A sign in Madison, Wisconsin touting a municipal well project funding by President Biden's bipartisan infrastructure law. | Photo by Ruth Conniff/Wisconsin Examiner

In the last days of the Biden administration, just before Trump’s triumphant return and swearing-in on the site of the violent Jan. 6 Capitol insurrection, I happened across a sign touting federal investment in an infrastructure project on Madison’s east side. 

Next to a strip mall, set back from the road and barely visible from busy East Washington Avenue, the sign touted PFAS treatment and upgrades to a municipal well. In large type it declared: “Project Funded by President Joe Biden’s Bipartisan Infrastructure Law.”

Too little, too late, I thought. The sign, practically hidden on a scruffy corner where few eyes can see it, seemed like a metaphor for the Biden administration’s failed effort to take credit for all the good it did. Through federal investments it paved roads, repaired bridges, shored up the economy and set us on a path to recovery from a global pandemic. By the end of 2024, wages, job growth, employment, even consumer prices that had spiked worldwide after COVID hit, apparently driving voters in this country to elect Trump, are all in good shape. In the third quarter, real GDP hit its highest level of 2024 at 3.1%. Consumer spending was up. Unemployment was 4% nationally and 2.9% in Wisconsin. And everywhere across Wisconsin, federal investments have boosted the economy and improved lives.

As Erik Gunn reports, the Biden administration touted  $9.2 billion in federal infrastructure investments in our state, including $1 billion for desperately needed repairs to the Blatnik Bridge connecting Superior to Duluth, Minnesota. There were also hundreds of smaller projects like PFAS remediation in that municipal well on Madison’s east side, which was shut down in 2019 and will be operational again by the summer. 

Because of the Biden administration’s efforts, about 300,000 Wisconsin Medicare recipients are saving an average of $475 per year in prescription drug costs, which were capped under the Inflation Reduction Act. And the Department of Education projects that 62,000 Wisconsinites have had over $2.4 billion in student debt canceled thanks to Biden’s student debt relief efforts.

These are just a few of the highlights in a long list of Biden administration accomplishments put out by the Democratic National Committee as the former president bade farewell. 

Wisconsin lost 83,500 jobs during Trump’s first term. During Biden’s four years in office, it added 186,800 jobs, as we bounced back from the pandemic. Federal pandemic relief funds allowed Wisconsin Gov. Tony Evers to shore up schools, infrastructure, child care and health care in our state, even as Republican legislative leaders tenaciously blocked every effort to use the state’s historic multibillion-dollar surplus to fund any of those priorities. 

Now Biden is gone and Trump’s MAGA Republican party has taken over every branch of the federal government. Here in Wisconsin, as across the country, MAGA loyalists are repeating Trump’s counterfactual talking points about how terrible Biden was for the economy and how government must be cut back in order to unleash a new era of American prosperity.

The battle between those who want to harness the power of government to help people and those who would rather drown it in the bathtub has been going on for decades. But the contrast between those ideologies has grown sharper. It’s more important now than ever to recognize what’s at stake.

At the start of the new legislative session, Wisconsin Republicans pledged to ignore Evers’ budget requests and focus exclusively on giving away the state surplus in the form of tax cuts.

“The money that we set aside for that tax cut will not be spent by this Legislature on other wants,” Assembly Speaker Robin Vos declared, “no matter how many special interests or tax-and-spend politicians apply pressure to get it out of the treasury’s hands.” 

“More than $4 billion of taxpayer money is sitting in a bank account here in Madison, while rising prices impact the families who sent us here to serve them,” Senate Majority Leader Devin LeMahieu concurred. “[Evers] wants to use that money to grow the size of government and send Wisconsin backwards.” 

Even a state effort to curb school shootings, through Evers’ office of violence prevention, which he announced after the Abundant Life school shooting in Madison, came in for scathing cynicism from Republican legislative leaders. 

“It takes a bureaucrat to think that another government agency is actually going to be effective,” Vos spat, summing up the effort as “a whole bunch of touchy-feely bureaucrats that are going to go around wasting time, wasting money.”

