Pantsuits and Lawsuits with Attorneys General Kris Mayes and Dana Nessel

The $625 Billion Cut That Could Break America's Healthcare System

• Attorneys General Kris Mayes & Dana Nessel • Season 1 • Episode 9

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The fight for America's health and wellbeing takes center stage as we tackle the most alarming proposals coming from Washington. Attorneys General Dana Nessel and Kris Mayes break down their ongoing legal battles against unconstitutional actions by the Trump administration – revealing why they've each filed over 15 lawsuits (and won most of them).

Our candid conversation explores the real-world consequences of federal budget cuts already taking effect across America. From overflowing toilets at the Grand Canyon to park facility closures at Sleeping Bear Dunes, national treasures are deteriorating before our eyes. Meanwhile, vital nonprofit organizations that feed vulnerable populations face extinction as funding disappears.

The heart of our episode features Georgetown University's Joan Alker, who delivers a masterclass on Medicaid's essential role in American healthcare. As Republicans propose slashing at least $625 billion from Medicaid – the largest cuts in history – Alker explains who stands to lose the most. Did you know Medicaid covers 40% of all births nationally and nearly half of all births in rural communities? Or that it's the primary funder of long-term care for seniors and covers almost half of all children?

We examine how these proposed cuts would devastate rural healthcare systems already struggling with provider shortages and hospital closures. Alker also dissects the problematic "work requirements" some states have tried implementing – revealing shocking statistics about how they've increased bureaucracy while causing thousands to lose coverage.

What makes this episode particularly powerful is the bipartisan concern emerging around these issues. As Nessel notes, people across the political spectrum are showing up at town halls worried about these changes. The message becomes clear: speaking up works, whether through contacting representatives, writing op-eds, or joining local meetings.

Join us for this urgent conversation about protecting the programs that make America healthy. The time to make your voice heard is now.

Attorney General Kris Mayes:

Welcome back to another episode of pantsuits and lawsuits, your one-stop shop to find out what you need to know about the most pressing legal topics impacting America today, and it's great to be back with you, Dana.

Attorney General Dana Nessel:

It's great to be back with you, Kris. You know it's hard to keep track because I know every time we get together we talk about some of the latest and greatest lawsuits that have been filed by the Democratic AGs against the Trump administration. But it's like when we say that we'll sue Donald Trump and his administration every day if we have to I don't think everyone knew that we were being so literal about that, but it's turned out to be a lot of litigation. But I think we should be really clear about it. It's because there's so many illegal actions by the administration that allows us to file these lawsuits Even oftentimes, of course, for things that he could do legally if he chose to. He just doesn't want to.

Attorney General Kris Mayes:

Well, I think that's really the point, and I get that question a lot too, which is you know, Kris, how many times are you going to sue Donald Trump? And my answer always is I'll stop suing Donald Trump and Elon Musk and Doge when they stop doing unconstitutional things, and Elon Musk and Doge when they stopped doing unconstitutional things. And they could try I'm not sure they would succeed with many of the things they're doing, but they could try to do them the constitutional way by going to Congress, and I think obviously one of the reasons that we're having so much success with these lawsuits I think we're both up in the 18 lawsuit range. In almost all of those, we've achieved a temporary restraining order or a preliminary injunction, which is a lot of winning. That's going on.

Attorney General Dana Nessel:

Yeah, and I think what's interesting too is we are seeing in a lot of cases where you have an action or a proposed action that the administration is going to take and when they get enough pushback, sometimes they just drop it altogether. And it's really an important and valuable lesson. Whether I'm having town halls, which I know you're doing, many of those-

Attorney General Kris Mayes:

I see you out there on social media.

Attorney General Dana Nessel:

We are, but we're also doing now smaller meetings with specific stakeholders. So let me just tell you, I went up to Traverse City this last weekend and on Saturday and Sunday. First of all, we worked with a coalition of folks representing libraries and museums.

Attorney General Dana Nessel:

And obviously we know what's happened there. We talked to a bunch of people who are, I should say were employed with AmeriCorps, talked about their work, and we also went to, you know, sleeping Bear Dunes, the national park that I always talk about, and we talked to- I couldn't get anybody who works there now, but I got the former director of the park to sort of walk through with me what was happening at the park as a result of funding cuts and the.

