Big, Beautiful, and Bleeding: How 8.5 Million Americans Could Be Cut Off—and Cut Down—by Policy

Policy made in Congress, tragedy made everywhere else.

May 14, 2025

On a cold spring morning in rural Kentucky, 57-year-old Raymond awakens with a crushing pain in his chest. He’s felt twinges for weeks, but ever since losing his Medicaid coverage under new rules, he’s avoided the doctor’s office. Now the pain is unbearable. His wife dials 911, and as the ambulance wails toward their farmhouse, Raymond drifts in and out of a haze – thinking of the grandkids he promised to take fishing this summer. By the time he reaches the nearest hospital, his heart muscle is starved of oxygen. The ER physician delivers the news: Raymond is having a massive heart attack. In a better scenario, his condition could have been managed – his high blood pressure treated, his arterial blockages stented before they became lethal. But without insurance, Raymond delayed care until his heart was irreparably damaged. He doesn’t survive the night. His death is one of the hundreds of thousands each year attributed to America’s number one killer, heart disease – a death that, but for lack of timely health care, might have been prevented.

A thousand miles away in Texas, Jenna is gasping quietly in pain, trying not to alarm her two young children. The 45-year-old single mother has a lump in her breast that she first noticed eight months ago. Back then, it was small – maybe benign, she hoped. She had just lost her subsidized Affordable Care Act insurance plan when federal budget cuts allowed enhanced subsidies to expire, and without those subsidies, the premium became untenable on her waitress wages. So Jenna put off seeing a doctor. Now the lump is the size of a walnut and hard as a rock. When she finally arrives at a clinic, helped by a charity program, the diagnosis is advanced breast cancer that has spread to her lymph nodes. Jenna undergoes chemo infusions that she cannot afford, signing up for hospital payment plans that will likely follow her for life. The treatments come too late. She passes away in a hospice bed, her children at her side. Had she been insured, Jenna would have had access to routine mammograms and early treatment; instead, she became one of countless uninsured cancer patients diagnosed at an extremely late stage, with far poorer odds of survival. Cancer is the second-leading cause of death in America, claiming over 600,000 lives a year. Jenna’s story paints a grim picture of how many of those lives are lost: not inevitably to disease, but to delayed care and missed chances.

Late one night in Oklahoma, Tyler, 28, stares at the ceiling of his garage-turned-bedroom, sweat beading on his forehead despite the cool air. He’s trying to ignore the deep ache in his belly and the nausea that won’t subside. Two days ago, Tyler fell from a ladder while doing some off-the-books construction work. He landed hard, but he brushed it off, unwilling to go to the emergency room. He recently aged out of his parents’ insurance and, with the tightening of Medicaid eligibility, he isn’t covered now. He knows an ER visit for a possible internal injury could bankrupt him. But as dawn breaks, Tyler collapses, vomiting and writhing. By the time his panicked roommate gets him to a hospital, doctors discover a ruptured spleen and massive internal bleeding – injuries from the fall that should have been treated immediately. After emergency surgery and transfusions, they manage to stabilize him, but it’s touch-and-go. Tyler never wakes up. He becomes another victim of “unintentional injury,” the third-leading cause of death in the nation. In truth, his death was all too intentional – the result of a conscious choice to forgo care because he couldn’t pay. Had he been insured, Tyler would have called an ambulance at the first sign of severe pain. Instead, fear of medical bills cost him his life.

The Congressional Budget Office (CBO) estimates the House plan would strip roughly 8.5–8.6 million Americans of their health insurance by 2034. In a country where about 26 million people already lacked coverage in 2023, this policy would swell the ranks of the uninsured by roughly a third.

One Big, “Beautiful” Budget Cut

These stories are fictional, but they reflect a looming reality. Across the United States, millions of people now teeter on the edge of losing their health coverage due to a new House Republican budget proposal – a sweeping plan championed by President Donald Trump and nicknamed the “Big Beautiful Bill.” Behind that ironic moniker lies a stark fact: the Congressional Budget Office (CBO) estimates the House plan would strip roughly 8.5–8.6 million Americans of their health insurance by 2034. In a country where about 26 million people already lacked coverage in 2023, this policy would swell the ranks of the uninsured by roughly a third. It amounts to a stealth rollback of the Affordable Care Act’s coverage expansion and a historic cut to Medicaid – changes so far-reaching that health experts warn they will set in motion thousands of preventable deaths.

