The Second Trump Administration: Medicaid, Austerity, and the Fight for Survival Beyond the State
How ‘Make America Healthy Again,’ with Dr. Oz and RFK Jr. leading the charge, will become the state’s war on the poor, disabled, and chronically ill.
[Image description: Bitmap image of lightning and the logo for Centers for Medicare and Medicaid Services (CMS) star rating system in the background.]
The Second Trump Administration: Medicaid, Austerity, and the Fight for Survival Beyond the State
How ‘Make America Healthy Again,’ with Dr. Oz and RFK Jr. leading the charge, will become the state’s war on the poor, disabled, and chronically ill.
As the incoming second Trump administration looms ahead of us, the consequences for health and welfare policy are clear: millions of people—disproportionately poor, disabled, chronically ill, trans and indigenous people—will face increased barriers to survival. Programs like Medicaid, already tenuous and rife with administrative burdens, are primed to become a testing ground for state austerity and privatization, much like under the first Trump administration. At its core, the ‘Make America Healthy Again’ agenda is not about improving health or increasing access to care. It’s about control: control over who is deemed worthy of survival, over the bodies subjected to punitive policies, and over the resources to be extracted by privatized actors ready to make markets out of state abandonment.
For those of us in the surplus class—this isn’t just a policy shift. It’s also a call to action. As the state doubles down on eugenicist policies that treat us as disposable, we must build solidarity-based alternatives to help each other survive. As the incoming administration dusts off its old playbook—punitive work requirements, privatization, and funding cuts—it’s clear that the next four years will not only deepen existing harms but accelerate them.
A second Trump administration demands that we abandon any lingering faith in the state and its electoral systems as a venue to seek power and influence. For those of us used to (or more comfortable) lobbying for better funding or policy tweaks, it’s time to rethink the terrain of struggle. The state has shown us time and again that it is here to manage abandonment. The tools many have been taught to rely on, like petitioning elected representatives or supporting marginal incremental improvements will be especially futile up against the Trump administrative state.
The state is not a benevolent entity that will save us out of the goodness of its heart—it is not an empathetic being but a system designed to chew up the vulnerable and spit us out. And if we are to survive the coming onslaught of the state’s war on the poor, we need to build the power we need together, outside of state structures, to sustain our survival and work towards liberation. Instead of directing our limited energy and capacity toward a state apparatus built to exclude, we must organize outside and against it.
‘Make America Healthy Again’: The State’s War on Survival
The incoming administration’s ‘Make America Healthy Again’ (MAHA) agenda, led by figures like Dr. Mehmet Oz and Robert F. Kennedy Jr., not to mention Covid minimizers like Dr. Marty Makary and Dr. Jay Bhattacharya, represents a wellness grift masquerading as a health policy agenda. It’s not about improving health, it’s about further codifying and entrenching exclusion and abandonment into the welfare state. Their rhetoric cloaks neglect and privatization in the language of personal responsibility and wellness, hiding the fact that the goal of MAHA is to dismantle the very state infrastructure designed to address systemic or emergent health crises.
In this week’s episode of Death Panel podcast, we covered some of the nominated health agency appointees from Dr. Oz (CMS) to Makary (FDA) and Bhattacharya (NIH) at length (as well as Dr. Janette Nesheiwat (SG) and Dr. Dave Weldon (CDC)). Make sure to give that episode a listen; we discussed who each of these people are, what they are known for, what the responses have been to their nominations so far, and the broader ideological picture that is painted from looking at all these nominations together, including RFK Jr. at HSS, and what that might tell us about policy under a second Trump administration.
And if you haven’t caught last week’s Death Panel podcast deep dive on RFK Jr., nominated to run HSS, check that episode out as well.
