People Are Going to Die, but Only After the Midterms

Ronald Reagan once had a line about the chaos in his White House, that sometimes the right hand didn't know what the far-right hand was doing. For the Trump White House, a sharper version fits better, sometimes the far-right hand doesn't know what the radically confused right hand is doing.

An old word fits here, kakistocracy, first used in the 17th century, from the Greek, literally the rule of the worst and most unscrupulous people. In a broader sense, it means the most incompetent and disgraceful form of government. The term fell out of use in the last century, even well-informed people had never heard it. Kids who know the word "kaka" will probably still get something from it, and they should pay attention now.

Read also our article: The Measurement of American Mortality: How Partisan Politics Decides Over Years of Life

As bad as the first term was, compared with this one it was harmless. An anti-science, anti-government nihilism, paired with deliberate ignorance of the consequences of its own actions and the interactions between different areas of policy, will hit with full force starting next year, especially in health policy. Three devastating developments from different areas are coming together and driving an already strained system into catastrophe.

First, the delusional conspiracy stories against vaccines that Health and Human Services Secretary Robert F. Kennedy Jr. and his allies have pushed to the center, and that Trump has amplified even further. A measles outbreak and the return of tetanus cases are already putting pressure on the system. On top of that come the attacks on flu and Covid-19 vaccines. The dismantling of food safety programs has contributed to outbreaks involving norovirus and E. coli, along with cyclospora and listeria. Costs are rising, hospitals are carrying more of the burden, and with flu season and new Covid variants, the situation will get even worse.

Then there is the deportation policy. Many people without legal immigration status work in meat processing plants, by some estimates as many as 200,000. Where they are gone, fewer workers are expected to handle the same volume, while food safety is in part left to the industry's own self-regulation. On top of that comes the forced departure of those who lose Temporary Protected Status. More than 100,000 Haitians work in health care, many caring for older people in nursing homes or at home, others working as aides and caregivers in hospitals. Their work keeps part of the health care system running, something no law can replace overnight. If they are gone, the system takes a serious hit.

The biggest problem carries a pretty name. When the Republican-controlled Congress passed Trump's "One Big Beautiful Bill" in July 2025, it contained cuts to Medicaid of around $1 trillion over 10 years. They arranged it so those cuts would not take effect until 2027, conveniently after the midterm elections.

The timing reveals the intention. A cut whose victims only become visible after the votes are cast relies on the short memory of the ballot box and the long suffering that comes afterward. A legislature that knows the damage and places it beyond Election Day has removed accountability from its own trade. What happens after the election no longer changes a majority. At the center are burdensome work and documentation requirements, built to push recipients out of the program. They work like a sieve through which the poorest fall first, often because of the paperwork burden before their eligibility is even reviewed. Between 10 and 15 million people could lose their Medicaid coverage this way and be left with no insurance at all. Millions more will lose their coverage or pay dramatically higher premiums because Affordable Care Act subsidies expire.

The impact reaches far beyond the insured. Medicaid money does not go to recipients, it flows to doctors and hospitals. If a large part of that revenue disappears, the shock runs through the entire structure. The American health care system was never built as a single whole, it remained a patchwork, public and private at the same time, divided between the states and the federal government. Public and private do not stand apart, they work like organs in one body, if one fails, the others suffer. A cut in one place bleeds in many.

The damage starts with hospitals. Many have been under pressure for years, not just in rural areas, which has led to major consolidations. To stay solvent, hospitals have had to get creative. Independent, community-rooted hospitals have declined sharply, while huge health systems dominate the market. Within them, financial investors buy up medical practices, as do large health insurers with their pharmacy chains. A significant share of their revenue, especially through emergency rooms, comes from Medicaid.

If that money disappears, hospitals close, in cities as well as in rural areas. In the hospitals that remain, the added burden on emergency rooms drives costs up and overwhelms staff. Hospitals have to treat every emergency, whether the patient can pay or not. Poor people and people without papers will either come to the ER with no prospect of paying the bill, or they will postpone necessary treatment and medication. That means more emergencies and more deaths, while the burden on the entire system grows with them.

The loss of revenue forces many hospitals to cut staff, which puts even more pressure on the doctors and nurses who remain. Staffing will already become scarce once the deportations fully take effect. Fewer hands mean more danger for patients who are no longer treated in time. And hospitals will pass their losses on to paying patients, whose costs and premiums will rise as well. Then come the nursing homes. Nearly 2 thirds of elderly and disabled residents have their care paid for through Medicaid, after spending down their assets to almost nothing in order to qualify. That allows them to live in a facility instead of with their children or alone in unsafe conditions. If the money disappears, many could literally be put out on the street.

Read also our article: What People in Germany Don’t Know – The Forgotten Americans

Their families will have to take them in, and then comes the next blow, because subsidies for home health care, including care provided by family members, are also set to be cut drastically. That gets even worse once trusted Haitian caregivers have to leave the country. What a paid professional did before will then fall to an exhausted family, without training and without pay. Nursing homes will close too, others will cut staff and wages, and the ratio of caregivers to residents will get worse. Then help does not come, with medications at the right time and with trips to the bathroom. Repositioning patients to prevent bedsores will be neglected too, along with help during acute medical emergencies. A worse caregiver-to-resident ratio means, in practice, that a call bell rings longer without anyone answering. More untrained staff, in turn, will likely mean more abuse.

It will be felt across the entire country, by everyone who is part of this interconnected system, those who work in it and those who depend on it. The weakest will pay the price first, the elderly in nursing homes and the sick without insurance. It is no coincidence that Republicans scheduled the cuts so voters would not feel their effects until after the midterms. Kakistocracy sounds funny, but it describes a reality with deadly consequences.