At the federal level, Republicans are singing the same discordant tune.

Scott Bessent, the hedge fund manager Trump nominated to lead the U.S Treasury Department, said during his confirmation hearing that extending Trump’s 2017 tax cut which disproportionately benefited the very wealthy is “the single most important economic issue of the day.”

“If we do not renew and extend, then we will be facing an economic calamity,” Bessent said. When Georgia Democratic Sen. Raphael Warnock pressed Bessent on whether people who make more than $10 million per year really need a tax cut, Bessent replied, “There is no income level that I don’t think we should continue the [tax cut] as it was.” On the flip side, he endorsed deep cuts to federal spending that benefits less fortunate Americans. “We do not have a revenue problem in the United States of America; we have a spending problem,” Bessent said. 

The real economic calamity is shaping up as the incoming Trump administration eyes deep cuts to Medicaid and other cuts that will fall most heavily on poor families. For good measure, Bessent also said he opposes raising the federal minimum wage above $7.25 an hour.

Ever since Ronald Reagan championed trickle-down economics in the 1980s, Republicans have promised that cutting taxes on the wealthy and reducing the size of government will benefit most Americans. But it hasn’t worked out that way. “Cutting taxes for the rich over the past 40-plus years has had a huge impact, leaving less money for public programs that benefit millions of Americans while enriching a tiny percentage of the population,” the Center for Public Integrity reports. Income inequality skyrocketed: “As more money flowed upward, the gap in accumulated wealth widened,” the Center reports. “In 2019, the top 10% of Americans had three times the wealth of everyone else in the country combined.”

It comes down to this: Do you believe it’s better for rich people to get tax cuts and for all of us to pay more to meet basic needs — getting only the health care, education, infrastructure – even firefighting — we can afford to pay for out of pocket? Or do you think we can, as a society, create a world where there is a baseline level of wellbeing, decent education, food, shelter and security for all? 

Republicans have been arguing for a long time that government is broken, should be “drowned in the bathtub” — that no one should be required to chip in to support things like public schools or provide decent housing and health care and education to all, including children born into families that can’t afford all these things on their own.

Now we face an aggressive push by the incoming Trump administration and the Wisconsin Leislature’s majority to destroy programs that benefit poor kids, poor families and society as a whole

After years and years of underfunding Wisconsin’s public schools and our once-great university system, Republican  legislators now say there’s no point throwing good money after bad, using the struggles of an underfunded system as an excuse for further cuts.

If we can’t remember what it’s like to have a functional society, it’s easy to become cynical and give up on the idea of a healthy public sphere. 

Now, as we enter the era of Trump 2.0, it’s important to remember what we had, what we lost, and what we need to fight like hell to hang on to.

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U.S. President-elect Donald Trump speaks at a news conference at Trump's Mar-a-Lago resort on Dec. 16, 2024 in Palm Beach, Florida. (Photo by Andrew Harnik/Getty Images)

Under President Joe Biden, enrollment in Medicaid hit a record high and the uninsured rate reached a record low.

Donald Trump’s return to the White House — along with a GOP-controlled Senate and House of Representatives — is expected to change that.

Republicans in Washington say they plan to use funding cuts and regulatory changes to dramatically shrink Medicaid, the nearly $900-billion-a-year government health insurance program that, along with the related Children’s Health Insurance Program, serves about 79 million mostly low-income or disabled Americans.

The proposals include rolling back the Affordable Care Act’s expansion of Medicaid, which over the last 11 years added about 20 million low-income adults to its rolls. Trump has said he wants to drastically cut government spending, which may be necessary for Republicans to extend 2017 tax cuts that expire at the end of this year.

Trump made little mention of Medicaid during the 2024 campaign. The first Trump administration approved work requirements in several states, though only Arkansas implemented theirs before a federal judge said it violated the law. The first Trump administration also sought to block-grant funding to states.

House Budget Committee Chair Jodey Arrington (R-Texas) told KFF Health News that Medicaid and other federal entitlement programs need major changes to help cut the federal debt. “Without them, we will watch this country sadly enter into fiscal collapse.”

