The Senate Republicans released the initial text of their reconciliation bill last night. It contains similar in magnitude cuts to Medicaid as the passed House bill with differences in the mechanisms that achieve those cuts.
Medicaid is a critical component of supporting the rural medical sector. Slashing Medicaid will do bad things to rural hospital availability.
So in the great tradition of the 2017 ACHA/BCRA Repeal and Replace attempt, the Republican Party has written into law a FIG LEAF FUND:
H/T @andrewdesiderio.bsky.social. The fund to shore up rural hospitals.
– $10,000,000,000 for fiscal year 2028
-$10,000,000,000 for fiscal year 2029
-‘$2,000,000,000 for fiscal year 2030
– $2,000,000,000 for fiscal year 2031
-$1,000,000,000 for fiscal year
Altogether, this is $25 billion— Eric Michael Garcia (@ericmgarcia.bsky.social) June 28, 2025 at 12:42 AM
In 2017, the MacArthur Amendment would allow states to opt out of guaranteed issue and community rating policies. If a state opted out, that basically means anyone with any substantive pre-existing condition would be quickly priced out of any coverage.
So the response was a Fig Leaf Fund:
An earlier amendment to the House bill from Rep. Tom MacArthur would let states waive the ACA’s prohibition on charging people with pre-existing conditions higher premiums and its requirement that all health insurance plans cover basic medical services.[2] Now, congressional leaders are reportedly considering adding an additional $8 billion in federal funding to the bill over five years —$1 to $2 billion per year — to try to mitigate the serious harm that such waivers would do.
The details behind this additional $8 billion are unclear; some accounts suggest it would go to fund state high-risk pools, while others suggest it would go for other purposes. But either way, the additional funding wouldn’t come remotely close to addressing the severe problems that the bill creates for people with pre-existing conditions. Notably, the $8 billion would restore less than 1 percent of the nearly $1 trillion the House bill cuts from programs that help people afford coverage…..
In both cases it is an attempt to buy good headlines of So and SO supports RURAL HEALTH/Expensive Health care with 2% or 3% or 5% localized and temporary reduction in cuts that they are voting for.
rikyrah
It’s absolutely garbage 👎 👎
Another Scott
I heard a snippet of someone saying that the bill would cut $150B from hospitals and the earlier proposal would restore $15B. Such largess! How can we ever afford it!! :-/
Going up to $25B shows that enough of them are concerned about the fallout and what it would mean to their reelection chances. It’s the wax job on the rusty rebuilt wreck of a car on the Buy Here Pay Here lot. Drive on by…
Grr…
Thanks.
Best wishes,
Scott.
tobie
How much do rural hospitals cost? I’ve heard widely divergent figures on how much rural hospitals usually receive in aid from $100 billion to $350 billion. I’d love to know if the $25 billion carve-out for rural hospitals brings their funding in line to what it was or not. My bigger worry is frankly innercity hospitals that serve larger populations. They’re already overcrowded and underfunded. Best I can tell, this bill is telling metro hospitals and metro populations, “Drop dead.” (Daily News readers from the 1970s will recognize the headline.)
Baud
@tobie:
They would love it if urban areas would drop dead. Look up what Tommy Tuberville recently said about it.
tobie
@tobie: This is the most I can find on what rural hospitals would lose with the plan and how much the carve out would restore in funding.
Steve LaBonne
@Baud: But they’re very stupid so instead they’re going to kill rural base off their red rural base.
tobie
@Baud: I did see it. And the irony was that Alabama receives more in federal expenditures than it pays in taxes. I checked out Maryland’s revenues vs expenditures in 2024 and found out that with the exception of Baltimore City, the counties that received more in aid than they paid in state tax were all rural. Everyone makes noise about funding rural America. Both parties do it. Who advocates loudly for cities? It’s so frustrating.
Ruckus
Did anyone actually expect any different? That the people that think that anyone not them should die so they don’t have to pay all these taxes because so many people have a hard time making an actual living wage because republicans do not want to spend money for anything or anyone other than themselves even though many of the working people of this country do jobs that provide stuff to the people that don’t want to pay them even though they do quite well while others around them don’t – because they can’t see the concept of anything but themselves and how much greater they are than everyone else?
Baud
@Ruckus:
None of us here did.
lowtechcyclist
@Baud:
Yeah, I saw that. He doesn’t want any Federal money sent to those rat holes.
Maybe someone could encourage him to suggest that they secede. If the urban areas seceded, all those Good Rural Yeomen wouldn’t have to support them anymore. ;-)
ETA: I guess in his mind (like so many others on the right) it’s still 1975 and “Ford to City: Drop Dead.”
laura
I’m an old, so I remember preACA that volunteer doctors and dentists doing weekend jamboree big tent on the fly healthcare to meet pressing needs. America was so great then!