What exactly is the “Big Beautiful Bill”? In dry legislative language, it’s the House GOP’s budget reconciliation package for 2025 – a cost-cutting agenda that hits health care hardest. Lawmakers on the House Energy and Commerce Committee have been tasked with finding massive savings in federal health programs to help finance new tax cuts. Their target: at least $1.5 trillion in spending reductions over the next decade, including roughly $900 billion from programs under the committee’s jurisdiction (primarily health care). Medicaid, the government insurance program for the poor and disabled, faces the deepest cuts. President Trump explicitly demanded “one big, beautiful bill” to deliver on his fiscal priorities, and House leaders are rushing to meet that demand by Memorial Day.

The bill’s health-care provisions amount to a stealth repeal of key elements of the Affordable Care Act (ACA) and the Medicaid expansion. Rather than openly outlawing those programs, the proposal erects new administrative barriers and sunsets pandemic-era expansions – moves that achieve similar outcomes by shrinking the pool of people eligible or able to stay enrolled. For example, the legislation imposes work requirements on Medicaid coverage for “able-bodied” adults: to keep insurance, beneficiaries would have to prove they are working at least 80 hours a month or engaged in approved activities. Ostensibly, disabled individuals, pregnant women, and some others are exempt, but in practice these policies have a way of ensnaring even people who should be exempt. The bill also calls for more frequent eligibility redeterminations and stricter ID checks, creating what one doctor called a “thicket of red tape” that could trip up even rightful enrollees. Patients would face new co-pays and premiums in some states – fees that may seem modest on paper but can deter low-income families from maintaining coverage. And in a direct swipe at the ACA, the House plan lets the enhanced marketplace tax credits expire on schedule without renewal. The expanded subsidies that made Obamacare plans more affordable for middle- and working-class Americans during the pandemic would vanish, likely pricing many out of the individual insurance market. CBO analysts found that just the subsidy rollback would increase the number of uninsured by about 4.2 million people in coming years if no replacement is passed.

The CBO’s 8.5 million coverage loss figure includes millions of expansion enrollees expected to be forced off Medicaid as they face new paperwork or fees to keep their insurance. Many of these individuals are the working poor – people with low-wage jobs, gig workers, caregivers – who don’t get job-based insurance yet under the new rules could be deemed “too idle” for Medicaid. An Urban Institute analysis estimated that a federal Medicaid work requirement could cut off between 4.6 and 5.2 million adults within the first year or two. Crucially, “most of those people would lose coverage not because they refuse to work, but because they can’t overcome the reporting hurdles

Layered together, these changes hit hardest at low-income adults, particularly in Southern and rural states. It’s no coincidence that the highest uninsured rates in the country have long been concentrated in the South – regions where many states refused the ACA’s Medicaid expansion or only grudgingly implemented it. Under the ACA, 40 states (including several in the South) did expand Medicaid eligibility to cover adults up to 138% of the federal poverty level. This expansion proved transformative: by 2018, states that expanded Medicaid saw their uninsured rates drop to about 8%, roughly half the rate of non-expansion states (15%). The House proposal threatens to reverse those gains. It would effectively end the ACA expansion as we know it, either by prompting holdout states to further resist coverage or by causing expanded states to shed enrollees through bureaucratic attrition. The CBO’s 8.5 million coverage loss figure includes millions of expansion enrollees expected to be forced off Medicaid as they face new paperwork or fees to keep their insurance. Many of these individuals are the working poor – people with low-wage jobs, gig workers, caregivers – who don’t get job-based insurance yet under the new rules could be deemed “too idle” for Medicaid. In reality, most adult Medicaid recipients are working or meet an exemption, but studies show work requirements would still cause massive coverage losses because people struggle to report their hours or navigate the red tape. An Urban Institute analysis estimated that a federal Medicaid work requirement could cut off between 4.6 and 5.2 million adults within the first year or two. Crucially, “most of those people would lose coverage not because they refuse to work, but because they can’t overcome the reporting hurdles,” explains Shalina Chatlani, summarizing the study. As one advocate in Arkansas – a state that piloted work requirements – noted, “Especially in a rural state like Arkansas, work requirements fail to take into account a lot of realities… job opportunities may not be available in some of these rural towns.” The likely outcome is that thousands of eligible people will be erroneously purged from Medicaid rolls due to missed paperwork, lack of internet access, or simple confusion. In states with large rural populations, the impact will be magnified, hitting communities already short on doctors and hospitals.

