If you’re trying to make sense of US healthcare under Trump 2.0, buckle up. The second Trump administration has taken a sledgehammer to the health policy landscape, mixing in Elon Musk’s tech-heavy vision, Robert F. Kennedy Jr.’s vaccine skepticism, and Trump’s signature flair for deregulation. The result? A healthcare system staring at big shifts in coverage, funding, and trust.
At the heart of the administration’s plan is HR1, the so-called One Big Beautiful Bill. The legislation slashes subsidies for Obamacare marketplaces and tightens Medicaid eligibility. Sherry Glied, Professor of Public Service at NYU’s Robert F. Wagner Graduate School of Public Service, didn’t mince words:
“Analysts indicate that the loss of enhanced premium subsidies will mean that a 55-year-old in Wyoming with earnings of about $63,000 annually will see a premium increase of at least $12,790. Many people will forego coverage at these premiums.”
That’s not small change—it’s the difference between being insured and going without for many families. And while Wyoming never expanded Medicaid, Glied notes that new rules will still make it harder for residents to qualify for and keep coverage.
Matthew Fiedler, the Joseph A. Pechman Senior Fellow in Economic Studies and a senior fellow with the Center on Health Policy at the Brookings Institution, echoed the alarm bells, projecting that around 15 million more Americans could end up uninsured because of Trump’s changes:
“The uninsured rate has never risen as far, as fast as we appear likely to see in the years ahead. This reduction in insurance coverage will be consequential. We have clear evidence that people who lose their coverage because of these policy changes will be less financially secure, have more trouble getting the care they need, and ultimately be in worse health. Many others who retain their coverage will pay more for it. The administration has also announced some notable changes to Medicare policy. The administration has announced plans to tighten certain audits targeting Medicare Advantage plans, expand use of prior authorization in traditional Medicare, and make broader use of “site neutral” payments for certain outpatient services.”
The pain won’t be evenly distributed. Rural America is set to take the hardest hit. Medicaid cuts are especially damaging for small hospitals, which rely on the program for a disproportionate share of revenue. Ateev Mehrotra, the chair of the Department of Health Services, Policy, and Practice at the Brown University School of Public Health, spelled it out:
“Unfortunately the cuts to Medicaid under the OBBB will imperil the financial health of rural hospitals. Many rural hospitals were already struggling to stay open. Given they differentially care for patients with Medicaid, they will have to care for more uninsured patients. The Rural Health Transformation Program is supposed to help with rural healthcare, but I’m unsure whether it will be enough.”
Translation: expect more rural closures, which means fewer ERs, fewer maternity wards, and longer drives for basic care.
Trump’s restructuring of the Department of Health and Human Services (HHS) has only added to the turmoil. The White House created the “Make America Healthy Again Commission” while reshuffling entire agencies under what’s now known as the Department of Government Efficiency (DOGE).
Critics argue this is more about politics than efficiency. Senator Patty Murray described it as “hollowing out HHS” in a way that threatens Americans’ health and wellbeing. Democratic lawmakers warned that the move is likely illegal and “an attempt to dismantle federal health protections.”
RFK Jr., now serving as Health Secretary, has leaned into his anti-vaccine reputation. Under his leadership, the CDC and FDA are bleeding experienced staff, raising alarms about preparedness for the next pandemic. Glied pointed to an early warning sign:
“The COVID vaccine is now only approved for people 65+ and those with certain pre-existing conditions. But that means that caregivers and family members of this high-risk population — who may themselves be healthy — won’t be able to get the vaccine to protect their loved ones if they choose to do that. That’s just the first decision we’ve seen — the risks will only grow from here.”
Not all of the administration’s changes are purely cuts. The Trump team has announced tweaks to Medicare that could, on paper, improve efficiency. These include expanding prior authorization in traditional Medicare, tightening audits of Medicare Advantage plans, and moving toward “site-neutral” payments.
As Fiedler notes, these reforms could save money and streamline care—but only if implemented with precision. Given the broader chaos, that’s a big “if.”
For Trump, Musk, and RFK Jr., the healthcare shake-up is framed as a necessary disruption—a war on bureaucracy in the name of efficiency and freedom. For critics, it’s a dangerous gamble that leaves millions more uninsured, destabilizes hospitals, and weakens the very agencies meant to keep Americans safe in a crisis.
One thing is clear: the second Trump term marks one of the fastest reversals of health coverage gains in US history. Whether that gamble pays off in innovation or ends in public health disaster will be a defining question of the next four years.
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