Public health under Trump: The United States Senate has just approved what former president Donald Trump hails as a “big, beautiful bill.” Buried beneath the hyperbole is the deepest rollback of federal health support in modern times—one that independent analysts say will push nearly 17 million Americans off health insurance, hollow out Medicaid, and gut scientific research. For India, where public spending on health still hovers around 2 per cent of GDP and out-of-pocket expenses remain ruinously high, the American drama offers an unmistakable warning: austerity masquerading as reform can win headlines yet destroy lives.
Over the next decade the Senate measure pares almost a trillion dollars from Medicaid, Medicare and Affordable Care Act (ACA) subsidies. Congressional projections indicate that 12 million people will lose coverage by 2034 from these cuts alone. The bill also revives a stringent work-reporting rule: every adult in Medicaid expansion states must document at least eighty hours a month of employment or study. When Arkansas piloted a similar requirement in 2018, most beneficiaries who fell off the rolls were still eligible but failed the paperwork maze. This is less health policy than welfare theatre, and its punitive design will be felt in every rural county where Medicaid now finances one-fifth of hospital admissions and nearly half of all births.
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Public health sacrificed for tax relief
While legislators haggle over insurance, the administration has terminated or suspended thousands of research grants—worth several billion dollars—across oncology, virology, mental health and basic science. The National Institutes of Health (NIH) faces a freeze that threatens its global leadership, while the Centers for Disease Control and Prevention (CDC) has lost personnel tasked with tracking pandemics, lead poisoning and opioid overdoses. A handful of court orders have restored selected grants, yet the wider damage is already visible: laboratories mothball projects, post-doctoral fellows seek visas abroad, and pharmaceutical pipelines slow.
Cuts of this magnitude do not remain confined to spreadsheets. With profit margins already wafer-thin, rural hospitals rely heavily on Medicaid reimbursements to keep emergency rooms open. The Senate bill sets aside a one-off $25 billion rural health stabilisation fund, but the permanent funding losses dwarf that cushion. Closure of even a handful of critical-access hospitals cascades into longer travel times, delayed treatments and spikes in maternal mortality—outcomes that sting red-state voters who otherwise champion fiscal restraint.
Republicans paid a steep political price after their 2017 attempt to repeal the ACA; the 2018 mid-terms delivered the House of Representatives to the Democrats. Polling today shows the new bill is similarly unpopular, yet its architects calculate that the benefits of tax cuts will overshadow the abstract threat of lost insurance. Whether that wager holds will be revealed at the ballot box, but the immediate fallout for America’s most vulnerable is not in doubt.
Lessons India must heed
Like the United States, India runs a patchwork of programmes—Ayushman Bharat at the Centre, multiple state schemes, Employees’ State Insurance for the organised sector and private covers for the affluent. Fragmentation invites both duplication and political gaming: a single scheme can be attacked, defunded or reshaped to serve ideology. A constitutionally backed Health Council on the lines of the GST Council could pool risk, harmonise benefits and protect funding from annual swings in mood or ministry.
Trump’s work-reporting rule exposes how bureaucracy can expel eligible families. Indian policymakers flirt periodically with ideas such as monthly Aadhaar-linked income verification for Ayushman renewals. Any move in that direction would punish migrant households and informal-sector workers who already struggle with documentation. Universal systems thrive on simplicity; complexity merely enriches middlemen.
India’s biomedical ecosystem lacks deep pockets: the Indian Council of Medical Research works with a budget that is only a sliver of NIH’s. Sustained, ring-fenced funding is not a luxury but a hedge against future pandemics and lifestyle diseases. A National Health Research Fund capitalised by a modest cess on luxury travel, high-end insurance and sin goods—matched by private philanthropy—would insulate laboratories from yearly budget volatility and keep young scientists at home.
Spend more—and spend wisely
At 2 per cent of GDP, public health expenditure is inadequate for a nation of 1.4 billion. Doubling that ratio to 4 per cent by 2030 is feasible if government prioritises primary and secondary facilities over headline-grabbing tertiary subsidies. Every district hospital must be equipped for essential surgeries, comprehensive obstetric care and tele-medicine links, so that citizens are not forced into costlier private wards for routine ailments.
Portability remains the Achilles heel of state-based schemes; patients moving across borders often discover their coverage is worthless. Automatic enrolment at birth, a single biometric identity and nationwide portability would transform Ayushman Bharat from a patchwork safety net into a genuine social contract. Direct-to-provider payments and standard claim forms would cut overheads and curb fraud without erecting new barriers to entry.
The American reversal on health coverage and research is a cautionary tale, not a blueprint. Fiscal rectitude need not collide with social justice, but it certainly does when reforms are weaponised to finance tax cuts at the expense of the poor and the sick.
India can either emulate an experiment that hollows out the very foundations of public health or chart a course that invests in people, integrates schemes and insulates science from partisan tempests. The price of getting it wrong is counted not merely in rupees and percentages but in shortened lives and squandered human potential.