All told, the toll is expected to fall largely on poor adults under 65 – people who are often in the prime of life, and disproportionately people of color. Paradoxically, seniors on Medicare won’t directly lose coverage from this bill, but some will lose Medicaid wraparound benefits (like help with nursing home costs), and their younger family members will. The Centers for Medicare and Medicaid Services has warned that policies like frequent income checks and work verification tend to disenroll even eligible individuals, causing churn in coverage. The House budget’s authors insist these measures are about “program integrity” and encouraging employment, accusing critics of “fear-mongering”. But the numbers tell a different story: CBO confirmed the primary effect is fewer people insured, and the budget savings only materialize because millions lose access to care.

The Medicaid and ACA subsidy cuts are projected to save the federal government over $700 billion in the next decade, money that House Republicans plan to use to extend the Trump-era tax cuts for corporations and wealthy individuals.

Why would anyone design a health policy that knowingly results in millions losing coverage? The answer lies in the trade-offs at the heart of the budget. Slashing health spending is how the bill pays for tax cuts. The Medicaid and ACA subsidy cuts are projected to save the federal government over $700 billion in the next decade, money that House Republicans plan to use to extend the Trump-era tax cuts for corporations and wealthy individuals. In other words, the plan takes insurance away from low-income Americans to help finance a package of tax benefits that will disproportionately flow to high earners. Democratic critics have not been gentle in their assessment of this priority: Representative Frank Pallone denounced the budget as imposing “devastating Medicaid cuts so billionaires can get another tax break”. Even some Republicans have voiced unease. Senator Josh Hawley of Missouri – who had earlier cautioned his party against attacking Medicaid – acknowledged that “there’s going to be coverage losses…and I’m OK with that” as a byproduct of the anti-fraud and work rules. The philosophical wager, it seems, is that trimming public insurance rolls is worth the price of budgetary savings and tax relief. But what is the human price? On spreadsheets, it’s measured in billions of dollars. In real life, it will be measured in pain, sickness, and yes, lives lost.

Harvard scientists in 2009 estimated that about 45,000 American deaths each year could be linked to being uninsured. Gawande and colleagues found that for every 300 to 800 adults who gain health coverage, one life is saved per year. Flip that around and it suggests a terrifying arithmetic: if 8.5 million people lose coverage, we could expect on the order of 10,000–28,000 additional Americans to die each year as a result. Even using a more conservative estimate (one life lost per 1,000 uninsured per year) yields about 8,500 deaths in the first year from this coverage loss – roughly the same number of Americans who die from diabetes in a year. Over a decade, that would be around 85,000 preventable deaths. And some analyses warn the toll could be higher. Back in 2017, when Congress was considering a similar rollback of the ACA, one Vox analysis projected 208,500 extra deaths by 2026 under the Republican plan being floated at the time.

Health policy can sound abstract, all dollars and bureaucracy. It’s easy to lose sight of what an “uninsured” statistic really means. To be uninsured in America means being one illness or accident away from catastrophe – or one step closer to death. Multiple studies have confirmed what might seem obvious: having health insurance significantly improves health outcomes and survival. One landmark review in the New England Journal of Medicine concluded that insurance expansions under the ACA led to “significant, multifaceted, and nuanced benefits to health.” Conversely, taking coverage away has the opposite effect. The Institute of Medicine warned years ago that lack of insurance is associated with higher mortality, and subsequent research quantified the harm. Harvard scientists in 2009 estimated that about 45,000 American deaths each year could be linked to being uninsured – a toll that likely fell after the ACA but is still tens of thousands annually. Atul Gawande, the surgeon and writer, put it bluntly during a previous debate on health reform: “There will be deaths.” In fact, Gawande and colleagues found that for every 300 to 800 adults who gain health coverage, one life is saved per year. Flip that around and it suggests a terrifying arithmetic: if 8.5 million people lose coverage, we could expect on the order of 10,000–28,000 additional Americans to die each year as a result. Even using a more conservative estimate (one life lost per 1,000 uninsured per year) yields about 8,500 deaths in the first year from this coverage loss – roughly the same number of Americans who die from diabetes in a year. Over a decade, that would be around 85,000 preventable deaths. And some analyses warn the toll could be higher. Back in 2017, when Congress was considering a similar rollback of the ACA, one Vox analysis projected 208,500 extra deaths by 2026 under the Republican plan being floated at the time. The proposal now on the table – this “Big Beautiful” budget – may not cut quite as deep as a full ACA repeal, but it follows the same deadly logic. It is, in effect, a mass divestment in Americans’ health, the consequences of which will play out in clinics, ERs, and cemeteries long after the political fight is over.

