA, which is part of the Department of Health and Human Services, I contacted and accessed effective treatment and services. I found information on their website to help understand my problems and how to recover. I found peer and family support that the agency funded. Most importantly, I found a reason for living: to support others who experience these conditions.
In 1995, after working in local community mental health, I landed my dream job at SAMHSA. I recently retired after 30 years as a senior leader in the agency, where my roles included director of the Center for Mental Health Services, executive officer of SAMHSA and, most recently, founding director of the first-ever federal Office of Recovery.
SAMHSA was signed into law in 1992 by a Republican, President George H.W. Bush, after being introduced into Congress by a Democrat, Sen. Edward Kennedy (HHS Secretary Robert F. Kennedy Jr.’s uncle) to provide federal leadership to improve mental health and substance use services. Over the past 30 years, SAMHSA has been instrumental in expanding effective services, reducing opioid overdose deaths, establishing the national 988 mental health crisis response network, identifying evidence-based practices, collecting national data on behavioral health, promoting innovations such as the peer workforce, and funding key programs to reduce underage drinking and assist youth with psychosis. Most importantly, SAMHSA’s establishment represented the federal government’s recognition that you can’t improve the health and well-being of the nation without prioritizing mental health and addictions.
That is why I and so many are disheartened by the Trump administration’s decision to eliminate SAMHSA and many of its key programs. In just three months, Trump and Kennedy have dismantled 30 years of federal mental health and substance use leadership.
Since January, Trump and Elon Musk’s Department of Government Efficiency (DOGE) are firing up to one-half of the agency’s staff. The loss of these dedicated public servants severely hampers the ability of SAMHSA to carry out its mission. Remaining staff have told me that they are overwhelmed and have no idea how to proceed. SAMHSA’s Office of Recovery has lost more than 50% of its staff, and the entire team that led the National Survey of Drug Use and Health — which provides key data on mental health and addictions — was part of the reduction in force. These layoffs were seemingly at random with no clear plan or guidance. How does this achieve any semblance of efficiency, let alone effectiveness?
At the same time, $1 billion was cut from state and local behavioral health programs. These funds, appropriated via the American Rescue Plan Act (ARPA), were to help deal with Covid-19. Their termination fails to recognize the ongoing mental health and substance use impacts of the pandemic. While the courts are determining the fate of these funds, critical safety net programs are shuttering their doors. These include crisis services treatment programs for mothers with children, youth programs addressing serious mental illness along with community and collegiate recovery programs.
In March, HHS announced a dramatic restructuring in keeping with Trump’s executive order “Implementing the President’s ‘DOGE’ Workforce Optimization Initiative.” This included the elimination of SAMHSA and combining mental health and substance efforts with disparate and disconnected programs such as occupational health and safety and toxic substances under the new “Administration for a Healthy America.”
Like the firings and budget cuts, SAMHSA’s abolition was done without public input or engagement — including without Congress.
And perhaps most egregious was recent news leaked on the president’s budget proposals that show SAMHSA zeroed out of the budget and the gutting of more than 40 different mental health and substance use programs. This includes ending critical services such as crisis care, certified community behavioral health clinics, programs serving children and families, tribes, unhoused individuals, those in criminal justice systems, and pregnant and postpartum women along with ending efforts that link primary and behavioral health care and prevent overdoses, among other things. Almost all of the agency’s recovery-focused grants are targeted to end.
These cuts would make it far more difficult for state and local infrastructure to meet the needs of vulnerable Americans. Though the president’s budget is traditionally a wish list rather than something that Congress enacts, this political environment is different. The Republican-led Congress could put this budget into action. If enacted by Congress, these cuts will result in Americans experiencing greater rates of early mortality and disease burden.
We continue to face a mental health and addictions crisis, and the need for effective federal leadership is more important than ever. Instead, we get calls from Kennedy to investigate psychiatric medications that many rely on and calls from Trump to re-institutionalize people by putting them in back wards rather than back home where they can recover. That makes calls to destroy the one agency trying to improve service delivery look intentional, not accidental.
TITLE: The Ranks of Obamacare ‘Fixers’ Axed in Trump’s Reduction of Health Agency Workforce
https://kffhealthnews.org/news/article/hhs-reduction-in-force-many-obamacare-fixers-gone/
EXCERPTS: They’re the fixers, the ones who step in when Affordable Care Act enrollees have a problem with their coverage, like a newborn incorrectly left off a policy or discovering that a rogue broker had signed them up or switched their plan without consent.
Specially trained caseworkers help resolve such issues, which might otherwise cause consumers to rack up large doctors’ bills or prevent them or their family members from getting care. Now, though, the broad federal reduction in force set in motion by the Trump administration has cut the ranks of those caseworkers, slashing two out of six divisions of caseworkers, according to one affected worker and a former Centers for Medicare & Medicaid Services official familiar with the situation, Jeffrey Grant.
Currently, the number of ACA enrollees is at an all-time high of 24 million. The ACA — known as Obamacare — has long drawn disfavor from Republicans and Trump himself. The health law faces additional changes next year that, if adopted, could sow confusion and more problems. Consumers would face a new learning curve with extra paperwork and rules. And the caseworker cuts might extend the time needed to resolve any difficulties.
“It impacts not only our jobs, but all these people we serve,” said one New York City-based caseworker, who was let go in a Feb. 14 purge affecting federal employees in their probationary periods. “Usually, we would have on average 14 days to take care of a case that was very difficult, although the urgent cases would be solved within two to three business days. It will now be delayed so much more. Whole teams got wiped out completely.”
The cuts have demoralized caseworkers, whose jobs demand a grasp of complex and arcane health insurance rules in a little-known government department that most consumers don’t interact with — CMS’ Exchange Customer Solutions Group — until they need help.
CMS, which oversees the ACA and other government health programs, will lose about 300 workers, including about 30 caseworkers scattered nationwide. The cuts come amid thousands of other federal job losses, including front-line workers across an array of agencies, from Social Security field offices to the National Park Service.
In a press release, HHS estimated its reduction in force will save taxpayers $1.8 billion a year. No one from CMS responded to KFF Health News’ questions about the caseworker reductions.
When consumers have a problem with their ACA plan, their first step is usually to call the federal or state marketplace on which they purchased coverage.
Those call centers can handle basic questions about plans purchased on the federal exchange, which serves 31 states. (State marketplaces handle their own complex cases and don’t rely on federal caseworkers.)
When someone calls the federal marketplace 800 number with coverage problems, the inquiry probably winds up on a caseworker’s desk, said one affected caseworker. That employee received a reduction-in-force notice several days after losing access to their work computer on April 1.
Caseworkers usually don’t speak directly with consumers, the worker said. Using information sent over by the federal marketplace — including notes taken when consumers called in with problems, as well as ACA applications — they handle or oversee consumer requests, such as canceling a
Starting next year, the Trump administration has proposed several changes to the ACA, including ending year-round eligibility for very low-income applicants, requiring additional financial and eligibility documentation, and charging some people a monthly $5 fee when auto-reenrolled in coverage until they confirm their eligibility.
Such changes will “make things harder, so there you will have more things that go wrong,” said Grant, the former CMS official, who founded Schedule F Healthcare Strategies after leaving CMS. “You will then also have fewer caseworkers to handle the work.”