Attorney General Dana Nessel:

You know, the one thing that I was hearing over and over again is that people were afraid to say anything because they thought it would only make the situation worse.

Attorney General Kris Mayes:

Yeah, right

Attorney General Dana Nessel:

, but what I think we've both seen is that actually speaking up can cause the administration to change their mind, and sometimes it's because they lose in court and then they don't want to proceed because they don't see a pathway for them legally. But many times as well, the administration just gets so much opposition, including from other Republicans, that they see it's not viable politically anymore.

Attorney General Kris Mayes:

Yeah, I mean, I mean that's a really good point and it is why I mean it's our job to stand up for the people of our states, to stand up for the Constitution but also, you know, the rule of law. But I'm hearing the same things that you're hearing. We have done, I think, 11, I've done 11 total town halls, most of them in Arizona, a couple in other states. But up in Flagstaff, where we had 250 people turn out, we had a few workers from the Grand Canyon National Park turn out and talk about like one woman, one ranger spoke about the fact that they have laid off so many people that in the campground, one of the campgrounds, the toilets are literally overflowing with crap which is a public health issue.

Attorney General Dana Nessel:

Right, it is a public health issue. And actually, when I spoke to the park rangers at Sleeping Bear Dunes, they said that there were going to be a number of their facilities they were going to have to close down altogether because they just simply didn't have the summer workers to maintain them. So they were going to close them. Which means, you know, now, for a lot of people that want to be able to enjoy that park but also maybe don't want to have to dig a little ditch for themselves, you know they're just not going to go, rather than have that kind of experience. And the problem is, you know, as this former director relate to me, is that you know, word of mouth travels fast and if people are like I went to that national park, it was a complete mess the the trails were not properly cut and the restrooms were unusable. You're not going to go.

Attorney General Kris Mayes:

No, or it took. It took me four hours to get into the Grand Canyon National Park because they didn't have enough people at the entrance to let people in or they couldn't. No, you're not going to go. And then not only does that disrupt the experience of the people who want to go to our national parks, which belong to the people of America, but it also affects the economies around the parks.

Attorney General Dana Nessel:

And you're also talking about the massive defunding of all our nonprofits, right, because nonprofits?

Attorney General Dana Nessel:

Usually they're sustained from federal grants, state money and then, of course, whatever contributions people have.

Attorney General Dana Nessel:

Well, if people aren't making any money, those donors are going to close their pocketbooks. They're not going to be contributing the state. You know, in Michigan, 42% of our budget, of our state budget, comes from the federal government. So now they're not going to have the money to provide grants to these nonprofits, and nonprofits provide so many services to people that I don't think people fully understand or grasp. And even talking to those AmeriCorps workers, you know many of them are involved in a lot of these food sustainability programs, right, yeah, they're the ones that are feeding people in impoverished areas and growing the food and distributing the food for them the food banks, the food pantries and also Meals on Wheels. We are literally talking about starving people to death. It is that significant. Here we are in one of the wealthiest countries in the world and we're going to have a significant number of people who literally won't be able to have food to eat because of these cuts made for literally absolutely no reason at all.

Attorney General Kris Mayes:

It's insane. That doesn't even speak to the disruptions to Social Security that we have been seeing, although, as you pointed out, it looks like the Trump administration may have backed off a couple of the things that they were doing to disrupt Social Security. We'll see what that looks like. And then we have Medicaid, which is what we're talking about on this episode. I mean, it feels like the perfect storm in all the worst ways, when you put together the cuts to the federal agencies, the cuts to grants to nonprofits, the cuts, the problems with Social Security, profits, the cuts, the problems with Social Security, and then you layer on top of that the proposed cuts to Medicaid, which are enormous, I think, nationally. The latest proposal that Congress, the Republicans in Congress and Trump are looking at would gut Medicaid by upwards of $715 billion in order to provide a $4 trillion tax break for the wealthiest Americans, and I think it's important to note also that it would balloon the deficit and our debt.