Eric S.
I mentioned this on LGM last night. I work for a regional utility with service across 4 states. We have rural and urban hospitals that rely heavily on Medicaid. Many of those hospitals struggle to pay their utility bills. The loss of health care is the clearly the biggest issue but the cuts have other knock on affects. Doctors, nurses, and technicians will be cut. Contracts for cleaning, food services, and maintenance will be scaled back or cut. Businesses that support those people will be hurt.
Shalimar
I have been to Rural a few times. No one should live there.
Hoodie
@Eric S.: Hospitals are the main economic engines in a lot of places. Universities too. It’s mindboggling that conservatives think that it’s a sin to subsidize industries like those that have a lot of positive knock-on effects but, yeah, let’s subsidize extractive industries like coal mining, which has godawful externalities. I guess it’s because having all those guys work in a nice clean hospital will turn them gay.
Funny related story. My cousin decided to study nursing in college because he figured it would give him more opportunities to hook up with women. He joined the Navy as a nurse and ended up only having to do one tour at sea during the first Gulf War. Otherwise, stationed in San Diego, Rota (Spanish Mediterranean coast) and Charleston. Tough duty.
Gvg
Saying let them succeed is just as shortsighted as them saying cut funding for Medicaid or food stamps. Everything is interconnected. Cities do need food grown, and rural areas need hospitals and manufactured goods. If the urban areas cut off the spiteful tiresome rural areas, they would have to pay more to get the food from somewhere else and it would hurt them. Not as much as it would hurt the rural areas, but still. And they are tiresome.
What we need is a way to teach them what’s wrong. It’s not as simple as they are being lied to and played for suckers, though they are.
1- there are no simple answers, especially about getting rich. Anyone who tells you that there is, is a con man. Cutting taxes is a con. Cutting waste in government is a con.
2-the people in the cities/country are people too. Citizens. Americans. Respect that. Don’t respect those who blame everything on the other for your vote. People everywhere have to get up, eat raise family work and maybe sleep. Most of them don’t care that much about politics and don’t have time.
3-regions don’t vote, people do. The majority vote in an area wins, but that can be by 1 vote and there are still all those individuals who disagreed or who couldn’t vote.
Anonymous At Work
Let’s call it for what it is: The Suzy Collins WAS CONCERNED But Now Reluctantly Is For It Amendment. This lets her hem-and-haw but ultimately support whatever garbage the Republican Party puts in front of her, to let her try to retain her Senate seat when a victorious Democrat would be in the Senate until their death (and/or arrest in a drug shoot out with police).
Shalimar
@Gvg: If Republicans take away their shit, there isn’t anything we can do about it except elect more Democrats again to provide some of their shit back. Hopefully, many of them will learn not to trust Republicans out of this whole cycle. Unfortunately, this is not what happened in any of the previous cycles.
Eolirin
@Gvg: ‘Cept they’re in the process of destroying US agricultural output by cutting foodstamps, throwing tariffs around, and also removing a major source of labor with their immigration policies.
So cities will need the rural areas even less since they’ll already have to be outsourcing their food. Pretty much just leaves resource extraction as a viable source of income for any of these areas, and only where there’s something valuable to dig up.
Pensive
@laura: Remote Area Medical was a 2013 documentary about this. I was horrified to see basically volunteer provided health care in the US. https://www.imdb.com/title/tt2180503/?ref_=nv_sr_srsg_0_tt_1_nm_0_in_0_q_remote%2520area%2520medical
WTFGhost
@Baud: To be brutally honest, I wasn’t sure they wouldn’t have bought an ad campaign, celebrating Trump, so that they threw actual money at it is a surprise, but… the ad campaign would have cost them money, spending federal dollars doesn’t, so… no *hugely* different expectation.
WTFGhost
@Gvg: I agree with every single thing you said, including 50% or more of the punctuation choices. That said, choosing to die on the hill of rural hospital’s economic health means spending our political capital where it does us no good. I’ll settle for a decent wound on that hill, and not a fight to the death. But I would hire an ad consultant to mock up a few spots to run against the Republicans voting in favor, maybe drop one of the weakest ones as a fair-warning shot, and a chance for the rural folks to figure out their best interests.