Dr. Oz, the nominee to head the Centers for Medicare & Medicaid Services (CMS), represents the ultimate neoliberal fantasy of health capitalism. His brand—a toxic mix of pseudoscience and positivist wellness rhetoric—has always been about profit and the perpetuation of the myth of rugged American self-reliant individualism, not care. He sells the idea that if you just buy the right things, and make all the right choices (no matter your social, economic, or political circumstances) you can achieve health alone through personal responsibility and individual discipline, never needing to acknowledge the pesky, messy interdependence of life. Under Oz’s leadership, CMS will likely accelerate the push for a total takeover by Medicare Advantage, a privatized alternative to Medicare that funnels public funds into private companies while denying essential care.
RFK Jr., meanwhile, has similarly disguised his disdain for basic public health under the guise of “fighting chronic illness.” His rhetoric, pitched as individual choice and “freedom” from health mandates and state oppression, is really an ideological assault on the collective measures necessary to address ongoing public health crises like Covid-19, poverty, and a lack of basic health and dental care in the U.S. We should expect the incoming second Trump administration to use this framework to deny the legitimacy of chronic illness, erase not just the ongoing pandemic but also its material and biological effects like Long Covid, and rationalize further neglect and abandonment of sick and disabled people under the premise that we are burdens on “healthy America.”
Further, the nostalgia implied by “again” in ‘Make America Healthy Again’ is deeply misleading. When, exactly, was America “healthy”? For much of its history, the U.S. has denied basic healthcare to marginalized communities of all kinds, exploited and experimented on Black, Brown, and Indigenous people, and systemically excluded disabled people and elders from public life.
The MAHA narrative also feeds into harmful narratives of health as a position of moral superiority. It divides people into “deserving” and “undeserving” based on their health status, stigmatizing those who are sick, disabled, or struggling—not just as individually unhealthy—but as making the whole of America unhealthy. Such frameworks are inherently racist and ableist, ignoring and erasing how racial capitalism produces ill health through a myriad of ways from unsafe working conditions, toxic infrastructure, environmental degradation, financialization, and inadequate on the ground public health interventions, etc.
Medicaid as a Weapon of Class Discipline
Medicaid, the largest safety net health program in the United States, has always been more than healthcare. Medicaid has long been a tool of class discipline, and under the first Trump administration, Medicaid became a testing ground for punitive policies that tied access to basic care to economic productivity, compliance with onerous bureaucratic requirements, and reinforced class hierarchies.
Like the first Trump administration, we should expect the second Trump administration to weaponize Medicaid against its enrollees. Through Section 1115 waivers, the first Trump administration introduced work requirements, premiums, and lock-out periods—policies that systematically excluded the most vulnerable while enriching private interests and pleasing Republicans obsessed with reducing federal expenditures. These waivers functioned as mechanisms to destroy Medicaid from the inside, shrinking the number of beneficiaries and deepening exploitation.
Take Arkansas, where over 18,000 people lost Medicaid due to the implementation of work requirements using a Section 1115 waiver. This policy didn’t increase employment or improve health care access for those that remained enrolled; they simply created administrative barriers designed to disenroll people. Most Medicaid recipients are already working or physically unable to work, but increasing the workforce was not the point. The point was to send the message that there were people out there getting something for nothing, free riders, burdens, wastes, frauds, and cheats. This approach reflects the state’s broader logic toward poor folks: care is a tool for maintaining order, not addressing need.
Similarly, the first Trump administration issued waivers to states who wanted to experiment with eliminating retroactive eligibility—a safeguard that covers medical bills incurred in the three months immediately before Medicaid enrollment—which was a policy proposal designed to expose countless people to catastrophic medical debt that Medicaid is specifically designed to prevent. These measures had a dual goal, saving money for the state and enforcing compliance, ensuring that the sick and poor remained trapped in cycles of precarity and insecurity. Debt after all is a market too.