Rep. Chip Roy (R-Texas), a member of the Budget Committee, said Congress needs to explore cutting federal spending on Medicaid.

“You need wholesale reform on the health care front, which can include undoing a lot of the damage being done by the ACA and Obamacare,” Roy said. “Frankly, we could end up providing better service if we do it the right way.”

Advocates for poor people fear GOP funding cuts will leave more Americans without insurance, making it harder for them to get care.

“Medicaid is an obvious target for huge cuts,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families. “An existential fight about Medicaid’s future likely lies ahead.”

Medicaid, which turns 60 in July, is nearing the end of a disruptive period, after covid pandemic-era coverage protections expired in 2023 and all enrollees had to prove they still qualified. More than 25 million people lost coverage over the 18 months after the “unwinding” began, though it has not notably increased the number of people without insurance, according to the latest census data.

The unwinding’s disruptions could pale in comparison to what happens in the next four years, said Matt Salo, former executive director and founder of the National Association of Medicaid Directors. “What we are going to see is an even bigger seismic shift in who Medicaid covers and how it operates,” he said.

But Salo said any efforts to shrink the program will face pushback.

“A lot of powerful entities — state governments, managed-care organizations, long-term care providers, and everyone under the sun who wants to do well by doing good — wants to see Medicaid work efficiently and be adequately funded,” he said. “And they will be highly motivated to push back on something they see as draconian cuts, because it could affect their business model.”

The GOP is looking at several tactics to reduce the size of Medicaid:

• Shifting to block grants. Switching to annual block grants could lower federal funding for states to operate the program while giving states more discretion over how to spend the money. Currently, the government matches a certain percentage of state spending each year with no cap. Republican presidents since Ronald Reagan have sought to block-grant Medicaid with no success. Arrington said he favors ending the open-ended federal funding to states and replacing it with a set annual amount based on how many people each state has in the program.
• Cutting ACA Medicaid funding. The ACA provided financing to cover, through Medicaid, Americans with incomes up to 138% of the federal poverty level, or $20,783 for an individual last year. The federal government pays 90% of the cost for adults covered through the law’s Medicaid expansion, which 40 states and Washington, D.C., have adopted. The GOP may try to lower that funding to the same match rate the feds pay states for everyone else in the program, which averages about 60%. “We should absolutely note that we are subsidizing the healthy, able-bodied Medicaid expansion population at a higher rate than we do the poorest and sickest among us, which was the original intent of the program,” Arrington said. “That’s not right.”
• Lowering federal matching funds. Since Medicaid began, the federal match rate has been based on the relative wealth of a state’s population, with poorer states receiving a higher rate and no state receiving less than a 50% match. Ten states get the base rate — all but two are Democratic-run states, including New York and California. The GOP may seek to cut the base rate to 40% or less.
• Adding work requirements. During the first Trump term, federal courts ruled that Medicaid law doesn’t allow coverage to be conditioned on enrollees’ working or seeking jobs. But the GOP may try again. “If we can get strict work requirements on able-bodied adults, that can be a huge cost savings by itself,” Rep. Tom McClintock (R-Calif.) told KFF Health News. Because most Medicaid enrollees already work, go to school, or serve as caregivers, critics say such a requirement would simply add red tape to obtaining coverage, with little impact on employment.
• Placing enrollment hurdles. About 10 states offer some populations what’s called continuous eligibility, whereby people stay enrolled for years without having to renew their coverage. That policy’s been shown to prevent enrollees from falling out of the program for short periods because of hardships or paperwork problems, which can lead to surprise medical bills and debt. The Trump administration could seek to repeal waivers that allow states to grant multiyear continuous eligibility, which would require people in those states to reapply for coverage annually.

If the GOP’s plans to shrink Medicaid are realized, Democrats and health experts say, low-income people forced to buy private insurance would face challenges paying monthly premiums and the large copayments and deductibles common to commercial plans that typically don’t exist in Medicaid.

The Paragon Health Institute, a leading conservative think tank run by former Trump adviser Brian Blase, has issued reports saying the billions in extra money states took to expand Medicaid under the ACA has been a boon to private insurers that manage the program and relatively wealthier people it says shouldn’t be enrolled.

