The Real Cost of the “Big Beautiful Bill”: A Rural ER Doctor’s Perspective on Medicaid Cuts
The so-called “Big Beautiful Bill” that passed last week—Trump’s crown jewel of budget reconciliation—was anything but beautiful for my patients.
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Here we go again.
As a rural emergency physician in West Michigan, I’ve seen more than my fair share of suffering. I’ve cared for patients in cardiac arrest, overdose, psychosis, and sepsis—sometimes all in the same shift. But nothing prepares you for the slow, preventable unraveling of a health care system caused not by a virus or a natural disaster, but by the very people elected to protect our democracy and improve our lives.
The so-called “Big Beautiful Bill” that passed last week—Trump’s crown jewel of budget reconciliation—was anything but beautiful for my patients. The Medicaid cuts buried in that legislation will devastate rural communities like mine. It’s not an exaggeration to say that people will die because of it. And as physicians, we have a responsibility to say so plainly.
This Isn’t Theoretical—It’s Personal
In my county, nearly one in four residents relies on Medicaid for their health coverage. Many are working-class folks holding down two jobs at local farms, restaurants, or small manufacturing shops. Others are older adults not yet eligible for Medicare, living on fixed incomes, or doing seasonal labor. A significant portion are kids. Medicaid isn't a handout here. It’s the difference between untreated hypertension and a stroke. Between a manageable case of diabetes and a double amputation. Between catching a cancer early and catching it too late.
When the ACA expanded Medicaid in Michigan through the Healthy Michigan Plan, it changed everything. Patients who had avoided the ER for years because they couldn’t afford a follow-up visit began showing up earlier in the course of their illness. I started seeing fewer emergencies that had spiraled out of control because someone lacked coverage for a blood pressure med that costs $4 at the pharmacy. Lives were saved. Health improved. That wasn’t abstract policy success—it was visible in every shift I worked.
And now, with a stroke of a pen, millions of Americans are being shoved back into the shadows of uncertainty. Fourteen to seventeen million people will lose coverage because of this bill. That includes thousands in West Michigan.
The Rural Hospital Death Spiral
Let’s be very clear: this bill will cause rural hospitals to close. Medicaid is often the lifeline for small community hospitals. When a patient walks into our ER, we don’t ask if they’re privately insured, on Medicaid, or uninsured. We stabilize them. We treat them. But the economics don’t vanish with the moral imperative.
Medicaid reimbursements may not be generous, but they keep the lights on. Strip that away, and many rural hospitals—already operating on razor-thin margins—will collapse. And when a rural hospital closes, people don’t just lose emergency care. They lose maternity services. Dialysis centers. Rehab programs. Chemotherapy. Radiology. That’s what this bill puts on the chopping block.
Cruelty Disguised as “Work Requirements”
One of the most insidious parts of this legislation is the so-called “work requirements.” Proponents say these provisions encourage people to get back to work. But here’s the truth: most people on Medicaid are already working, in school, caring for loved ones, or disabled. The bureaucracy involved in “proving” compliance is a feature, not a bug—it’s designed to kick people off coverage.
I saw what happened in Arkansas when work requirements were tested: over 18,000 people lost insurance. Employment didn’t go up. ER visits did. That’s what happens when you insert red tape between people and their care. In Georgia, the state’s own pilot version of work requirements cost seven times more to administer than standard Medicaid. This isn’t fiscal responsibility—it’s cruelty with a price tag.
The Political Theater of Misinformation
While my colleagues and I continue working ER shifts, treating patients who are trying to survive on the margins, Fox News and right-wing influencers flood the airwaves with tropes about “young men playing video games in their parents’ basements on Medicaid.” It’s a lazy, dishonest caricature designed to justify gutting a safety net that protects working-class Americans.
That’s not who I see in my ER. I see a 47-year-old farmworker with a neck abscess because he delayed care. A 58-year-old woman who skipped mammograms for years because she didn’t think she could afford the follow-up. A 19-year-old kid with a newly diagnosed mental illness and no coverage for therapy.
The truth is, Medicaid doesn’t hand people money. It pays for a doctor visit. It covers an insulin refill. It helps someone afford to go to physical therapy after a work injury so they can get back to their job. This bill strips all that away in order to fund permanent tax breaks for millionaires and billionaires.
The Physicians’ Oath—and Our Moral Obligation
We didn’t go to medical school to become politicians. But the truth is, politics is now shaping the very conditions in which we practice medicine. This bill, passed with zero Democratic votes and signed gleefully by Trump, is a moral betrayal.
Physicians have a duty not only to treat disease, but to prevent harm. The Hippocratic Oath doesn’t end at the exam room door. When politicians enact policies that we know will cause suffering and death, silence becomes complicity.
So we must speak up. Again. Like we did in 2017, when the ACA was on the chopping block and the late Senator John McCain gave his iconic thumbs-down on the Senate floor, ending that effort—temporarily. We must remind our fellow Americans that elections have consequences. That the difference between a just healthcare system and a brutal one can come down to a single Senate seat.
What Now?
This fight isn’t over. But it is urgent.
We need to organize—not just as doctors, but as patients, advocates, neighbors. We need to vote like our lives depend on it, because for many people, they do. We need to share stories from the front lines, so Americans understand what’s truly at stake.
Because while Trump and his allies are popping champagne over their “Big Beautiful Bill,” my community is bracing for a storm. Patients will forgo care. Hospitals will close. And physicians like me will be left to pick up the pieces.
If we truly mean it when we say we will “keep our patients from harm and injustice,” now is the time to act like it.
Because the harm is no longer coming. It’s here.