The Dismantling of American Health Care, NY Review of Books, July 8, 2025, by Adam Gaffney, David U. Himmelstein, and Steffie Woolhandler
On July 4 President Donald Trump signed into law a piece of legislation that amounts to a declaration of war on the working-class and the sick. The “One Big Beautiful Bill Act” will slice more than $1 trillion from Medicaid over the next decade, stripping health coverage from more than 11 million lower-income Americans by 2034 and sending tens of thousands to an early grave—all in exchange for tax reductions for corporations and the wealthy. Despite Trump’s promises to the contrary, the law will also cut nearly $500 billion from Medicare over the same period by making the deficit surge past a point at which the Office of Management and Budget “is required to order a sequestration to eliminate the overage.”
This assault on the nation’s major public insurance programs is only the latest front in an ongoing right-wing campaign against health. On April 1 Trump’s hammer fell on the Department of Health and Human Services (HHS), the sprawling agency that encompasses the Centers for Disease Control and Prevention (CDC), the Centers for Medicaid and Medicaid Services (CMS), the National Institutes of Health (NIH), and the Food and Drug Administration (FDA), among other health-focused agencies. Having already forced out 10,000 HHS personnel earlier in his term, the Trump administration terminated 10,000 more on dubious legal grounds, devastating entire teams focused on major public health problems like tobacco control and occupational health. Altogether 25 percent of HHS’s workforce was dismissed. Since then a minority of the fired employees have been reinstated in the face of political pressure—but the depth and capriciousness of these chaotic cuts is without precedent. Disease surveillance, outbreak investigation, vaccine uptake, violence prevention, infection control, food safety, and opioid overdose prevention will likely suffer.
Meanwhile the nation’s biomedical research enterprise—in large part conducted by publicly financed scientists employed at universities— has been facing a sustained attack. NIH research grants that address important but now illicit health issues—like HIV/AIDS, racial health inequities, vaccine hesitancy, and LGBTQ health—have been wiped out in recent months. Not all of the cuts stem from specific bêtes noires: the administration has broadly decimated funding by canceling more than $1.8 billion in existing NIH grants in less than a month and a half (although some have been temporarily reinstated by court orders), reducing the issuance of new grant awards by 28 percent, and attempting to slash the “overhead” payments that cover universities’ costs for space and utilities via a now-stayed order that would have reduced grants from multiple federal agencies, including the NIH. This is on top of the funding blockades that the administration has imposed on many elite universities to bring them to heel—including all of the Ivies except Dartmouth and Yale.
The three fronts of this assault—on tax-funded medical coverage, public health, and medical research—have overlapping aims. The campaign to slash Medicaid—relied on by the poor since its establishment in 1965—follows a long neoliberal tradition of prescribing austerity for the working class and largesse for the rich. Trump and his allies seem to view public health, for its part, as waste that can be excised (DOGE-style) to fund tax cuts, as a source of regulatory excess that constrains profit-making, and as a locus of “woke” ideology and inconvenient facts. The assault on medical research is driven by similar concerns, with the added benefit of dominating rival centers of power like universities and the professions.
Yet such economic and ideological motivations do not explain the full measure of the administration’s agenda. It rests, too, on a Dark Ages disdain for science, part and parcel of Trump’s claim to be the arbiter of facts and truth. …
It seems difficult at present to resist Trump’s regressive anti-health juggernaut, much less to envision something better for tomorrow. But the medical community, which still wields considerable power and influence, appears to be reaching a boiling point. Colleagues fear seeing their coworkers and patients deported; academic freedom is threatened; medical decision-making is constrained by political fiat and managed care restrictions; research funding has disappeared; public health protections have been eviscerated; access to vaccinations has been curtailed; and charlatanism is displacing science at the highest level. Health professionals, having watched Congress slash the public insurance programs on which their patients and institutions rely, are soon to witness the needless suffering and death that will predictably follow. All these assaults are also breeding disaffection among voters. As many polls indicate, health is perhaps Trump’s weakest suit with the general public; most Americans favor more funding for science and public health, as well as universal coverage.
Comment:
By Jim Kahn, M.D., M.P.H.
This article is a tour-de-force review of the myriad ways that the Trump administration is undermining health care (especially public insurance), public health, and medical research. These are all areas that have yielded benefits to health over three-quarters of a century. The funding cuts have been massive, rapid, sometimes targeted, and often seemingly arbitrary. The cuts and their justifications often conflict or fail to withstand scrutiny. Further cuts are looming. As the article says, the actions bespeak a “Dark Ages disdain for science.”
For those interested in a survey of the anticipated effects of the budget bill on public insurance, in the context of health insurance trends, read Adam’s testimony to a Congressional committee.
At the end, Gaffney et al note that both the medical profession and voters dislike the broad assault on health care and science. We must hope that that this discontent will grow, and as political power shifts, we will soon have historic opportunities to rebuild, doubling down on our commitments to the public’s health, even – or especially – when that goal collides with the imperatives of maximizing shareholder value.
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