Josh Archambault, a senior fellow with the conservative Cicero Institute, said he hopes the Trump administration holds states accountable for overpaying providers and enrolling people in Medicaid who are not eligible. Conservatives have cited CMS reports saying states improperly pay Medicaid providers billions of dollars a year, though the federal government notes that is mostly due to lack of documentation.

He said the GOP will look to scale back Medicaid to its “traditional” populations of children, pregnant women, and people with disabilities. “We need to rebalance the program that most people think is underperforming,” he said. Most Americans, including large majorities of both Republicans and Democrats, view the program favorably, according to polls.

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.

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This article first appeared on KFF Health News and is republished here under a Creative Commons license.

The NorthLakes Community Clinic health center in Washburn is one of a group of community health centers across northern Wisconsin. A new report finds that rural residents are at least as likely to rely on Medicaid for health coverage as people in other communities. (Photo courtesy of NorthLakes Community Clinic)

Residents of rural areas and small towns are more likely to rely on Medicaid for health coverage than city dwellers, a new report issued Wednesday finds.

Authors of the report said the findings highlight the potential harm that could particularly affect rural residents if Congress imposes drastic cuts to Medicaid as is reportedly being considered.

The analysis was released by the Georgetown University Center for Children and Families less than a week after a published report that U.S. House Republicans are contemplating cutting Medicaid by up to $2.3 trillion as part of their plan to renew tax cuts enacted in the first Trump administration.

“That equates to almost one-third of federal Medicaid spending,” said Joan Alker, executive director of the center and a research professor at Georgetown’s McCourt School of Public Policy, during an online press briefing Wednesday. “Rural communities are at grave risk if substantial Federal cuts are enacted.”

Medicaid provides health care coverage for about 80 million low-income Americans. Closely related, the Children’s Health Insurance Program (CHIP) extends coverage for children in families with incomes too high to qualify for Medicaid but too low to afford private health insurance coverage. Both programs are funded jointly by states and the federal government and are managed by states under federal rules.

 “Medicaid is the backbone of many aspects of our health care system, including paying for the majority of nursing home residents, covering 40 to 50% of children and births nationwide, depending on where you live, covering people with disabilities and many other low income people,” Alker said.

Medicaid’s rural footprint

The report looks at 2023 federal census data to estimate the share of urban as well as rural and small town residents covered by Medicaid and CHIP. The data source, the American Community Survey, is useful for comparisons among states but may undercount Medicaid enrollment, Alker said, making the report’s estimates conservative.

In 40 out of 48 states, the report finds, Medicaid enrollment in rural counties was similar to or higher than in urban counties. (The report defines a rural county as one with no urban communities of 50,000 people or more. New Jersey, Rhode Island and the District of Columbia have no designated rural counties.)

Medicaid and CHIP covered more than half of all children living in rural areas and small towns in six states: New Mexico, Louisiana, Arizona, Florida, South Carolina and Arkansas.

Ten states had the largest difference between rural and urban children in the programs. Arizona headed that list, with 55.9% of rural or small town children enrolled in Medicaid or CHIP compared with 34.9% of children in metro areas.

Among all states, Texas had the largest number of children — 239,100 — enrolled in Medicaid or CHIP, followed by North Carolina, with 237,800; Georgia, with 205,200; and Kentucky, with 199,200.

Higher rural Medicaid enrollment also showed up among adults. In 15 states at least 20% of rural or small-town adults ages 18 to 65 were covered by Medicaid. Arizona again headed the list, with 35.9% of rural non-elderly adults enrolled in the program compared with 16.8% of urban adults.

“Medicaid is protecting families and people from exposure to high medical costs, and Medicaid is very good at that,” Alker said. “Cuts to Medicaid, which is already a very lean payor in our health care system, will result in transferring costs, shifting costs to families and providers cutting services and in rural communities,” Alker said.

Wisconsin patterns

Overall, Medicaid coverage is highest in urban Milwaukee County (27.4%) and rural Menominee County (29.9%). On average, Medicaid covers about 15% of Wisconsin adults under 65, rural and urban alike, and Medicaid or CHIP cover about one-third of children on average, whether they live in urban or rural communities.