Attorney General Dana Nessel:

And in Michigan. I mean, we're talking about between 700 to 750,000 Michiganders who are going to lose their health insurance should this big beautiful bill be passed. And just as the time of this taping, you know, there's the president trying to strong arm the members of his own party who, I think, see the writing on the wall, the wall and they just absolutely know like they're not going to be back again after the 2026 election, in the event that they go through with this, because it's going to impact so many of their constituents. And even talking about it from an economic perspective, people who aren't healthy can't work. Yeah.

Attorney General Kris Mayes:

I mean, I don't know how this makes America healthy again. Dana Like this is not Maha. This does not make America healthy again to strip people of their health insurance.

Attorney General Dana Nessel:

I just think it's important that we make this point to everybody. You know who is listening to this or sharing it, but the only thing that actually works is speaking out.

Attorney General Dana Nessel:

And you know you again.

Attorney General Dana Nessel:

If you're somebody who supported this president, it doesn't matter.

Attorney General Dana Nessel:

If you see what's happening now and you see that it's hurting yourself and your family and the members of your community, it is more important than ever to say this is bad for people in my state, this is bad for people in my community, for all of these many different reasons, and to keep it up to call your congressional representative, to call your US senators, to call your state electeds, to call everybody that you can to do, whether you're doing op-eds in the local paper, whether you're filming a video on Instagram and circulating it amongst all the people that you know, whether you're going to local city council or county commission meetings and you get your three minutes and you wait through the meeting and your three minutes is talking about hey, I want everyone to understand how bad this is for this town.

Attorney General Dana Nessel:

It's important to make your voice heard because it is actually making a difference and, yes, our lawsuits make a difference. But this is an all hands on deck situation, right where we have to try everything. We have to try, you know, talking to our representatives and congressionals. We have to, you know, file these lawsuits and we have to be really loud and talk about how we want to preserve all the things that make America great for us, and that includes, of course, us having health insurance, which everybody deserves.

Attorney General Kris Mayes:

People are coming to our town halls who are not, who are, who are Republicans, independents and Democrats, and I think that is a good thing. I think that's frankly a beautiful thing, and I'm going to keep doing my town halls and meetings as long as people will come in and listen to me.

Attorney General Dana Nessel:

Absolutely. These conversations matter.

Attorney General Kris Mayes:

They do Well. Hello everybody. We are talking today to Joan Alker, who is the executive director and co-founder of the Center for Children and Families and a research professor at the Georgetown University McCourt School of Public Policy. Joan is a nationally recognized expert on Medicaid and the Children's Health Insurance Program, CHIP, and she's going to give us some insights into how these proposed Medicaid cuts would affect the health care landscape nationwide, especially for children and in small towns and rural communities. So welcome, Joan. Thank you so much for joining me.

Attorney General Kris Mayes:

Dana couldn't be with us for this interview, but she sends her regards and thank you for being with us and for being willing to talk to us about this incredibly important topic. So I guess what I would love to start with is, as we know, oftentimes when we're talking about Medicaid the conversations get sort of bogged down in statistics. It can sort of start to feel very wonky very quickly, but health care and insurance are, in all honesty, really deeply personal topics, incredibly important to all of us, and it's so taboo sometimes that folks don't often discuss the reality of Medicaid with their friends and neighbors. Even so, help us set the record straight how do Americans qualify for Medicaid and who does Medicaid serve today?

Joan Alker:

Sure Well, thanks so much for having me.

Joan Alker:

It's a pleasure to be here and you know I often say Medicaid is the backbone of the United States health care system.

Joan Alker:

It's performing many, many different functions and it's actually doing things that other parts of our health care system aren't doing.

Joan Alker:

So I'll talk first with how does Medicaid serve seniors and, of course, Medicaid not to be confused with Medicare, which is the primary health care program for seniors and people with disabilities in some instances, but Medicare does not cover long term care. So that is a very, very important function that Medicaid is playing in essentially making Medicare work for seniors in our country and families and older adults who need long term care. Both Medicaid is paying for the majority of folks in nursing homes. Medicaid is also supporting home and community based care for seniors and people with disabilities and it's also paying the cost sharing for the 20% of the poorest seniors on Medicare, because those deductibles and co-pays can get pretty high if you're on a fixed income and it's low. So at the other end of the spectrum of life, Medicaid is the most important public payer for births and paying for over 40% of births nationally and in rural communities, paying for almost half of all births.

