The Republicans Are Going to Kill People—but Not Until After They Vote

One of Ronald Reagan’s most famous lines, referring to disarray in his White House, was, “Sometimes the right hand doesn’t know what the far-right hand is doing.” More appropriately for the Trump White House: “Sometimes the far-right hand doesn’t know what the radical lunatic right-wing hand is doing.”

In fall 2017, less than a year into President Trump’s first term, I wrote a piece in The Atlantic titled “American Kakistocracy.” As I wrote then, “Kakistocracy is a term that was first used in the 17th century; derived from a Greek word, it means, literally, government by the worst and most unscrupulous people among us. More broadly, it can mean the most inept and cringeworthy kind of government. The term fell into disuse over the past century or more, and most highly informed people had never heard it before (but to kids familiar with the word “kaka” it might resonate).” They should pay attention now.

Bad as the first Trump term was, it was nothing compared to this one. And the key components of the anti-science, anti-government nihilism, combined with willful ignorance about the consequences of their actions, and the interrelationship across policy areas, is about to play out big time starting next year, with health care and policy on the front lines. Three components of horrible policies across disparate areas will interact to engender a catastrophe in an already stressed health ecosystem.

One is the insane anti-vaccination conspiracy theories brought into full focus by Health and Human Services Secretary Robert F. Kennedy, Jr. and his cohort in the Trump administration, all amplified by Trump himself. The measles outbreak, the emergence of tetanus cases, the attacks on the flu and Covid-19 vaccines, and the evisceration of food safety programs leading to outbreaks of norovirus, cyclospora, e-coli, and listeria, have begun to put more stress on the system, with increased costs, more hospital burdens, and likely more trouble ahead when flu season begins and new Covid strains emerge. Not only that, many undocumented immigrants have been working in meat processing plants—some estimates have been as many as 200,000. The massive deportation policy has left many of those plants with fewer workers to do the same volume of processing, and often a form of self-regulation by the industry for the safety of their products.

Add to that the soon-to-be forced removal and deportation of Haitians, among others losing Temporary Protected Status. Over 100,000 Haitians have been employed in the healthcare sector, many taking care of seniors in nursing homes and via home health care, others working hospitals as orderlies, nurses, or other jobs. It will be a significant blow when those jobs are vacated.

Now comes the biggest problem. When the Republican Congress enacted Trump’s One Big Beautiful Bill in July 2025, it included massive cuts in the Medicaid program, totaling around $1 trillion over 10 years—but made sure to postpone them until 2027, conveniently after the midterm elections. The cuts focused on adding onerous work and paperwork requirements, all designed to force recipients off the rolls, and will remove somewhere between 10 and 15 million people from the program, leaving them without any health coverage. That is in addition to the millions losing coverage or facing huge premium increases with the erasure of subsidies for the Affordable Care Act. But the impact will go far beyond those directly losing their health insurance. Medicaid money does not go to Medicaid recipients. It goes to the providers. The loss of a major chunk of the money going out to them will have big reverberations.

The American health care system, unlike in most advanced countries, was jerry-built, a combination of public and private entities, and state and federal involvement. But the public and private are not separate. They are like the organs in the human body—if one declines or fails, it has huge impact on the others. And these cuts are going to reverberate in many catastrophic ways.

Start with hospitals, most of which already face major financial strain, and not just in rural areas. There have been major consolidations as those strains have increased; hospitals have had to be creative, to say the least, in finding the revenue to stay solvent. Independent, community-based hospitals have declined precipitously, and the market has shifted to giant, integrated health systems, with major involvement by both private equity firms and large corporations like health insurers and pharmacy giants buying physician groups and integrating vertically and horizontally. Significant revenue, especially via the emergency rooms, comes from Medicaid.

Cut that revenue, and some hospitals will close, in both urban and rural areas. For those that remain, the burden in the ERs will increase their costs and strain their staffs. The law requires hospitals to provide emergency care to anyone in health crisis coming to their ERs, whether they can pay or not. Poor people and the undocumented will either go to the ER and not be able to pay, or will defer any treatment, including drugs they need, and that will mean more emergencies, more deaths, more burden on the broader system.

The loss in revenue may cause many hospitals to reduce staff, adding to the burden on nurses and doctors who remain. For many, their staffs will already be burdened when the deportations take full effect. And reduced staffs will also put more hospital patients in jeopardy if there are fewer nurses and doctors to watch over them and care for them. Of course, to maintain revenue, hospitals will find ways to charge more for their paying patients, so those cost burdens for them and their insurers will go up as well.

Next, turn to nursing homes. Almost two-thirds of those elderly and disabled people living in nursing homes have their care paid for by Medicaid. They have all reduced their assets to a negligible level to qualify for Medicaid coverage, enabling them to be in these facilities instead of in their children’s homes or in precarious situations living on their own.

Nearly all nursing homes rely heavily on that Medicaid revenue. Lose it, and many elderly and disabled will be out on their ears. Their families will take them in—but there is a double whammy here. The subsidies that exist for home health care, including by family members, are going to be slashed as well, leaving families with their own terrible dilemmas, worsened when trained and trusted Haitians depart.

As for the nursing homes, some will close; others will cut staff and staff pay. The ratio of residents to staff will decline, meaning residents unable to secure help when they need it for such vital tasks as getting medications when they require them, getting help going to the bathroom, getting help in bed to prevent bedsores or worse, having responsive care during a health trauma or emergency. More unqualified staff could mean more abuse of the residents.

There will be more effects seen throughout the country, for everyone who is a part of our intertwined health care system, from those working in it to those using it. No wonder Republicans made sure none of the Medicaid cuts would happen before voters experienced the impact. It turns out that kakistocracy is not just a funny word, but a reality with horrific consequences.