Photo by Gregory Conniff for Wisconsin Examiner

On July 4th, in the towns and counties of rural western Wisconsin, there were celebrations like on any other Independence Day: grilling bratwurst, drinking Leinenkugel’s, fireworks showering high in the summer night. 

That very same day, a thousand miles away in Washington, DC, HR1— also known as the “One Big Beautiful Bill Act” (OBBBA) — was signed into law. Yet for people here, the passage of the bill was a mere blip in the national headlines. It was not apparent that it would become an economic earthquake, triggering a tsunami of devastating after-effects soon to crash down on our rural communities.

The massive tax cut and spending bill is the most dramatic restructuring of federal budget priorities in six decades. The president called the OBBBA his “greatest victory” and the “most popular bill ever signed.” The White House issued only a scant 237-word press release summarizing the 900-page law; the substance of the law itself was barely mentioned. When it was enacted, nearly two-thirds of Americans said they knew “little or nothing” about what was in the bill.

When asked about his support of the bill, my own representative from Wisconsin’s 3rd Congressional District, Derrick Van Orden, dismissed any suggestion that the White House had influenced his vote. “The president of the United States didn’t give us an assignment. We’re not a bunch of little bitches around here, OK? I’m a member of Congress, I represent almost 800,000 Wisconsinites.” 

The OBBBA permanently extends the 2017 tax cuts and locks in a historic upward transfer of wealth. The top 1% of households receive an average tax cut of $66,000. Working families earning $53,000 or less get a tax cut of just $325. Roughly $1 trillion dollars will flow to the richest households over the next decade, while Medicaid, nutrition assistance, and health coverage are drastically scaled back, pushing 15 million people off insurance. 

‘I want to be part of a strategy, something that’s actually effective’

Last August, 70 of us gathered on a Saturday in Woodville, Wisconsin, population 1,400, with the understanding that something consequential was happening in our nation, yet struggling to figure out how we can respond. We filled a community center on Main Street for six hours: teachers, farmers, retirees, retail workers, students, small business owners. People brought notebooks and coffee. The windows were open. Ceiling fans spun slowly overhead. 

“I’m tired of complaining, feeling like a victim, worried about what’s going to happen next,” one of our members put it plainly. “I want to be part of a strategy, something that’s actually effective.”

I organize with Grassroots Organizing Western Wisconsin (GROWW). Our work has always started from a simple question: How does power move in the places we live? Since the organization began, our focus has been on local issues like housing, agriculture and rural broadband. But, at that meeting in Woodville, we were trying to name what was happening: how the political chaos in our federal government was flowing down to our families, counties, schools, cities, hospitals, town boards. And, most importantly, what we could actually do about it. 

That day in Woodville we made a plan. It did not involve protest or messaging. Our organizing has never been about reacting the fastest or shouting the loudest. Power is built methodically: identifying who makes decisions, who feels the consequences, and where solidarity can be established and strengthened before a harm is normalized and written off as inevitable. That is why we started with listening.

During the following three months we sat down face to face with nearly 100 local leaders across four counties. We met in offices, conference rooms and coffee shops. We spoke with school superintendents, sheriffs, county administrators, hospital executives, clergy, elected officials, business owners. We asked the same questions over and over: what were people experiencing in their jobs, what pressures were they under, what was keeping them up at night?

Many people we spoke with were overwhelmed by the effort required to stay focused on their jobs: the to-do lists, budgets, hiring, planning. One program director told us her job was mostly “putting out fires.” When we asked how they were reacting to federal policy changes, most people didn’t have much to say. Unless it was affecting them today, they didn’t have the luxury to worry about it. 

Each conversation made clear how county governments in rural Wisconsin are lifelines, not faceless bureaucracies. They plow snow, run elections, maintain roads, administer BadgerCare and SNAP, respond to mental health crises, operate nursing homes, and answer 911 calls. And they are already stretched thin.