In 27 rural counties across northern and central Wisconsin, however, the share of children on Medicaid is higher than the state average.

“Nearly 1.5 million Wisconsin residents live in rural areas and small towns, and Medicaid plays a critical role in ensuring access to health care for these communities,” said William Parke-Sutherland of Kids Forward. “Congress is considering enormous funding cuts to Medicaid in the year ahead, and this new report confirms how disastrous this would be for our rural communities and small towns.”

Rural patients and providers alike count on Medicaid to support the health care infrastructure and provide health care services, providing preventive care, dental care and behavioral health services, according to Ana Tochterman, CEO of NorthLakes Community Clinic, a federally supported health clinic with facilities across northern Wisconsin.

“Medicaid is an absolutely essential program that provides insurance for the majority of patients served at our rural Community Health Center,” Tochterman said. “Rural patients face unique challenges like transportation barriers and limited access to resources found in larger communities, and Medicaid is an important tool that enables rural patients to thrive.”

Rural health and resources

The report identifies several health care challenges for rural areas. Those include a greater scarcity of providers, limited internet connectivity and longer distances between people and their health care providers, exacerbated by a lack of public transportation.

Medicaid cuts could threaten already-shrinking rural health care networks, the report warns. “Health care systems are already under enormous pressure and can ill afford any loss of resources,” Alker said.

Care for mothers and newborns is especially likely to suffer, said Katy B. Kozhimannil, a health policy researcher at the University of Minnesota who has studied hospital and delivery room closures.

In 2010, more than 43% of rural hospitals and almost 30% of urban hospitals didn’t offer obstetric care, she said. By 2022, that was true of more than 52% of rural hospitals and more than 35% of urban hospitals.

“More than a decade into a maternal health crisis in the United States, fewer U.S. hospitals provide obstetrics every year, with rural hospitals experiencing the greatest losses,” Kozhimannil said.

The high cost of specialized facilities and staff to deliver babies have to be covered by revenues that vary depending on how many children are born each year and how much the hospital gets paid for each birth, she explained. Those factors put a bigger burden on smaller hospitals and on hospitals with more Medicaid patients, because Medicaid usually pays less than private health insurance.

Beside care at and before birth, she added, Medicaid can make it possible for families to get health care for children growing up with special health needs, mental health care or substance abuse treatment for teens, or long-term care for the elderly.

“These are all areas of deep need in our rural communities that are disproportionately financed through Medicaid programs,” Kozhimannil said.

‘A crucial backstop’

Hutchinson Regional Medical Center in central Kansas serves a population of about 100,000 people, but its service area extends into Western Kansas. 

“Our health system, which cares for that region, is sustained largely, or in part, by Medicaid,” Benjamin Anderson, the medical center’s CEO, said during the Georgetown press briefing.

He mentioned a baby born earlier this week at the hospital whose mother never had access to prenatal care. The infant will now spend months in the facility’s neonatal intensive care unit, incurring health care expenses likely to top $1 million.

“Much of that would have been preventable with adequate prenatal care,” Anderson said.

Maternal and child health is a major part of the facility’s mission, “but older adults, too, are also cared for by moms and they are also particularly vulnerable,” he added. “Cuts to Medicaid mean fewer providers, and just speaking very plainly, fewer providers are able to sustain receiving patients that have Medicaid. Fewer poor people will be able to access care at a health system like ours that takes all payers — and those who can’t pay — and is currently operating at break even.”

The COVID-19 pandemic put health care systems into a metaphorical intensive care unit and “we’re still recovering,” Anderson said — striving to address needs ranging from maternity care to seniors who need long-term care, perhaps at home in the face of nursing home bed shortages.

“Medicaid is a crucial backstop for that to happen, and it’s so important that we sustain it, that we prop it up,” Anderson said. “We have an opportunity to rebuild a system right now, and there are many in this country that are doing that following the pandemic. And significant cuts, as are identified in this report, would cripple those efforts to recover.”

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