President Donald Trump's second term has made health care harder to obtain for many Americans, from efforts to dismantle the Affordable Care Act to backing Republican lawmakers' attacks on Medicare and Medicaid. Now a new report argues that millions of Americans will literally die because of these policies — and that the toll will arrive only once their votes for Trump are in the bag.

"When the Republican Congress enacted Trump's One Big Beautiful Bill in July 2025, it included massive cuts in the Medicaid program, totaling around $1 trillion over 10 years—but made sure to postpone them until 2027, conveniently after the midterm elections," wrote The New Republic's Norman J. Ornstein on Sunday. "The cuts focused on adding onerous work and paperwork requirements, all designed to force recipients off the rolls, and will remove somewhere between 10 and 15 million people from the program, leaving them without any health coverage. That is in addition to the millions losing coverage or facing huge premium increases with the erasure of subsidies for the Affordable Care Act."

The reach of those changes is broad: Medicaid, the federal-state program that states administer under federal rules, covers more than 70 million low-income, disabled, and older Americans — roughly one in five people in the United States. Under the new law, most able-bodied adults without dependents must document 80 hours of monthly work, schooling, or service, and states must recheck eligibility every six months instead of annually, the mechanics behind the projected enrollment losses. The nonpartisan Congressional Budget Office has projected that the law, combined with the expiration of the enhanced Affordable Care Act subsidies created in 2021 and set to lapse at the end of 2025, would leave close to 12 million additional Americans without insurance by 2034.

Ornstein added, "But the impact will go far beyond those directly losing their health insurance. Medicaid money does not go to Medicaid recipients. It goes to the providers. The loss of a major chunk of the money going out to them will have big reverberations."

After detailing how the cuts will harm hospitals and nursing homes in essential ways, Ornstein characterized the consequences as devastating to American patients. Under the hospital cuts, emergency rooms will be overtaxed while hundreds of necessary workers are thrown into unemployment. Patients will find it more difficult to receive care, even as health workers struggle to make ends meet. Medicaid is also a principal payer for rural hospitals, more than 100 of which have closed across the country since 2010.

The nursing-home exposure is similarly structural: Medicaid is the largest payer of nursing home care in the United States, covering the long-term care of the majority of nursing home residents. "As for the nursing homes, some will close; others will cut staff and staff pay," Ornstein wrote. "The ratio of residents to staff will decline, meaning residents unable to secure help when they need it for such vital tasks as getting medications when they require them, getting help going to the bathroom, getting help in bed to prevent bedsores or worse, having responsive care during a health trauma or emergency. More unqualified staff could mean more abuse of the residents."

How the requirements unfold is still to be settled: federal courts blocked an earlier round of Medicaid work requirements during Trump's first term, after Arkansas' 2018 version removed thousands of people from the rolls, and states will now need implementation plans that clear federal review before the new requirements take effect in 2027.

He concluded, "There will be more effects seen throughout the country, for everyone who is a part of our intertwined health care system, from those working in it to those using it. No wonder Republicans made sure none of the Medicaid cuts would happen before voters experienced the impact."

Referring to America as a "kakistocracy," or government run by the least competent and most corrupt, Ornstein opined that "it turns out that kakistocracy is not just a funny word, but a reality with horrific consequences."