Funding was the issue mentioned the most. A county administrator walked us through the elaborate gymnastics required to balance a county budget under state-imposed levy limits that make raising revenue nearly impossible: wheel taxes, bond sales, consolidating services. One-time fixes layered on top of structural gaps. Again, it came back to resources. Not culture wars, not ideology. Money.

Delaying the pain

What surprised us most was what we did not hear. Despite anxiety about shrinking budgets, very few people mentioned the One Big Beautiful Bill. It had not yet made a mark on their daily work. That is not accidental. The new law is designed to delay the pain, disperse responsibility, and conceal the damage out of public view until it feels inevitable.

We decided to look into the law’s ramifications. We did our own research, and what we learned is that rural and small-town communities in western Wisconsin are in for a slow-motion fiscal disaster, and that regular people will be the ones who pay the price. 

Starting in 2027, the federal government is scheduled to cut its share of SNAP administrative costs in half. In counties like Dunn, that shift could mean hundreds of thousands of dollars in new local costs. A smaller administrative budget means fewer staff, which means slower processing, higher error rates, and federal penalties that reduce funding even further. The OBBBA seems designed to trigger countless downward spirals that degrade programs until they can be declared broken.

The repercussions for Medicaid follow the same pattern. At Golden Age Manor, the beloved county-run nursing home in Amery, where most of the services are Medicaid funded, even modest reimbursement cuts will translate into tens or hundreds of thousands of dollars lost each year. At the same time, more uninsured residents will still need care.

Across our counties, more than 10,000 people rely on ACA Marketplace coverage for their health insurance. Since federal tax credits expired at the end of 2025, families face premium increases averaging around $1,600 a year. Some will pay far more. Many will drop coverage altogether. When they do, costs will shift to county-funded behavioral health systems and other services already operating at the limits of their resources.

One sheriff described what that will look like in practice: “When someone is in a mental health crisis, our deputies already spend hours driving them across the state because there are no beds here,” he said. “If people lose coverage, those crises do not go away. They show up as 911 calls.”

We must act before the tsunami arrives

A tsunami is set in motion by a distant earthquake that no one feels. Life happens on shore while energy gathers fiercely far out at sea. Only a seismograph sounds the alarm. Once the wave arrives, entire cities are engulfed, communities washed out to sea. Trump’s massive tax cut and spending law was that earthquake. We have decided to act before the wave arrives.

Local governments will be forced to navigate what policy expert Eric Schnurer described as “fiscal and operational crises,” but few people will be able to connect what happens to a bill passed last year. “Most Americans don’t realize how dramatically state and local governments — which most directly affect their daily lives — are about to change.”

County budget hearings were held in November. They often happen with no public comment, gaveled in and gaveled out in a matter of minutes. Last year we showed up and filled the rooms. We brought letters we had drafted, breaking down projected budget impacts county by county. We delivered testimony from the podium. Our goal was not to blame our county leaders, but to signal our alignment with them. 

After one hearing, a county administrator, a self-identified fiscal conservative, met with us and said, “Every point you raised in your letter was correct. Our county government has to brace for what’s coming, and you made that clear to everyone in the room.”

The people who will be hit hardest

We know our county boards are not responsible for causing this disaster, yet they will be forced to deal with it, while we, the residents, will be the ones who feel the cuts most deeply. Our members of Congress who voted “yes” for this bill are the ones responsible for this mess. 

Letters and testimony are not enough. What we need is power. For regular people like us, there is but one path to power: organizing. That means we have to talk to those who will be most affected, inviting them to see their personal stake in this fight. The single parent in River Falls, juggling two part-time jobs and relying on SNAP to keep food on the table. The kid with asthma in Boyceville, whose parents rely on ACA coverage, now at risk of losing access to care. The retired farmer outside Balsam Lake, whose wife’s long-term care at Golden Age Manor nursing home is covered through Medicaid. 