In the end, we do have to pick our battles, and if it was between preserving habeas, and preserving rural hospitals, I’m sorry – fuck the hospitals, until we have a law-abiding government.
caphilldcne
It’s still worth calling Republican Senators and tell them to vote no. Here’s an action alert from HIV groups I admire:
The Senate is working to finalize and vote ASAP on a reconciliation package that would result in millions of people losing health coverage from cuts to Medicaid and Medicare and changes to the Affordable Care Act; individuals and families losing access to food from billions in cuts to SNAP; banning needed health care for trans people and women; and billions in new resources for the targeting and detention of immigrants. The Senate is expected to pass the bill this weekend and send it to the House of Representatives for a vote next week. Please call your Senators andRepresentatives now to push back against these killer cuts and policies that would harm so many people living with HIV, costing some people their lives – the time to weigh in is now!
Call Your Senators and Representative:
How to call:
Call the Capitol Switchboard at 202–224–3121 and ask for your Senators and Representative by name.
To find your federal Representative and two federal Senators, please visit:https://ballotpedia.org/Who_represents_me
Suggested call script:
Please feel free to change the script below as needed to best reflect your lived experience and/or jurisdiction.
If you leave a voicemail: Please state your full street address to ensure your call is counted.
Thank you for helping to beat back this bad bill and feel free to share this alert!
tobie
@Gvg: Im not sure I buy that investing less in rural hospitals would endanger America’s food supply. Farming soy, corn and grain are now entirely mechanized operations. Where farming is labor intensive, it’s done by migrants who often don’t have access to local hospitals.
What bothers me is not that we subsidize rural America. It’s that we don’t show the same largesse when it comes to cities. Republicans would never do this but even Democrats fail on this score.
Anonymous at Work
@Gvg: can’t follow you all that way. Lack of rural hospitals will exacerbate current trends in depopulation of rural communities but nothing more. There’ll be loss of “farm to table” fruits and vegetables but Republicans already are killing that program. Organic produce will become rarer and more expensive but only “Dirty Effing Hippies” eat organic, dontchano?
The acceleration of depopulation will be from both elderly farmers having to move to cities for health care and because young people will “nope the eff out” even faster. Why start a family when your ob-gyn is a three plus hour drive away?
But industrial farming will take up the slack with export-heavy, subsidized bulk crops.
Ruckus
@rikyrah:
You are too nice.
It would have to move up a lot of steps to only be garbage.
Ruckus
@Pensive:
Not disagreeing with you but.
Think about this from a different perspective. The doctor’s perspective.
Go to school through college then medical school. That’s what 7-8 years after high school. And then you most likely start at the bottom of the pay scale. Sure you likely will do fine on the pay scale after a bit but you’ve spent a while just getting to the medical school end point.
It is a good, decent profession but it takes a lot to get there. And I know, I started down that road after HS. And ended up some place else in the general scheme of things job wise. Vietnam and the draft got in my way, among other things. Like eating and having a roof over my head.
@Anonymous at Work:
You sound like a city person, not a rural person.
Rural has a lot going for it – I know, I’ve lived in somewhat rural areas in this country. And in big city areas. Ended up that I like the big city areas better than rural. Not everyone sees this in the same way as I do.
Ealbert
As I said on a very dead thread the other day, instead of talking about the large number of people who will be thrown off of Medicaid and large numbers of rural hospitals that will close. Instead we need to personalize it: state that in your area XXXX number of people will lose their healthcare and as a result Hospital Name will probably have to close. I live in the Madison, Wisconsin area. We have 2 hospitals, St. Mary’s Hospital and University Hospital. Between the 2 of them, they have about 1,000 rooms. I am not familiar with the situation in the whole state, but my husband’s family lives in the southwest part of the state. My mother-in-law died this last December (at 88). When we went to see her at the hospital in Platteville, I learned that the hospital had 22 patient rooms (and some amount of birthing suites). That is it for a multi-county area. If you have something serious or complicated, your choices are traveling 2 to 3 hours to Madison, Milwaukee, or Dubuque Iowa. Platteville is not in a poor area of the state and is home to one of the UW campuses. But if the hospital were to close it would have such a devastating affect on the area.
Anonymous At Work
@Ruckus: City-living but family and I have been deep in rural areas. There’s a reason I write about ARKANSAS ballot initiatives every other fall. Rural areas have lots of land for cheap but that doesn’t help if there aren’t basic services. Given a choice in jobs and/or job locations, families won’t move to where there aren’t pediatricians to take care of their kids. Old people either won’t stay or their children won’t allow them to stay where there aren’t hospitals.
The rural areas that have arrested a death spiral, not ironically owe it all to immigrant influxes bringing in demand for more services bringing in demand for better services. Stephen Miller is winning the “raid everywhere for non-whites” and it’s only a matter of time before rural Iowa and Nebraska towns have their new residencies decimated.
Westyny
@Shalimar: Unless you like being surrounded by birds, trees and big skies . . . Happily, my rural county in the Hudson Valley has turned reliably blue.