Do Not Pervert Justice.
“Woe to those who make unjust laws, to those who issue oppressive decrees, to deprive the poor of their rights and withhold justice from the oppressed of my people, making widows their prey and robbing homeless children.” (Isaiah 10:1-2)”
In September of 2016, then Republican presidential candidate Donald Trump proposed repealing the Affordable Care Act (ACA). He was asked many times what he would replace it with. In his 2016 statement, he said he had a plan which he titled, in typical Trumpean terms, “Healthcare Reform to Make America Great Again.” The proposal was an empty shell of promises. But now, in July of 2025, we finally know his plan. It is rationing to lower health care costs, plain and simple. And it is unjust rationing.
He delivered the plan as a component of his ‘Big Beautiful Bill’. Trump’s plan focuses on the destruction of Medicaid, cuts to accessing the Affordable Care Act, the imposition of absurd Medicaid work requirements and co-pays, and decreasing payments to Medicaid-dependent health care facilities. This is simply rationing by cutting the poor out of health care. And it means all will suffer as many hospitals now on the edge of insolvency lose Medicaid income and face collapse, while emergency rooms overflow with uninsured people with nowhere else to go. As such, it is the most unjust, immoral health reform ever undertaken in the history of the United States.
No credible ethical theory of justice says that when finances are tight, take it out on the poor. No theories of the best allocation of health care resources suggest when hard choices have to be made about a budget, identify the poorest of all Americans, pregnant women, the disabled, the frail elderly, and children, and yank their often difficult to access coverage. None.
Aside from the gross injustice of picking the least well off to go without, the Trump ‘plan’ doesn’t engage the core problem facing Medicaid, Medicare, the VA, private insurance, and those paying out of their own pockets—health care in America simply costs too much. We spent over five trillion dollars on health last year. Costs are up 7% this year following an 8% rise last year. In 2023, we spent $13,500 per person, sick or not. The closest comparable countries spent $8441 (Germany), $7136 (France), and $7013 (Canada), with the gap among peer nations widening.
Anyone in Congress who voted for this bill and its health care devastation should be ashamed. Rather than solve the problem causing Medicaid insolvency and family bankruptcies-uncontrolled costs and price gouging—they went with Trump’s solution—let the health care avalanche of expenditures continue. Just leave the many millions of extremely poor persons, the defenseless, the frail, the voiceless, and the vulnerable on their own. Talk about death panels. The big beautiful bill’s solution to our burgeoning health cost disaster is to launch an all-out lethal war on the poor.
The media coverage of the moral choice that has been made to let the weak and poor die is inadequate. Religious voices who know better are far too silent. Academics who claim to care about equity are nearly voiceless. Rationing by reducing eligibility for coverage is repugnant and more should have said so.
Trump and Congress’s health plan rests on indifference. It is now policy. That is both lamentable and evil.
Arthur Caplan, PhD, is the Drs. William F. and Virginia Connolly Mitty Professor of Bioethics at the Division of Medical Ethics, NYU Grossman School of Medicine.
The opinions expressed here are my own and not reflective of any institution or organization.