Attorney General Kris Mayes:

Wow, that's a statistic.

Joan Alker:

Yeah, and then Medicaid is doing lots of things in between. So Medicaid and its sister program, CHIP, is covering almost half of children in the United States, so it goes beyond low income to moderate income families because there's higher eligibility for children. And then, of course, medicaid is covering lots of people with disabilities and lots of low wage working adults and parents

Attorney General Kris Mayes:

Wow, you know, it's just a really important point. I think that you make that so many Americans rely on that. Toward the end of our lives, and especially as we live longer or we experience illnesses like Alzheimer's, this becomes all the more important that we have this safety net.

Joan Alker:

Yeah, absolutely, and of course we have an aging population in this country, and so the need for long-term care is going to grow.

Attorney General Kris Mayes:

And I guess in Michigan the statistic is that more than 2.6 million Michiganders are on Medicaid. Over 200,000 Medicaid-enrolled providers are in Michigan, and that includes 1 million children. And I think we have some Arizona statistics here too: nearly 2.2 million Arizonans are enrolled in Medicaid, which is what we call ACCESS or kids care, which is our CHIP program, with 93000 Medicaid enrolled providers. So I guess would it be fair to say that's not unusual for states and other states would have a similar story to tell.

Joan Alker:

Yeah, they would certainly. On the children's side of the equation, because, I mentioned, medicaid is covering between 40 and 50 percent of children nationwide. That does vary by state, but it's incredibly important program along with CHIP for kids and, of course, if states have picked up the Affordable Care Act, medicaid expansion for adults, which both Arizona and Michigan have. It's a more important source of coverage for parents and low-wage working adults.

Attorney General Kris Mayes:

That's a great point. So we keep hearing about how these cuts would have an outsized impact on rural communities, and I think you've sort of spoken a little bit to this already. But why is that? And then why should Americans who don't live in a small town care about health care capabilities and other less populated parts of the country?

Joan Alker:

Yeah. So this is a project we've been working on for about 10 years now, looking at Medicaid's role in rural communities and small towns, and you know we've already talked about Medicaid is incredibly important for everywhere, Every. There's no part of the country. There's not many families around that are very far removed from Medicaid for one reason or another But as important as Medicaid is for our health care system more generally, it's even more important for rural areas and small towns and I think folks you know maybe think, oh, you know, this is more like people in cities who rely on Medicaid. Well, that's actually not true.

Joan Alker:

There's a higher rate of Medicaid being your health insurer if you live in a rural community, small towns, if you are a child or if you're a non-elderly adult, and so we've been looking at this data for some time and it's interesting because the ACA Medicaid expansion, which is very much under attack right now in Congress, has been really important for rural communities under attack right now in Congress has been really important for rural communities and you do see these higher shares, both in terms of children we talked about births up front, higher percent of births covered in rural areas and the reality is that rural areas and small towns are already struggling with access to health care. Right, I mean they. There have been rural hospitals have been closing. We have a new report coming out in a couple of days looking specifically women of childbearing age in rural communities, and that is critical because rural communities have lost labor and delivery units. They've lost obstetric services capacities in those rural hospitals. So if there's nowhere to have a baby safely, it's really hard for a community to grow and thrive.

Attorney General Kris Mayes:

Can you speak more to the provider shortage in rural America, like what is going on with that, because that is definitely something, like I said, that we've seen here in Arizona.

Joan Alker:

Many, many communities have been facing these provider shortages, and that's a huge problem that needs to be addressed. This is exactly why we worry so much about these Medicaid cuts and their impact on rural communities, because not only do they have these provider shortages already, they also have, and one of the reasons why rural communities do rely on Medicaid more is because they tend to have lower income. Right, they're just not doing as well and they have more people who are aging, they have more people with disabilities, so they have a profile of folks who really are going to have to rely on Medicaid. So there are ways to look at things like telehealth. You know other ways to try to rely on Medicaid, so there are ways to look at things like telehealth. You know other ways to try to address some of these provider shortages, but that's not going to help when you have a heart attack or you want to have a baby.

