We've Come Undone

“But just so we're reminded of the ones who are held back,
up front there ought to be a man in black. - Johnny Cash

America needs no more explanation as a country this Fourth of July weekend than to take note of developments related to our current national leadership. We are building concentration camps to house immigrants while we drastically cut funding for food and health care for our poor. Immigration and Customs Enforcement (ICE) has just been granted $121 billion dollars by Congress to build a border wall, construct detention centers for 100,000 immigrants, and to hire 10,000 new ICE officers along with 8500 more Customs and Border Patrol agents. Our country is becoming an armed camp and men in masks carrying AR-15s and sidearms will become common sights on American street corners, arresting anyone they suspect might be on U.S. soil without the proper paperwork.

To help pay for such nonsense, cuts to Medicaid, the Affordable Care Act (ACA), and the Children’s Health Insurance Program (CHIP) are expected to rob as many as 17 million people of any form of health care. The key drivers of coverage loss include 80-hour/month work requirements, which are often impossible to meet for the disabled and those living in rural areas without job opportunities or transportation, heightened documentation, and increased mid-year income checks. The rural, disabled, and homeless are likely to be most heavily impacted because they tend to not have the resources to comply with bureaucratic hurdles. Hospitals serving people outside of urban areas, which rely heavily on Medicaid payments to remain financially solvent, are expected to cease operations.

As usual, Texas, the second largest population in this country with more than 31 million people, is the iconic example of harm caused by bad policies at the federal and state levels. Five million Texans under the age of 65 are without health insurance already, and Trump’s Death Star of a bill will cause another 1.7 million Texans of all ages to lose coverage. We boast about everything under the Lone Star so very soon I expect a bit of braggadocio about the fact that we have the highest uninsured rates in America with 22 percent of adults living without any protective health policies while 12 percent of all children are uninsured. The percentage of children without health care coverage is double the national average and totals just under one million. An estimated two-thirds of children without the security of health care coverage in Texas, numbering 600,000, are Hispanic.

Health care has already been in a crisis state in Texas because of the governor and the legislature’s refusal to expand Medicaid. If the state increased coverage qualifications up to 138 percent of the federal poverty level, approximately 1.43 million adults would become eligible for Medicaid, which would lead to an anticipated 950,000 adults signing up for coverage. There is no logical reason for Texas politicians to refuse to expand Medicaid coverage since the federal government pays more than 90 percent of the state’s costs. Rationality, however, has little to do with conservative American policies, and the new mega-bill just passed will cause Texas to lose roughly $28 billion in federal Medicaid funding over the next ten years, which means that another 303,000 Texans will be dropped from Medicaid rolls.

Expansion of Medicaid would close the coverage gap for childless adults who earn too much to qualify for traditional Medicaid but not enough for Affordable Care Act subsidies. Federal funding would rise by $5.4 billion annually to Texas and the state’s share of Medicaid costs would be only $600 million. I guess math is hard when you hold an elected office, but that seems a simple calculation of value. How is that not a fiscal opportunity for Texas since that tax money is, instead, being parsed out to states with expanded Medicaid? The broader, ripple consequences for Texas and other states will take more time to do their harm, but it is coming, surely, and with great force, and will compound healthcare challenges in already marginalized communities.

In most of the U.S., and especially Texas, it has become politically axiomatic that rural residents tend to vote against their own interests, which means they are conservative and Republican, often without giving it much thought. If they did, some consideration would be given to the fact that price supports keeping many of their farm families in business, and Medicaid dollars sustaining their small hospitals, all come from Washington. Instead, they fall for the overworked trope about reducing taxes, rarely paying attention to the fact that conservatives only want to cut taxation to corporations and the wealthy.

Again, in this most embarrassing of categories, Texas is out front, pulling away, with 26 hospital closures across 22 communities between 2010 and 2020. We are #1 nationally in total rural hospital closures during that period, and a lack of sufficient Medicaid funding is the primary cause. Various studies have shown that Medicaid expansion reduced the likelihood of rural hospital shutdowns by 62 percent, and it ought not be surprising, at this point, that 75 percent of hospitals at greatest risk of closing their doors were in non-expansion Medicaid states. Texas has lost roughly half of its rural hospitals since the 1960s, dropping from about 300 to 158 in 2025, and rural areas have voted consistently for the Republicans who execute those funding cuts.

What are we doing with tax money instead of funding health care? We are building camps to imprison innocent people, who, out of desperation, came here to work jobs mowing lawns, cooking and cleaning, caring for our children, harvesting crops, framing new homes, and doing any task that will allow them to earn money to send home to support their families. How expensive is our xenophobia? The annual cost of detaining a single immigrant is $58,000, which could provide a year of Medicaid for three adults, a year of SNAP food benefits for 12 individuals, or fund multiple visits to emergency rooms at public hospitals. There is no long term benefit to the detention of immigrants but social safety net programs have significant economic benefits. SNAP boosts local economies by $1.50 to $1.80 for every $1 spent, and Medicaid reduces uncompensated care costs while improving population health. Detention does nothing more than drain federal resources.

One last, and profoundly important, dataset is about taxation. Immigrants, collectively, legal and undocumented, paid $652 billion dollars in federal, state, and local taxes in 2023, which amounts to 19.2 percent of total U.S. tax revenue. Undocumented immigrants, specifically, paid $59.4 billion in federal and $37.3 billion in state taxes in 2022, the latest reporting year statistics available. Over $25.7 billion was paid into Social Security, $6.4 billion into Medicare, and $1.8 billion into unemployment insurance, all programs from which they may not receive benefits. The 8.9 percent rate of taxation paid by undocumented individuals tends to be a higher effective state and local tax rate than this country’s wealthiest 1 percent, which pays 7.2 percent. Immigrants are more than funding the wall Washington wants to continue building to keep them out. In Texas, where most of the wall will rise, undocumented immigrants contributed $4.9 billion in state and local taxes. When combined with legal immigrant taxes paid, Texas got a total $53.1 billion from immigrants in 2022, which more than covers the billions the state’s governor wasted building 7 miles of border wall and dispatching thousands of state troopers and National Guard soldiers.

Americans are now, by their own choice, investing in concentration camps to hold innocent people, militarizing our borders with soldiers and tanks and guns, sending Marines into the streets of our cities, giving the world its first trillion-dollar military budget, and providing ICE with a bigger operational fund than all the Russian armed forces combined. All this happens as we abandon our allies, and scientific research, reduce spending on higher education, ignore our Constitution, reverse laws ending discrimination, and let a solitary man impose his twisted values on a nation. A nation that the world used to hold up as a standard for freedom, fairness, and innovation. The value of what we have surrendered is immeasurable. The reasons are unknowable and defy rational thought. If our democracy still works, we will rid ourselves of that man and his enablers.

If it doesn’t, there will be nothing left worth saving.