Our long game is to begin the conversation about what it will take for Congress to repeal the so-called One Big Beautiful Bill Act. The path to repeal will be fraught with political roadblocks and fiercely opposed by the corporate class, which has been true for every consequential victory working people have ever won in this country. Repealing the law must become a defining issue in every political conversation in America – at dinner tables, at bus stops, and on Reddit threads – starting now and continuing until the law is gone. 

Cracks are already beginning to form. Earlier this month, Rep. Van Orden, along with 17 other Republicans in the House of Representatives, backpedaled on his support of the OBBBA by voting to extend ACA tax credits (more than 30,000 people are expected to lose health insurance in Van Orden’s district). However, the opposition stiffens. Shortly after the vote, in a disciplinary move, Americans For Prosperity announced it was pausing support for those who defected.

Cutting services, expanding the machinery of repression

As I write, immigration agents are spilling into western Wisconsin from Minneapolis, swarming small towns and rural communities across the region. They are driving unmarked vehicles with out-of-state plates. Some members of our organization have built rapid response networks in solidarity with immigrant-led groups. Meanwhile, our neighbors are being terrorized, taken from their homes, and families are being ripped apart. Some local Mexican restaurants and grocery stores have closed their doors. Just sixty miles west, in Minneapolis, two American citizens have been killed by ICE agents. 

This is not a coincidence. While showering billionaires with tax benefits, the OBBBA also massively expands the machinery of repression. It quadrupled the budget of ICE, expanding its force by 10,000 agents and thereby transforming the agency into one larger than most national militaries. On one hand, the administration subjects us to the cruel spectacle of paramilitary raids, disappearances and death. On the other, the administration dismantles the social safety nets that keep people alive, then redistributes public resources to the wealthiest few. A loud disruptive culture war creates a smokescreen for a quiet methodical class war. 

The fight for Congress to repeal the OBBBA will be a David versus Goliath fight. It is a fight about whether the super-rich will be able to bleed us dry and starve our local institutions. Whether our neighbors will die as wealth is extracted from above. Whether daily life for a majority of Americans will be defined by relentless top-down class war. 

This fight will not be won by politicians, consultants, or pollsters. It will be won by regular people who have decided to build a movement town by town, county by county, state by state. The ramifications of the OBBBA are so wide and deep that a new political coalition will be necessary, one big enough to include anyone who isn’t a billionaire. Republicans, Democrats, independents, libertarians, socialists, and people who’ve lost faith in politics altogether. White people, brown people, Black people, young people, old people. The poor, the working class, the middle class. 

An unwavering commitment to big tent politics and multiracial solidarity is how we defeat the divide-and-conquer tactics this administration relies upon. Building trust and power across differences. Not reinforcing divides through purity tests or theoretical debate. Listening for common ground and shared humanity. Seeing every person as a potential ally, not an enemy to defeat. We must organize, strategize and mobilize until regular Americans have won the freedom to make ends meet, live with dignity, and have a voice in the decisions that affect us.

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This article first appeared on KFF Health News.

As Congress debates whether to extend the temporary federal subsidies that have helped millions of Americans buy health coverage, a crucial underlying reality is sometimes overlooked: Those subsidies are merely a band-aid covering the often unaffordable cost of health care.

California, Massachusetts, Connecticut and five other states have set caps on health care spending in a bid to rein in the intense financial pressure felt by many families, individuals and employers who every year face increases in premiums, deductibles and other health-related expenses.

Hospitals and other health care providers are citing Republicans’ One Big Beautiful Bill Act, signed by President Donald Trump in July, as one more reason to challenge those limits.

The law is expected to reduce federal Medicaid spending by more than $900 billion over a decade, which mathematically should help the overall health care system meet the caps. But the law is also expected to increase the number of uninsured Americans, mostly Medicaid beneficiaries, by an estimated 10 million people. Health care analysts predict hospitals and other providers will raise prices to cover the double whammy of lost Medicaid revenue and the cost of caring for an influx of newly uninsured patients.

