Dem
47
GOP
53
Donald Trump's BBB has disastrous consequences for medical care in rural areas, most of which voted for him in 2024. Hospitals are closing and the general level of care is going down. Addiction is up. People have to drive for hours to get care in some places.
So how is Trump treating these people, his supporters? He found a pot of $50 billion to use to alleviate some of their problems. Good for him. He cares.
But there is a catch, unfortunately. To get any money, states have to change their laws to agree with principles he approves of. For example, people on SNAP are restricted in what they can buy and states have to expand telehealth, so people can't go to an actual doctor, but have to see the doctor on their phone or, if they have one and they have broadband, on their computer. Another thing Trump likes a lot is "junk insurance." This is cheap health insurance that doesn't actually insure very much and has huge thresholds and co-pays that make it basically worthless—except to the insurance companies, which like the policies very much, thak you.
A few of Trump's requirements are not controversial, like having medical schools require medical students to take a course on nutrition as part of their study, but any of them are.
Carrie Cochran-McClain, the chief policy officer at the National Rural Health Association, said: "I've been working in government and health policy for 20-plus years, and I can't recall another scenario where it was quite this direct in terms of, 'If you work on these policy changes at the state level, we will give you funding.'" She was careful not to call it blackmail for fear of offending Trump. But she knows if it looks like a duck and walks like a duck and quacks like a duck it is probably not a mongoose.
The formula for doling out money is complicated, but it explicitly takes into account whether states have certain policies that Trump likes in place. They get full credit if the laws he wants are already on the books and partial credit if they say they will implement them shortly. However, the government is reserving the right to claw back funds granted if those changes aren't made by the end of 2027 or, in some cases, 2028.
Some blue states find the new requirements so repellent that they have flatly refused the federal money. But even red states that want to comply are having problems. The grant window is open now and health officials have to describe now what their state will do to implement Trump's policies. But state legislatures in many states are not in session now (and some state legislatures meet only every other year), so the health officials don't know what they can safely put in their applications. If they don't offer Trump enough red meat, they won't get the grant. But if they offer too much, when the legislature comes back into session, the legislators may balk at passing the laws Trump wants, and the money will later be clawed back.
When Secretary of HHS Robert Kennedy Jr. attended the Western Governors Association conference in November, the governors grilled him about the program and how the money will be distributed. He seemed not to understand the program and claimed ignorance of it and said he wasn't involved in it and couldn't change the formula. This is almost certainly a lie. The formula is not embedded in any law. It is just an HHS policy, which he can order HHS officials to change if he wants to. But since whole issue doesn't involve vaccines or dead bears or brain worms, he is not interested. (V)