Lives on the Line

Back in the real world, away from Capitol Hill’s debates, the fallout will be measured one person at a time. Consider Marjorie, a 59-year-old grandmother in Alabama, who works part-time cleaning motel rooms. Marjorie has battled high blood pressure most of her adult life. With Medicaid expansion, she finally got coverage a couple years ago and started on medications to keep her blood pressure in check – a relief, since uncontrolled hypertension is a silent killer that can lead to strokes. But this year, after new eligibility checks rolled out, Marjorie missed a renewal notice that was mailed to an old address. By the time she realized, her coverage had been canceled. Bureaucracy, not a doctor, decided her fate. Off her meds for several months, Marjorie began feeling dizzy spells and severe headaches. One afternoon, as she was hanging laundry in the backyard, her left side suddenly went numb. She collapsed, suffering a major stroke (the fourth-leading cause of death in the U.S.). Paramedics rushed her to the hospital, but without insurance, she was not a candidate for an inpatient rehab center after emergency treatment. Her adult son, a truck driver, took time off to care for her at home as she struggled to speak and walk. “If I’d had my medicine…,” Marjorie tries to say, knowing full well that a few pills a day might have prevented the blood clot in her brain. Now, partially paralyzed and without insurance, she faces an uphill battle to recover. In states like Alabama that did not fully embrace safety nets, stories like Marjorie’s have become tragically common. Stroke is survivable with prompt care and long-term therapy, but for the uninsured, those crucial supports often vanish quickly. Many, like Marjorie, are left with permanent disability – or don’t survive at all.

In West Virginia, Carl gasps awake in bed, fighting for breath. The 64-year-old former coal miner has late-stage COPD – chronic obstructive pulmonary disease – the legacy of years of dust and smoking. COPD, which includes emphysema, is the fifth-leading cause of death in America and a frequent reason people end up on oxygen or in the ER with pneumonia. Carl had gained Medicaid coverage through the ACA expansion in his state, which allowed him to afford inhalers and periodic check-ups. But after the new federal cutbacks, the state instituted premiums for Medicaid and more frequent paperwork to prove eligibility. Carl, whose memory isn’t great and whose income from odd jobs fluctuates, lost his coverage during a periodic review he didn’t even realize was happening. Now, he can’t pay for his maintenance inhaler or the steroid medications that help keep his inflamed lungs stable. One wintry night, Carl comes down with a respiratory infection that turns into a severe COPD flare-up. He put off going to the hospital as long as he could – pride and penny-pinching guiding his judgment – until he was literally suffocating. By the time he is intubated in the ICU, his oxygen-starved body is shutting down. His family watches in anguish through the glass as the ventilator pumps away. After Carl’s funeral, his sister wonders aloud if things would have been different had he still been insured. The answer is almost certainly yes. Regular medical care and affordable inhalers might have kept him stable, and at the very least, he would not have hesitated to seek help at the first sign of infection. Instead, lack of coverage turned a routine illness into a fatal crisis.