Attorney General Kris Mayes:

Well, let me back up a little bit and go to some of these proposals for Medicaid cuts. As you're looking at this, what in your mind is the worst case scenario and what would it mean to our states if Congress were actually to do it?

Joan Alker:

Well, a timely question, because Congress is literally working on this right now, as we're taping this, and the Congressional Budget Office, which is the nonpartisan kind of scorekeeper, just released some information and I have to say it's actually incomplete. It doesn't cover all of the cuts in the bill. The Republicans are moving cuts in the in the bill the republicans are moving, but so it would be at least 625 billion dollars of cuts over the 10-year period in medicaid, and it's, it's more than that. We don't have a complete number yet

Attorney General Kris Mayes:

wow

Joan Alker:

yeah,

Attorney General Kris Mayes:

$610 billion , with a b?

Joan Alker:

$625 billion correct

Attorney General Kris Mayes:

wow, and and what is that? What does that look like? What does that mean?

Joan Alker:

Yeah. So you know I'll say I've been working on Medicaid for a couple of decades now. This is definitely by far the largest cut and attack on Medicaid that I've ever seen. There are ways that Congress is going about this. As you can imagine, it's very complicated. Medicaid policy is very complicated and there's been an interesting dynamic within the Republican Party because the Republicans are very nervous about this. Ok, we should be.

Joan Alker:

We've had the president's own pollster, Tony Fabrizio, come out and say don't cut Medicaid. You know and have some polling data to indicate that voters of all political stripes do not want Congress to cut Medicaid. It's like literally the last thing they want, but yet Congress is moving ahead to cut Medicaid. There's kinda something in here for everyone to get hurt in terms of states, there's a variety of proposals. Quite a few of the proposals are kind of a direct attack on people who are getting coverage through the ACA Medicaid Expansion, like the work requirement, which we can talk about. But there are also proposals in here, them some of them they haven't t of e t Quite 't even estimated the the cuts yet that are really complicated about changing the way states raise their share. So states this is a federal state matching program, so states put up their money and they draw down the federal money. So some of the proposals that they're considering limit the ways that states can raise their share and so those kind of proposals are going to hit all states really red states, blue states, even if you've done Medicaid expansion under the ACA or not. So there are lots of things in here. Obviously the impact will vary state by state, but all states I would say

Attorney General Kris Mayes:

Wow, that's just stunning. Hard to believe, but it seems like they are at least trying to head down that path. It's it's catastrophic. So could you talk about that work? Proposed work requirement. So these are the proposed work requirements for Medicaid beneficiaries. Have measures like that been attempted in the past? How did that play out? And then, what are some of the unintended consequences of forcing sick people into the workforce?

Joan Alker:

Yeah. So this has been a big topic of discussion, I'd say, since President Trump's first term in office, and at that time we had some states that that tried these out. Ok, this was a voluntary agreement between states and the federal government to try this concept, and the proponents of work requirements say that the reason to do them is because they want people to work, and they, you know they want people to work. Okay, I mean, that's a fair goal. I think that's a fair goal for government, right, it sounds good. It's not.

Joan Alker:

You know, government might want to try to support work, but unfortunately this policy has it exactly backwards. If you want to support work and, by the way, most of these adults who can work are already working but if you want to support more of these folks working, then you've got to address their barriers to work, like child care, affordable child care, the lack of jobs or transportation, particularly in rural communities. But, most importantly, helping people be more healthy is going to help them work. So taking away their access to health care has it backwards, in my view, because people are less likely to be able to work if they're not able to address their chronic conditions that are preventing them from entering the workforce.

Attorney General Kris Mayes:

Yeah, so how? I mean, how would the work requirements actually work? I mean, what would? What would that look like?

