The spending cuts one state could face if Trump's massive bill becomes law
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Joe Sanka and Sylvia Goodman are both Kentucky natives, but neither of them had spent too much time in eastern Kentucky or Perry County before their recent reporting trip for Kentucky Public Radio. They went looking for people to talk to them about the Budget Reconciliation Bill, or as President Trump calls it, the Big Beautiful Bill, which passed in the U.S. House last month.

More specifically, they wanted to talk to people about the Medicaid cuts it proposes. How they would affect the health care industry, the various groups that are trying to help people in this region access food, access health care, how it would affect things like opioid treatment. You know, this is one of the epicenters of the opioid epidemic.

So we're just hoping to figure out exactly how providers are looking at some of these proposed cuts. Providers like Tanya Brock. She worked as a nurse in the Appalachian region for decades and now serves on the boards of the Kentucky Rural Health Association and the National Association of Rural Health Clinics. I've never seen as much concern and turmoil in health care before.

is what I'm seeing now. And I've been doing this since 1978. And in the case of Perry County, Kentucky, the effects could be bigger than just insurance. Greg Burke runs a substance abuse rehab center, and he told Sylvia and Joe a concern they heard again and again, that the work requirements the bill would put in place could have broader ripples, not just knocking people off Medicaid, but destabilizing an already fragile community. Listen, I'm going to tell you right now, you take Medicaid away from this area, and it's nothing but dust.

You're going to be left with basically abandoned little towns and probably some very, very sick people. Consider this. Sometimes to understand a big bill, it helps to go small. For our Reporter's Notebook series, we are zooming in on what Republicans propose Medicaid cuts could mean to one county in Kentucky. From NPR, I'm Scott Detrow.

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It's Consider This from NPR. The entire country has been watching the progress of the Republican budget reconciliation bill in Washington. But Kentucky Public Radio's Joe Sonka and Sylvia Goodman told me why one region of Kentucky could take it particularly hard. What was it about this specific region that jumped out to you? You could have gone many directions. This is a far-reaching bill. It affects people all over the country. What was it about this place that you picked? Well, it's a region that's especially dependent on Medicaid. It's a region that's

About a third of Kentucky is on Medicaid. That is especially true in eastern Kentucky. There are a dozen counties where over half of the population, majority of the population, is on Medicaid. So if you look at the Congressional Budget Office estimates of what this bill would do, the final version that passed the House, this could mean 20% of those on Medicaid being dropped in Kentucky, 20%.

This could be a $2 billion annual cut. So Kentucky currently gets about $15 billion from the federal government for Medicaid. And just to put that in perspective, we currently spend about $3.2 billion annually, roughly, on education per pupil in the state. That's the state's input to the education system. So $2 billion is nothing to sneeze at for Kentucky, definitely. Yeah.

And this is a historically poor and unhealthy region. It's a region that's really been snakebit and can't catch a break. Over the past four decades, the coal industry, which was once thriving, has kind of evaporated.

It was the epicenter of the opioid epidemic with the pill mills there. And also in recent years, it's been hit by natural disaster after natural disaster with major flooding. So top of all of that, they have this bill coming and the potential impacts that it could have. One of the other interesting aspects of your reporting is the way that you underscore when you talk about potential cuts to Medicaid. Obviously, that affects people on coverage, but it also affects whole industries. And you really paint this picture of people

healthcare facilities really filling the gap of other industries that have eroded. Like this is a big economic driver for this region.

Oh, I mean, 100%. One of the things we were really struck by reporting this story as we were driving out is just the number of healthcare clinics that are advertising on the side of the highway. We went to a few of these clinics and the number of services that they're able to provide. And talking to providers, it's really clear that that is because of Medicaid. One of the places we went to was Hazard, Kentucky. In Eastern Kentucky, there used to be

tens of thousands of coal miners, and that number has struck to just a couple thousand or 2,500. And then in its place, to some extent, is health care. It's this expansion of Medicaid, and it's a population that needs it. Like Joe was saying, it's historically unhealthy. There's a lot of chronic illnesses that people are dealing with, and Medicaid allowed a lot of those people to get care, and especially expansion allowed them to get care for the first time.

I covered state capitals. I covered Congress. And it was always interesting to me that when you're covering a major bill like the one we're talking about here, you talk to legislators in the hallway, you cover committee meetings, but then you go out and you interview people out in the real world about it. And it's often such a different perspective. So again, you are in...

this part of Kentucky, where this bill is incredibly relevant. We're talking about a proposal that as of right now would trim down Medicare mostly through these work requirements. This would affect directly a lot of the people in Perry County. What were the conversations like that you had?

Yeah. I mean, one of the providers we talked to said that she thought that many of her clients might fit into the work requirement category in the sense that they would not meet the work requirement. You know, they're not fully disabled. They might have a chronic illness or other health issues, but they might not be fully disabled. But maybe they were a former coal miner who lost their job sometime in the last decade and they don't have another education. They don't have another career they feel they can go into. And

there might not be a lot of jobs. There aren't a lot of jobs in this area. And these are the people that could get kicked off of Medicaid. And she was just, you know, saying that that's a disappointment to her. And there's also, you know, not everyone has a computer. Not everyone has an Internet access or strong Internet access.

And it's not just the work reporting requirements. It's the eligibility checks. And in the case of Arkansas in 2018, when they set up a work requirement for Medicaid, a lot of people who were working, they were the working poor, just fell through the cracks in the red tape and weren't able to report correctly and lost their Medicaid.

Though the lawmakers who represent these districts voted for the measure, right? How did they reconcile these two facts? Yeah. Four of the five Republicans in the House voted for this, and they said, no, we're actually preserving Medicaid. And they also touted the Kentucky Hospital Association, which put out a statement saying the same thing, that this vote was actually preserving Medicaid. And I think the reasoning there is that in D.C., Republicans were—

talking about many different options of what to do with Medicaid. Some were saying, well, let's end the Medicaid expansion completely.

Some were saying, let's change the split of what the federal government covers and what state covers when it comes to the expansion population. So there were many different parts of the bill that people were considering but ultimately didn't, and they stuck with the work requirements. So I did talk with one hospital executive who's from kind of northern Kentucky, and he said he traveled with the Hospital Association of D.C., and he

And he says that's really what it was. This could have been so much, much worse and just completely devastated all hospitals and everyone. But this was not so bad when you compare that. I'm curious if either of you had a moment that really stood out to you that's sticking in your mind from this reporting trip.

One of the scenes that really stuck out to me, we talked to a community health worker named Leanna Newsome, who works with some of the sickest patients, she said, in Martin County, Kentucky. And, you know, she's the one who helps them connect to benefits so that they can get better, so they can get some of their chronic illnesses dealt with. And, you know, she was just telling us those are some of the people that are going to fall through the cracks with additional eligibility checks.

And it's also people like her that help those people, you know, who are going to help those people deal with the eligibility checks. And, you know, she's already totally booked up. Her schedule is packed, you know, visiting people and helping them as is. That is Joe Sanka and Sylvia Goodman from Kentucky Public Radio. You can hear their reporting on the story next week. Thank you so much to both of you. Thank you. Thank you. This episode was produced by Megan Lim and edited by Adam Rain. Sammy Yenigan is our executive producer.

It's Consider This from NPR. I'm Scott Detrow. This message comes from Thrive Market. The food industry is a multi-billion dollar industry, but not everything on the shelf is made with your health in mind.

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