Leonard was a proud, salt-of-the-earth type – a 63-year-old truck mechanic in Mississippi who prided himself on never missing a day’s work. When Leonard started forgetting small things – misplacing his tools, getting lost on familiar roads – he laughed it off as “senior moments.” But soon the symptoms worsened. He’d come home agitated, unable to complete simple tasks, occasionally not recognizing his own daughter. The family grew worried this was early-onset Alzheimer’s disease, a devastating neurological illness and the sixth-leading cause of death in the U.S.. Under normal circumstances, Leonard would have gone to a specialist for evaluation and maybe started medications to slow the disease’s progression. But Leonard had no health insurance – his income was too high for Mississippi’s strict Medicaid limits and far too low to afford private insurance, and his state never expanded Medicaid to cover workers like him. As his cognitive problems mounted, Leonard had to quit his job, which meant he also lost his employer-sponsored health plan just a year shy of Medicare eligibility. For two years, until he turned 65 and qualified for Medicare, Leonard essentially went without consistent medical care. During that time, his Alzheimer’s (though not formally diagnosed until later) advanced unchecked. In one tragic incident, he wandered out of the house on a freezing night; disoriented and unable to find his way home, Leonard suffered hypothermia. Though he survived that scare, the downward spiral continued. When he finally did see a neurologist via Medicare, it was largely too late – the disease was advanced. Leonard died before his 66th birthday, lost in the merciless fog of dementia. His widow is convinced that if he’d gotten help earlier – counseling, medication, adult day care – he might have had a few more good years with his grandkids. Alzheimer’s is a grim illness no matter what, but lacking insurance turned Leonard’s case into a fast-moving train with no one at the controls.

On the south side of Chicago, DeShawn sits at his kitchen table, calculating how much insulin he can afford to use this week. At 29, he’s lived with Type 1 diabetes since childhood, requiring daily insulin injections to survive. Normally, insulin is a manageable expense with insurance – but DeShawn recently lost his job at a small trucking firm, and with it his employer coverage. He’s been searching for a new job, any job, but the economy is tough. He applied for Medicaid, but under the new federal rules, his state now requires proof of 80 hours of work a month to qualify for Medicaid as an adult without children at home. Unemployed and with no steady gig, DeShawn doesn’t meet the work requirement, so his application was denied. Now he is among the ranks of the uninsured diabetic – a uniquely dangerous status in America. The price of insulin out of pocket is exorbitant, often hundreds of dollars a vial, and DeShawn has been stretching his remaining supply by using less than prescribed. Each time he injects a lower dose, he knows he’s rolling the dice. One night, his girlfriend finds him on the floor unconscious – in a diabetic coma. By the time the ambulance arrives, DeShawn’s blood sugar has skyrocketed to levels that cause his organs to start failing. He’s pronounced dead at the hospital, another young life cut short. Diabetes is the seventh-leading cause of death in the nation, and in cases like DeShawn’s, the cause isn’t a medical mystery. Insulin is a 100-year-old medicine; it works, but only if you can afford it. DeShawn died not from diabetes per se, but from the systemic barriers that made accessing insulin impossible when he fell on hard times. His death sends shock waves through his community and church. For years, people heard about diabetics rationing insulin and dying – now they’ve lost a friend to exactly that scenario. It underscores an ethically jarring truth: in one of the richest countries on Earth, a treatable condition is claiming lives because policy choices have placed life-sustaining medicine out of reach for the uninsured.

Not far away, in a Detroit suburb, Gloria endures nightly dialysis in her cramped apartment. At 48, her kidneys are failing from long-uncontrolled high blood pressure. She first learned of her kidney disease a few years ago, when swelling in her legs and constant fatigue sent her to a clinic. With proper treatment – blood pressure medications, a kidney-friendly diet, and early interventions – the progression to full kidney failure might have been slowed or even averted. But Gloria had fallen into the coverage gap: her state hadn’t expanded Medicaid at the time, and she earned too little to afford an ACA marketplace plan even with minimal subsidies. So she went without regular care. By the time she got any help, her kidneys had deteriorated to the point where dialysis (mechanical blood filtering) was the only thing keeping her alive. Now she has end-stage renal disease – a condition that normally qualifies you for Medicare, but because of administrative delays and confusion, Gloria’s Medicare benefits haven’t kicked in yet. For the past few months, after losing a patchwork of emergency Medicaid coverage post-pandemic, she’s been getting dialysis only sporadically at an overwhelmed public hospital that accepts the uninsured for “emergency dialysis” – essentially, when patients show up on death’s door. On nights in between treatments, toxins build up in her blood, making her delirious and sick. One night, Gloria doesn’t make it to the ER in time. Her heart stops in her sleep, overloaded by potassium her failing kidneys couldn’t clear. This is the cruel reality of untreated kidney disease, the eighth-leading cause of death in America. In a just world, Gloria would have received steady care long before it came to this. In our world, losing insurance sealed her fate. The nephrologist who sees her body in the morgue shakes his head, knowing that no one should die for lack of something as basic as maintenance dialysis or blood pressure pills in 2025.

