The slang definition of “unwinding” means “to chill.” Other definitions include: to relax, disentangle, undo–all words that, on the surface, appear both passive and peaceful. And yet in Google searches involving such seemingly harmless definitions of decompressing and resting, news articles abound about the end of pandemic-era Medicaid expansion programs–a topic that, for the millions of people now without healthcare insurance, is anything but relaxing.
Imagine this: since March 2023, 16 million Americans–yes, that’s right, 16 million–have lost healthcare coverage, including four million children, as states redefine eligibility for Medicaid for the first time in three years. Worse yet, the nation is only halfway through the largest purge ever of Medicaid as the expansion and extension of healthcare to millions, brought on by the Covid-19 pandemic, have ended, leaving some families no longer eligible, while others need to reapply through a new process in their state.
This thrusting of tens of millions of Americans out of the national healthcare system at a moment when healthcare outfits, pharmaceutical companies, and health insurance corporations are making record profits has been termed “the great unwinding.” And it couldn’t be more cruelly ironic. After all, states have the power and authority to expand healthcare to all their residents; the federal government could similarly extend the declaration of a public health emergency that would let so many of us keep distinctly life-protecting access to healthcare. Yet millions have instead been pushed violently and rapidly from such life-saving care.
Some states are feeling the impact especially strongly. In Georgia, for instance, more than 149,000 children lost their pandemic Medicaid enrollment in just six months. Perhaps unsurprisingly, Texas is the epicenter of Medicaid’s unwinding. There, more than two million Americans have been removed from the state’s Medicaid program since federal pandemic-era coverage protections were lifted last April. As Axios reported, new state data indicates “that’s the most of any state and nearly equivalent to all of Houston–Texas’ most populous city, with 2.3 million residents–losing coverage in less than a year.” In fact, 61% of enrollees in Texas have lost Medicaid since last April.
Death by Poverty and the Lack of Healthcare
In my home state, policy analysts predict that more than 1.1 million New Yorkers will be pushed off Medicaid roles in this same unwinding. Fortunately, people are organizing in response, calling for the right to healthcare, living wages, the abolition of poverty, and more.
On Saturday, March 2nd, I stood next to Becca Forsyth of Elmira, New York, at the Poor People’s Campaign’s Mass Poor People and Low Wage Workers Statehouse Assembly in Albany, New York. Becca was one of dozens of low-income people who testified at simultaneous assemblies held in 31 state capitals and Washington, D.C. These assemblies launched 40 weeks of the mobilizing and organizing of poor and low-income eligible voters in the lead-up to the 2024 elections, while challenging those running for office, as well as elected officials, to confront poverty as the fourth-leading cause of death in America. Becca was not the only speaker to touch on the crisis of healthcare (and its connection to poverty and death), but her words stuck with me:
Just since December 19th, I have lost more than a dozen people I loved dearly. In 74 days, I’ve watched as people I’ve known most of my life were literally squeezed to death by poverty and the catastrophic impact it has on our entire lives. People like Missy, a 47-year-old woman who was found lying beside the railroad tracks, dead… Or Gary, who died at the hands of the police while in a hospital for a mental breakdown. Or Loretta, a friend who was a friend before I even knew what the word friend meant, who is no longer with us because my community won’t spend money on substance-use treatment. Chemung County leads this state in way too many negative ways. We rank 59 out of the 62 counties in New York for health outcomes. We have outrageous homelessness, food insecurity, premature death rates, and lead poisoning. Our chances for getting out of poverty are extinguished before we even have a chance!
Just two days before I stood with Becca in Albany, the state capital, demanding the right to thrive and not just barely survive, I rallied with healthcare workers and community members at SUNY Downstate Hospital. With the support of New York Governor Kathy Hochul, SUNY Chancellor John King recently announced that his outfit may close SUNY Downstate Medical Center in Brooklyn, New York, one of the few remaining public-safety-net hospitals in the state.
At that rally, community members, hospital workers, local politicians, and faith leaders shared information about the crucial role that hospital has played in the community. It served as a Covid refuge where thousands of lives were saved in the heat of the pandemic, as a critically safe birthing place for Black moms (crucial given the maternal health outcomes for so many women of color), as the only kidney transplant hospital in Brooklyn, and as one of the only remaining teaching hospitals in the area after the closure of such facilities, particularly in impoverished neighborhoods, across Brooklyn and the rest of New York.
Sadly, closing down hospitals or reducing their services in poorer neighborhoods is becoming all too typical of this nation. Big conglomerates are buying up chains of them and making decisions based only on their bottom lines, not the needs of our communities. In fact, more than 600 rural hospitals are now at risk of closing due to financial instability and that’s more than 30% of America’s rural facilities. For half of them, the possibility of closure is immediate, according to a new report from the Center for Healthcare Quality and Payment Reform (CHQPR).
Our Unwinding Health
Such Medicaid cuts and hospital closures are but two manifestations of a far larger attack on American health and healthcare in what’s fast being transformed into a death-dealing nation. They are but harbingers of an even larger “unwinding” of our health as a nation. Before the pandemic and the most recent cuts, 87 million Americans were already uninsured or underinsured. We’re talking about people sharing heart-attack medicine because they can’t afford their own prescriptions, burying their children for lack of healthcare, and relying on emergency rooms rather than preventative care, while going bankrupt in the process.
It’s simple enough. All too many of us are skipping needed care. In 2022, more than one of every four adults (28% of us) reported delaying or going without some combination of medical care, prescription drugs, mental healthcare, or dental care simply because they lacked the ability to pay.
