A few weeks ago, we argued the Trump administration was seeking to invent new ways to punish Americans. The idea was that the authoritarian impulses of the MAGA-run government will need to dial up the cruelty in order to sow chaos and pave the way for a broader assault on democracy.

Well, this week a rule was issued by Medicare and Medicaid services that shows just how proficient the Trump administration is at inflicting pain. And the consequences for poor, seriously ill Americans could be devastating.

Before we explain the rule, it’s worth contemplating the often destructive role healthcare — both the lack of it and exorbitant costs associated with it — play in the lives of working-class Americans.

Poll after poll shows that working people rank anxiety over healthcare costs at the top of the list of high-priority concerns. Unpaid medical bills are the most likely cause of personal bankruptcy in the US. Unlike any other wealthy nation on earth, when Americans lose their jobs, they often lose access to a doctor as well.

The US healthcare system is already inherently extractive — making it even more prohibitively expensive means more people will suffer with diseases that can be cured and die from afflictions that would otherwise be treatable. All of this makes the working class vulnerable and likewise incapable of asserting their right to be healthy.

And that’s where the new rule comes in.

The government agency that administers Medicaid has created a new criterion, ‘medically frail,’ which must be met to qualify for the program without working — even if you only have weeks to live. It didn’t exist prior to the passage of the Big Beautiful Bill. 

Before that landmark legislation was signed into law, Medicaid was primarily a means-tested program, accessible to those with low enough incomes to qualify. But the new rule means even if you have pancreatic cancer, HIV, or Parkinson’s, you will have to meet work requirements to maintain eligibility, or prove you are too sick to comply. Your doctor’s opinion won’t matter. It will be up to the bureaucrats.

Essentially, this amounts to navigating a process fashioned explicitly to kick people off the program. That means filling out forms and filing papers and hoping someone sitting at a desk determines you comply with a definition critics say is vaguely written and open to interpretation.

This is all part of a scheme hatched during the passage of the massively destructive Big Beautiful Bill last year. Trump and his MAGA cohorts wanted to give a trillion-dollar tax break to the top one percent. But the cuts were projected to add trillions to an already historically high federal debt.

The nonpartisan Congressional Budget Office projects the additional work rules will lead to 11.8 million people dropping Medicaid over the next decade — 7 million of whom they project will not find insurance elsewhere.

So, to conjure a so-called “pay for,” Republicans turned to Medicaid, the critical program that provides healthcare to the poorest Americans.

Simply slashing funding was politically unpalatable, even for the party best known for trying to dismantle Obamacare multiple times without providing a viable alternative. So Republicans came up with a workaround: make it more difficult to qualify.

In practice, that translated into the aforementioned new work requirements.

The medical frailty rule shows, in part, how this overarching plan will lead to fewer beneficiaries: create a complicated bureaucracy difficult to navigate, then cut people who can’t comply.

The nonpartisan Congressional Budget Office projects the additional work rules will lead to 11.8 million people dropping Medicaid over the next decade — 7 million of whom they project will not find insurance elsewhere.

And it won’t be millions of idle young men playing video games and refusing to work who are affected by the new rules, as House Speaker Mike Johnson suggested. Instead, as the CBO concludes, the burdensome paperwork and subjective standards will lead to most people simply dropping out, whether they qualify or not.

Democrats are pushing back hard against the regulation. In a letter to the Health and Human Services secretary, a group of Connecticut representatives argued that the rule exceeded the intent of the law.

“The overwhelming impact of this rule is that eligible citizens will be denied Medicaid coverage, states will expend unacceptable resources processing complex paperwork, safety-net providers will be further burdened, and population health will decline,” wrote Democratic Reps. John Larson, Joe Courtney, Rosa DeLauro, Jim Himes, and Jahana Hayes.

On the House floor, Courtney said vague standards and arbitrary rules would create confusion for critically ill people without care.

“The hope was that a medical diagnosis for cancer or HIV or other serious chronic conditions would qualify for protection. Instead the rule makes clear that a cancer diagnosis will not automatically qualify for an exception. Instead the patient will have to document that the disease actually impairs their ability to work,” he said.

“This rule will create chaos and dramatically increase the number of desperately ill people who will lose their coverage.”

We reached out to the Centers for Medicare and Medicaid Services, the agency that administers both programs. They have yet to respond.

In the meantime, if you’re skeptical that work requirements are mostly aimed at reducing the number of people on Medicaid, consider what’s happening with the federal government’s primary program for distributing food aid to low-income families.

The bureaucratic demands for SNAP are so extreme that some beneficiaries have been asked to provide documentation of money obtained from panhandling.

Known as SNAP, or Supplemental Nutrition Assistance Program, it’s been a frequent target for Republicans, who argue it’s rife with fraud and abuse. Those claims are exaggerated or unfounded — but, again, the Big Beautiful Bill imposed work requirements, and the consequences have been catastrophic.

A recent New York Times article reported that since the new paperwork requirements for SNAP were instituted in Arizona, nearly 440,000 recipients have lost assistance. The piece recounts how the bureaucratic demands are so extreme that some beneficiaries have been asked to provide documentation of money obtained from panhandling.

If this is what people receiving SNAP benefits have been subjected to, imagine what’s going to happen to people who will need to navigate the new Medicare requirements while struggling with a debilitating or terminal illness.

The point is that the same burdensome processes are combining to leave some of the poorest, sickest Americans facing death without care. That’s cruelty with a capital C. The frightening part is that it seems this administration is just getting started.

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