Down in Louisiana, 52-year-old Marcus spends his days lying on a worn couch, drained and jaundiced. His skin and eyes have the yellow tint of end-stage liver disease. As a younger man, Marcus had contracted hepatitis C – a virus that attacks the liver – likely from a brief stint of substance use when he was in his 20s. By the time a blood test revealed it, he had no health insurance and no steady doctor. Remarkably, in the past decade, medicine has developed a cure for hepatitis C: a course of antiviral pills that boasts a 95% cure rate. But that cure comes at a high price (tens of thousands of dollars), and without insurance, Marcus could never afford it. Louisiana’s Medicaid program might have covered it, but Marcus fell into a gray zone: he had a modest income from gig work that put him just above Medicaid’s cutoff and, until recently, he didn’t qualify for ACA subsidies either (his home state was slow to implement them). So the virus quietly scarred his liver year after year. Now Marcus has full-blown cirrhosis, the kind of late-stage liver disease that is often fatal and is the ninth-leading cause of death nationally. He suffers internal bleeding and frequent hospitalizations to drain fluid from his abdomen. A liver transplant could save him – but transplants are rarely given to uninsured patients because of the astronomical costs and complex post-op care. So Marcus is effectively sentenced to die. In his final weeks, he’s referred to hospice care. A social worker gently explains to him that a cure existed all along – a cure he likely would have received, had he been on Medicaid or a good insurance plan when his disease was still curable. Marcus offers a weak, bitter laugh. What can he say? The Big Beautiful Bill’s cuts don’t affect him retroactively – his tragedy was already in motion – but he hears about them on the news and shakes his head. More people will lose insurance now, more will miss out on life-saving treatments like he did. As he slips away, his story stands as a warning of what happens when medical breakthroughs meet unequal access: science can defeat disease, but policy can still let the patient die.

Finally, we must face an uncomfortable example that is fresh in America’s memory: COVID-19. Just a few years ago, this novel coronavirus stormed through every community, eventually killing over a million Americans. In the early waves of the pandemic, the federal government took the extraordinary step of covering COVID testing and treatment for the uninsured through emergency programs. Even so, uninsured Americans were more likely to avoid or delay care for COVID – with deadly outcomes. In the winter of 2021, Angel, a 38-year-old grocery store clerk in Florida, came down with a fever and cough. He had no health insurance; Florida’s refusal to expand Medicaid meant he fell in the gap, and he couldn’t afford an ACA plan on his meager hourly wage. When Angel’s symptoms worsened, he hesitated to go to the hospital, terrified of a bill that could crush his family’s finances. He tried to tough it out at home. By the time he was gasping for air and finally driven to the ER by a neighbor, his blood oxygen level was perilously low. He was intubated and placed on a ventilator in the ICU – but the delay had cost him. His lungs were too damaged by the virus. Angel died two days later, one of the roughly 187,000 Americans who died of COVID-19 in 2022 (and a statistic in what was then the third-leading cause of death). A doctor who treated him quietly confided that if Angel had come in a few days earlier, or had a primary care doctor to call at the first sign of trouble, the outcome might have been different. As the nation reflects on the pandemic, we often talk about vaccines and variants, mandates and masks. Less discussed is how lack of insurance magnified the tragedy. Uninsured workers like Angel were among the most exposed on the frontlines and the least protected by the health system. They had higher rates of uncontrolled chronic conditions that made COVID more deadly, and they sought care later – if at all – because of cost barriers. Now, imagine a future outbreak or a resurgence of COVID after millions have been dropped from Medicaid and ACA plans. The public health implications are dire. We learned in 2020 that viruses do not check your insurance status before infecting you – but your insurance status very much affects what happens next.