Whether regulators in some states will allow providers to justify higher prices and exceed the spending caps is unclear. Only California and Oregon can penalize providers financially if they fail to meet targets.

“Are we going to say, ‘That’s OK’? Or are we going to say, ‘Well, you exceeded the target. We’re still going to penalize you for that’?” said Richard Pan, a former state lawmaker and a member of the California Office of Health Care Affordability’s board. “That has not yet been decided.”

The California Hospital Association, the industry’s main state lobbying group, filed a lawsuit in October asking a state court to strike down the spending caps, which it argued fail to account for all the cost pressures hospitals face. Those pressures, it said, include an aging, sicker population; the rising cost of labor; expensive advances in medical technology; large capital outlays on required seismic retrofitting; and changes in federal policy, including the One Big Beautiful Bill Act. The hospital group’s lawsuit also asserted that the state affordability office, by hastily imposing ill-considered cost-cutting targets, was undermining its other key mission of improving health care access, quality and equity.

California’s affordability office last year set a five-year target to cap statewide spending growth, starting at 3.5% in 2025 and declining to 3% by 2029. The annual caps apply to a wide range of health care entities, including hospitals, medical groups, insurers and other payers.

Earlier this year, it imposed much lower spending growth caps — starting at 1.8% in 2026 and declining to 1.6% by 2029 — for seven “high-cost” hospitals.

“The spending caps set by politically appointed bureaucrats could force cuts that result in many Californians traveling farther for care, facing longer emergency room wait times, experiencing more overcrowding and losing access to critical services,” Carmela Coyle, the hospital association’s president and CEO, said in an October press release.

The California attorney general’s office, which will represent the affordability agency, has not yet filed a response to the hospital group’s complaint and did not respond to a request for comment.

Hospitals’ pushback

California is not the only state taking a close look at hospital prices, which are widely considered a primary driver of health care costs.

“States, armed with information that points to payments to hospitals as a driver of what is way beyond affordable commercial premiums, have begun to take increasingly targeted actions focused on commercial hospital prices,” said Michael Bailit, founder of the Needham, Massachusetts-based consultancy Bailit Health, which has advised multiple states, including California, on ways to tame health care spending. “It is not surprising that the hospital industry is going to oppose such state actions.”

In its lawsuit, the California Hospital Association said the affordability office’s own report showed that pharmaceutical and insurance companies are largely responsible for high costs.

Hospitals in some states with cost growth limits, including Connecticut and Massachusetts, have expressed objections similar to the ones raised in the California lawsuit. They could follow their counterparts in California if their lawsuit succeeds, said Peter Lee, who led California’s Affordable Care Act marketplace, Covered California, for over a decade and is now a senior scholar at Stanford Medicine’s Clinical Excellence Research Center.

Lee said the work of California’s affordability office and similar agencies in other states is just about the only systemwide effort being made to cut health care costs. They are basically saying, “‘Look, health care is taking money away from education, it is taking money away from the environment, it is taking money away from everything in the public sector, and in the private sector it is taking money away from wages,’” he said. “‘We don’t know how you, the health system, are going to do it, but it is your job not just to provide quality but to lower costs. Here’s the target.’”

To be sure, achieving the cost savings that California and those other states are seeking is no easy lift. It will ultimately require persuading large, financially powerful players that compete fiercely for health care dollars to adopt a different mindset and begin cooperating to reduce costs instead. And that, in many cases, will mean lower revenue.

But the status quo, as many people know all too well, means continued financial pain for millions.

In early 2020, Estevan Rodriguez, a bartender at California’s Monterey Beach Hotel, had surgery for a staph infection in his leg. The bill came to nearly $168,000. His insurance paid most of it, but he still owed $5,665, which took him two years to pay, more than $200 every month. “It may not be a lot to some people, but it was a lot to me,” Rodriguez said.