Medicaid, like other safety net programs, is structured to punish noncompliance, stigmatize poverty, and fragment working-class solidarity. Yet it is also a crucial lifeline for many of us. The second Trump administration is poised to take the punitive status quo of Medicaid even further under the potential leadership of Dr. Oz at CMS. Work requirements, never before actually enacted in Medicaid until Trump’s first term, will likely return. We’ll see harsher penalties, deeper funding cuts, medical debt, poverty, and preventable suffering—all in the name of fiscal responsibility and ‘Make America Healthy Again.’
Impact on Trans People and Indigenous Communities
Trans people, particularly Black, Brown, Indigenous, chronically ill and disabled trans people, are already among the most marginalized when it comes to “healthcare access” in the U.S. Medicaid is often the only lifeline to care, providing essential services like hormone replacement therapy (HRT) and surgery. However, Medicaid is not a guarantee of access; the system has long been plagued by administrative burdens, a lack of providers, deprioritization of trans-specific care, and a pervasive culture of medical gatekeeping.
Under a second Trump administration, the push to make Medicaid more punishing, like experimentation with work requirements and funding cuts will disproportionately impact trans people, and worsen the already significant barriers to basic healthcare. The administration’s austerity attacks on Medicaid, combined with the proliferation of attempts to restrict or criminalize HRT and surgeries will make the landscape of “access” much trickier than it has been recently. It’s also possible that we will see some states impose additional restrictions to trans-specific care under the guise of “protection” or “safety.”
These policies are not abstract, these coming attacks on Medicaid are not just about numbers but about people’s lives. This is also why we need to focus not just on saving our basic safety net systems like Medicaid, but building alternatives that are not subject to the whims of volatile election cycles.
Similarly, Indigenous communities, many of whom rely on the Indian Health Service (IHS) for basic healthcare needs, will also face the brunt of austerity under a second Trump administration. The IHS is chronically underfunded and overburdened, not to mention under-resourced and often outright hostile. Medicaid and the Children’s Health Insurance Program (CHIP) serve as critical band aids to help cover for the inadequacies of IHS. Cuts to and punitive experimentation with Medicaid will directly affect Indigenous communities’ “access” to care. Combined with the legacy of settler colonialism and the federal government’s long history of neglect toward Indigenous health, this will only compound existing disparities in care sought through the state.
The incoming administration’s push for Medicaid cuts and restrictions, alongside centuries of cultural warfare against Indigenous sovereignty, will deepen the harms already caused by decades of colonialism, extraction, and systematic theft of land and resources, stolen from Indigenous communities. As with other marginalized groups, the focus we should expect from a second Trump administrative state on market-based solutions that enrich private companies through the imposition of austerity regimes will harm Indigenous folks. Once again, this underscores the need to be organizing outside and against state structures.
Why ‘With the State’ Advocacy Won’t Save Medicaid, and Won’t Save Us
For decades, Medicaid advocates have primarily focused their work within the system—lobbying representatives, pushing for incremental reforms, and securing temporary funding boosts or increases in the types of care covered. These efforts, while important and well-meaning, have also consistently run into the same wall: the state’s role is to sustain capitalism, not to meet people’s needs. Medicaid as a safety net of the state will never be enough to truly give those of us who rely upon it the means to not just survive but thrive and live the lives that we deserve.
Take Medicaid funding. Advocates often fight for expansions to Medicaid, the removal of onerous reporting requirements, or increased appropriations, but these victories are always fleeting. Even under the Biden administration, which rolled back some of the first Trump administration’s worst Medicaid policies enacted using Section 1115 waivers, Medicaid unwinding—a bureaucratic process of undoing the pandemic welfare state that removed over 25 million people from the Medicaid rolls in the course of a year—has devastated “access” to care.
This is a perfect example of why the issue is not just which party is in power. It is the fundamental design of the system: a program built to police poverty through the making of healthcare markets cannot provide universal care.
Moreover, reforms often strengthen the very systems that we seek to dismantle. Expanding Medicaid, for example, has funneled billions into the hands of private managed-care organizations who have the contracts to run plans for various states. These companies profit from denying care, and their influence over Medicaid will grow under a second Trump administration, just as they did under Biden. By fighting for piecemeal changes within the existing framework, we risk reinforcing the very privatization and austerity that harms us.