Ten stories. Ten lives. Ten of the top causes of death in America, each story showing a different facet of the same truth: health insurance can mean the difference between life and death. When 8.5 million people are abruptly stripped of coverage, as the House’s Big Beautiful Bill threatens to do, it’s not hyperbole to say that people will suffer and die as a result. Each statistic in that CBO estimate is a real person like Raymond or Jenna or DeShawn – a person with a heartbeat, a family, a future that now hangs in the balance. The numbers are huge, almost abstract: billions in cuts, millions uninsured, thousands of potential deaths. But zoom in, and you see the human faces: a man clutching his chest in agony, a mother saying goodbye to her kids, a young worker who doesn’t wake up, an elder disappearing into dementia, a diabetic desperately rationing medicine. These are the stakes of health policy.

It’s important to acknowledge that not every uninsured outcome is fatal – many people who lose coverage will survive, albeit with worse health, crushing medical debt, or untreated illness. But even short of death, the suffering caused by lack of insurance is profound: children missing developmental check-ups, adults foregoing cancer screenings, mental health issues spiraling because therapy isn’t accessible, chronic diseases like asthma and hypertension getting out of control. The 8.5 million Americans facing the loss of coverage will feel these impacts intimately. Some will be relatively healthy folks who simply live with the anxiety of being one accident away from financial ruin. Others will be people in the midst of health crises who find the ladder they were climbing – Medicaid, ACA subsidies – suddenly kicked out from under them. The cruelty of administrative barriers is that they often target the most vulnerable: those with limited literacy, unstable housing, or intermittent employment – precisely the people for whom consistent health coverage can be most life-changing.

As a society, we are left with an uncomfortable question: Are these budgetary “savings” worth the human cost? The House Republicans have made a political choice that lower taxes and deficit reduction justify pulling health care from millions. Their rhetoric frames it as trimming fat, encouraging work, stopping fraud – making it sound almost virtuous. But on the ground, it looks like ordinary Americans showing up to ERs in dire condition, or not showing up at all because they’re already gone. It looks like grieving families asking why an affluent nation couldn’t find a way to keep their loved one insured and healthy. It looks like a moral crossroads where we decide if we truly value life, or if we are comfortable with a certain number of preventable deaths as collateral damage of fiscal policy.

Public health experts often talk about “excess mortality” – deaths above what is expected. The policies in the Big Beautiful Bill virtually guarantee excess mortality among the American people, year after year, as long as they remain in effect. These would be deaths by policy – as foreseeable as any outcomes can be in health care. We have seen time and again that when people gain insurance, they live longer, healthier lives. And when they lose it, some of them die. It’s that simple. As one health economist put it, the number needed to insure to save a life is in the hundreds – so imagine the lives that will be lost by un-insuring millions.

Every American life is precious. We often hear politicians declare that sentiment, especially when justifying war or combating terrorism: no cost is too high to save lives. Yet here we are, watching a policy choice that does the opposite – sacrificing lives to save costs. The House budget might pass or fail, be amended or litigated, but the very fact that it has advanced this far signals a disturbing tolerance for human sacrifice on the altar of austerity and tax cuts. If implemented, its effects will not be immediate headlines on cable news – they will trickle out over years in quieter stories: the obituary of a father who delayed care, the silent funeral of a child who lacked treatment, the statistics in a CDC report showing U.S. life expectancy stagnating or even dropping in the affected populations.

We as a nation have to ask: Is this who we want to be? The Big Beautiful Bill promises to reshape America’s health care landscape, but the picture it paints is anything but beautiful. It’s a landscape of widening disparities, shuttered rural clinics, and families mourning members lost to treatable diseases. It doesn’t have to be this way. Health coverage for millions could be preserved with a stroke of political will – by choosing to prioritize lives over ledger lines.

In the coming weeks, as the debate rages, remember Raymond’s heart that could have kept beating, Jenna’s life that could have been saved with early care, Tyler’s trauma that could have been treated, and all the others. Their stories are our moral ledger. If we abandon them, we are choosing a path of avoidable tragedy. The true measure of this budget bill will not be the dollars saved, but the lives lost. And if 8.5 million Americans lose health insurance, we will all have to live with the knowledge of what that cost in human terms – an outcome as predictable as a ticking heart that suddenly, needlessly, stops.

In memory of those who should not have been lost.

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