He said he dropped his Hulu subscription, switched to a lower-cost cellphone, and got cheaper car insurance. He started going to food banks rather than the grocery store, he said, and had a lot less time with his kids, because he was constantly working to pay off the hospital bill.

Community Hospital of the Monterey Peninsula, where Rodriguez had his surgery, is one of the seven hospitals identified by California’s affordability office as high-cost. A study by the office attributed high hospital prices in Monterey County to a lack of market competition “rather than higher operating costs or superior quality of care.”

The Monterey hospital referred a request for comment about its “high-cost” designation to the California Hospital Association. CHA spokesperson Jan Emerson-Shea declined to comment beyond the language of the lawsuit and Coyle’s press release statement.

Reduced competition

Health care analysts worry the One Big Beautiful Bill Act will reduce market competition even further by stressing already weak hospitals, leading some to shut services, merge with larger health systems, or close. One study estimates 338 rural hospitals are at risk of closing nationwide.

Less competition, in addition to fewer Medicaid dollars and an increase in uninsured patients, will only strengthen the incentive of health systems with the requisite market clout to raise their commercial prices, increasing premiums for employers and individuals.

“We think commercial prices will continue to increase as health care providers, and hospitals in particular, will seek to preserve or increase their revenue,” said Rachel Block, a program officer at the Milbank Memorial Fund, a foundation that focuses on health equity.

That in turn could pose a challenge to state affordability regulators tasked with overseeing compliance with growth targets for health care spending.

California’s affordability office is required to consider mitigating factors, including changes in federal and state laws. But some of its board members have expressed skepticism about letting hospitals offset Medicaid losses with higher commercial prices.

“There’s a lot of talk about using HR 1 and other federal policies as an excuse to raise prices on commercial payers,” Ian Lewis, an affordability office board member and policy director for UNITE HERE Local 2, a hospitality workers union in the Bay Area, said at the agency’s July board meeting, referring to the One Big Beautiful Bill. “There’s no more blood to be squeezed from this stone.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — an independent source of health policy research, polling and journalism. Learn more about KFF.

A vacant hallway at Vaughan Regional Medical Center in Selma, Alabama, on Tuesday, Sep. 3, 2024 in Selma, Alabama. (Will McLelland for Alabama Reflector)

WASHINGTON — President Donald Trump’s administration unveiled Monday hundreds of millions of dollars each state will receive this fiscal year as part of a massive $50 billion rural health fund baked into Republicans’ “big, beautiful” law. 

The five-year Rural Health Transformation Program — authorized under GOP lawmakers’ mega tax and spending cut package Trump signed into law in July — is designed to offset the budget impacts on rural areas due to sweeping Medicaid cuts.  

Half of the $50 billion will be distributed equally among each state between fiscal years 2026 and 2030, according to the Centers for Medicare and Medicaid Services.

The agency under the U.S. Department of Health and Human Services said the remaining $25 billion, doled out over the same time period, is being allocated to states based on several factors, such as steps states are taking to improve access to care in rural communities. 

Texas will get the highest first-year award at $281.3 million, followed by Alaska at $272.2 million, California at $233.6 million, Montana at $233.5 million and Oklahoma, at $223.5 million. 

New Jersey is receiving the lowest first-year award, at $147.2 million. 

“Thanks to Congress establishing this investment and President Trump for his leadership, states are stepping forward with bold, creative plans to expand rural access, strengthen their workforces, modernize care, and support the communities that keep our nation running,” CMS Administrator Dr. Mehmet Oz said in a statement alongside the announcement. 

Oz added that “CMS is proud to partner with every state to turn their ideas into lasting improvements for rural families.” 

Meanwhile, the nonpartisan health research organization KFF found that the program would only offset a little more than one-third of the package’s estimated $137 billion cut to federal Medicaid spending in rural areas over the next decade.

Ashley Murray contributed to this report.