Joan Alker:

Yeah, and I'll tell you, we've had. We've seen these in two states Arkansas, which enacted this on the first Trump term, and Georgia has has one in place right now. And, unfortunately, as a practical matter, what happens is that states have to set up very complicated bureaucratic red tape systems to kind of delve into every aspect of your life, right, so you have to report work hours, but then there's all these exemptions. So if you have, you're medically frail or you're doing this out of the other thing, you can get an exemption. So you have to prove that to the government. And so what has happened in practice is that folks in particularly in Arkansas, where we saw this rollout very quickly, thousands of people lost their health insurance because they didn't know they were supposed to do this. The website bizarrely went down at night when people who were working could actually enter their hours. The website didn't work as a matter of choice. So there's just been all these red tape barriers and the practical effect has been that people lose coverage.

Joan Alker:

And what's really shocking because I've been saying for a long time that this policy has a backwards, it's not going to work, it just doesn't work expand coverage ironically it's called pathways to coverage, but in fact, only a few thousand people have made it down the pathway and in the first year, 90 of the money went to corporate consultants to fund the construction of all this red tape.

Attorney General Kris Mayes:

Wow

Joan Alker:

so it's fiscally. Oh, it's been shocking to me. I always figured there'd be high administrative costs, but what's happened in Georgia is really quite shocking the use of taxpayer dollars there and, in fact, the House bill this, this is really a fun fact. So this is their kind of marquee policy, right? This is the one thing all the Republicans in the caucus can agree on. Well, first of all, it has the latest implementation date January 1st 2029, after the next presidential election. So they know this isn't going to work because they've pushed it back to presumably when Trump is going to be out of office. Because they know that it is going to require so many costly IT consultants and all folks to set up the red tape.

Attorney General Kris Mayes:

We've sort of touched on this a little bit. I wonder if you could speak to the idea that health care really is one of the largest industries driving our economy right now. You certainly can see that in a lot of different ways. How would a significant, abrupt loss of funding affect stability or profits across the whole health care industry? And I would just say I've got a couple of statistics here. For instance, michigan's healthcare industry is the largest industry in that state with a total economic impact of $77 billion a year. And then here in Arizona healthcare is also the largest employment sector in Arizona, employing over 400,000 people directly. 240,000 new jobs have been created in Arizona in the health care sector since the year 2000. So obviously it's important. What would these cuts mean in that respect?

Joan Alker:

Yeah, I mean, as we've talked about, there are economic effects of cutting Medicaid associated job loss. I think the kinds of providers who could be particularly hard hit by some of these proposals Congress is considering include long-term care facilities. We talked about Medicaid being the largest payer for long term care facilities. Hospitals, particularly rural hospitals, are very upset about these proposals and what could happen to them. And then you know the flip side is, like I said before, these are not doing anything to address the provider shortages we have. And I'll flag another area behavioral health. We haven't talked about behavioral health, but we have a huge behavioral health crisis in this country. Medicaid is the largest payer for behavioral health and substance use disorder treatment, so that's another piece of the puzzle that I'd really worry about. Of course, we need more providers there across payers, right? There's a shortage for anybody, regardless of what kind of insurance you have.

Attorney General Kris Mayes:

And what time frame do you anticipate this being addressed by Congress?

Joan Alker:

Yeah, well, they're moving on it now in the House. They're trying to get the bill to the floor soon, but in general I think they're going to have to be done by August, because they're trying to put the debt ceiling limit on this bill and we've just heard from the Treasury Secretary they're going to hit the debt ceiling limit in August. So I think you know right now. The rest of May, june and July are really the time when Congress is going to be dealing with this.

Attorney General Kris Mayes:

All right. Well, it is crunch time for Medicaid dealing with this, all right. Well, it is crunch time for Medicaid, and we appreciate you, joan, for helping guide us through this incredibly important topic that will impact our country for years and decades to come. So, joan Alker from Georgetown University, thank you so much for joining us. We really appreciate it.

Joan Alker:

Thanks so much for having me.

Attorney General Dana Nessel:

Well, that's all we have time for today.

Attorney General Kris Mayes:

Thanks for joining us on Pantsuits and Lawsuits. For more information, you can check out our websites or follow us on social media.

Attorney General Dana Nessel:

Yep, and we'll be back in just another few weeks with some insightful discussions shining a light on the legal issues affecting everyday Americans like us.

Attorney General Kris Mayes:

Until next time.