This is not a call to abandon advocacy entirely. It’s a call to shift and expand our focus. Instead of only asking the state to meet our needs, or even spending time demanding an entirely new system, we need to be building our own in the meantime.
[Image description: Dr Oz standing on the set of one of his 2022 senate race commercials in front of a potted plant and a screen that reads Dr Oz US Senate. Superimposed on the image is the CMS 5 star logo and a bitmap image of lightning.]
Organizing Outside and Against the State
This moment is heavy. The policies we’re bracing for—work requirements, privatization, austerity—are life or death for millions of people. But despair is not an option. As Mariame Kaba reminds us, hope is a discipline. It’s something we cultivate through action.
The fight for Medicaid is never just about protecting a welfare program—it’s about collective power and challenging the state’s control over our survival. This requires us to get creative and look beyond traditional advocacy towards creating solidarity-based alternatives that aren’t subject to the whims of election cycles, which party is in power, state budgets, or state ideas about whose lives are worth something and who is an expendable burden.
Here are some basic starting points if you want to dig deeper, need a refresh, you’re not sure what I’m talking about, or you are daunted by the idea of organizing outside and against the state:
Everyone should read Vicky Osterweil’s recent essay, Let's Get Started.
Mutual aid: mutual aid is not charity, by building networks that bypass state systems and provide care and resources directly we can meet each other’s needs while fostering the relational networks and solidarity needed to sustain ourselves long term. Look to histories of movements that do not focus on appeals to the state.
Recommended reading: William C. Anderson’s book The Nation on No Map, Dean Spade’s book Mutual Aid, or his forthcoming book Love in A F*cked Up World, Dylan Rodríguez’s book White Reconstruction, .
Community-led and driven research: Patient-led movements like ACT UP offer a model for confronting systemic state neglect of important research needed by patient communities. Militant community organizing like the Young Lords supported people’s takeovers of hospitals. Groups like the Black Panther Party did survival work that changed the landscape of sickle cell anemia care. Scientists and researchers need not wait either, we can look to the history of the development of penicillin or the polio vaccine for inspiration.
Recommended reading: Avram Finkelstein’s book After Silence, Mutual Aid Self/Social Therapy by the Jane Addams Collective, Johanna Fernández’s book The Young Lords: A Radical History, Alondra Nelson’s book Body and Soul: The Black Panther Party and the Fight against Medical Discrimination, the book Comrades in Health, Orisanmi Burton’s book Tip of the Spear, or Artie and my book Health Communism.
Rejecting productivity as a measure of worth: Advocacy must reject capitalist metrics that tie access to care to productivity. Our lives are not valuable because we can work or "contribute" to the economy—they are valuable because we exist.
Recommended reading: Health Communism, Micha Frazer-Carroll’s book Mad World, Sasha Warren’s book Storming Bedlam, Sami Schalk’s book Black Disability Politics, and Klee Benally’s book No Spiritual Surrender.
Coalitions across struggles: Health justice is inseparable from housing, labor, and environmental struggles. By connecting these fights, we can challenge the broader systems of exploitation that make us sick in the first place.
Recommended reading: Tracy Rosenthal and Leonardo Vilchils’ book Abolish Rent, Sunaura Taylor’s book Disabled Ecologies, Liat Ben-Moshe’s book Decarcerating Disability, Jess Whatcott’s book Menace to the Future, Sophie Lewis’ book Abolish the Family, M.E. O’Brien’s book Family Abolition, Victoria Law’s book Corridors of Contagion, Nick Estes’ book Our History is the Future, and Peter Gelderloos’ book They Will Beat the Memory Out of Us: Forcing Nonviolence on Forgetful Movements.
Listen to the episode: The Great Barrington Cabinet Versus the Administrative State (11/27/24)