Meanwhile, medical debt is growing all too rapidly. A Census Bureau analysis of such debt found that, in 2021, 15% of all American households owed medical debt–or 20 million people (nearly 1 in 12 adults). Indeed, the SIPP (Survey of Income and Program Participation) survey suggests that, in total, Americans owe at least $220 billion in medical debt, the biggest source of bankruptcy in the nation.
And of course, as I’ve written before, this is all connected to another reality: that life expectancy is down for everyone, while the poor can expect to die, on average, 12 to 13 years earlier than rich people. Worse yet, the death-rate gap between rich and poor in this country has risen by a staggering 570% since 1980. As the Washington Post reported,
America is increasingly a country of haves and have-nots, measured not just by bank accounts and property values but also by vital signs and grave markers. Dying prematurely has become the most telling measure of the nation’s growing inequality.
Poor Health
In the face of all of this, you might wonder how things could get any worse. Recently, Congress announced potential cuts to another crucial food and health program for the poor. The Special Supplemental Nutrition Program for Women, Infants, and Children (known as WIC) is at risk of a $1 billion shortfall, essentially guaranteeing harmful cuts to that lifeline for low-income families and children. If Congress refuses to fully fund the program, current funding levels simply won’t cover all eligible participants.
In fact, the $1 billion shortfall now slated to occur equals 1.5 months of benefits for all program beneficiaries or six months of benefits for all pregnant women and infants participating in WIC. House Republicans are currently refusing to approve the budget for this vital program that helps mothers and children up to age five access staples like fruit, vegetables, and infant formula, and connects them to healthcare resources.
In a statement to NBC News, Agriculture Secretary Tom Vilsack called WIC, “one of the most consequential, evidence-based public health programs available.” He implored Congress to fully fund the program, which provides “life-changing benefits and services” to its participants.
And Vilsack is anything but wrong when he speaks of the importance of that pro-poor, pro-health program. An abundance of research suggests the critical role that WIC plays in “supporting maternal health and child development. WIC participation during pregnancy is associated with lower risk of preterm birth, lower risk of low birth weight, and lower risk of infant mortality.” Children on WIC are more likely to consume a healthier diet, and this impact only grows the longer a child stays in the program, which also has a significant reach. As the Department of Agriculture reports,
Nearly 40 percent of America’s infants participate in WIC, which is available only to pregnant women, new mothers, infants, and children who meet income guidelines and are determined to be at nutritional risk by a health professional.
So Much More Is Needed
But as such programs are cut to the bone and more people experience a plethora of problems already plaguing the health of the nation, many are likely to give up entirely, assuming there’s nothing to be done and that it’s just too costly to address inequality and poor health. As someone who has been organizing among the poor for more than 30 years, however, I want to suggest that, as a nation, this just can’t be as “good” as it gets.
Across the span of my lifetime, there have been debates about how to address the larger health crisis in American society. When I was in high school, there was already debate about the effectiveness of establishing a national healthcare program, as President Bill Clinton and Hillary Clinton campaigned on expanding healthcare and actually proposed a new plan for it in 1993. At the time, I remember hearing criticism of the Canadia n system of nationalized healthcare. People there, it was said, experienced long lines, way too much paperwork, and a lack of options for patients.
Today, considering the way our healthcare system is unwinding, I could almost laugh (however grimly) at what it would mean to have that Canadian system of years past. All too sadly, however, that country has followed the United States in cutting and privatizing its healthcare system.
Many consider the Affordable Care Act (ACA) one of the most important policies adopted under the presidency of Barack Obama, given that more than 20 million people gained health coverage through it and the ACA’s policies made it easier for eligible people to enroll in Medicaid. In particular, the ACA expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($20,783 in 2024) and helped states with matching federal dollars expand Medicaid to more of their residents. Yet the ACA didn’t go nearly far enough. To date, 40 states and Washington, D.C., have adopted Medicaid expansion, while 10 states have not. Even in states with Medicaid expansion, too many of us are still not covered. And now we’re witnessing one of the greatest attacks on health and healthcare in decades (and just imagine what we’re likely to face if Donald Trump becomes our next president and/or the MAGA Republicans take Congress).
What this nation truly needs is a complete overhaul of its healthcare system. As a start, Medicaid needs to be expanded, extended, and built into a single-payer, universal healthcare plan. Workers need the right to living-wage jobs with generous benefits, including guaranteed paid family sick leave. Social welfare programs like the Supplemental Nutrition Assistance Program, WIC, and the Child Tax Credit need to be strengthened so that the abundance of this society is experienced by everyone. Household and medical debt would have to be cancelled, while drug-recovery programs would need to be fully funded. And parks and recreation centers, as well as grocery stores with quality, affordable food, would have to proliferate, starting in poor communities.
It’s not enough to protest the unwinding of pandemic Medicaid programs. Even that classic protest chant–“They say cut back, we say fight back!”–doesn’t go far enough. Instead, the 135 million poor and low-income Americans, and for that matter, the rest of us, must make healthcare and so much more into basic human rights.
Let me end then not with words of mine but with Becca Forsyth’s challenge to Americans in her Poor People’s Campaign testimony that day in Albany. “We must stop this raging storm of policy violence that is killing our friends and neighbors,” she said movingly.
It doesn’t have to be this way! We can wield our votes as powerful demands. The time for sitting on the sidelines is over. We have to move forward together like our lives depend on it… the lives of our children! Because they do!!
How right she is!
Liz Theoharis, a TomDispatch regular, is a theologian, ordained minister, and anti-poverty activist. Co-chair of the Poor People’s Campaign: A National Call for Moral Revival and director of the Kairos Center for Religions, Rights and Social Justice at Union Theological Seminary in New York City, she is the author of Always With Us? What Jesus Really Said About the Poor and We Cry Justice: Reading the Bible with the Poor People’s Campaign.