CLARIFICATION: An earlier version of this story noted the Children's Health Insurance Program as a component of Medicaid, before outlining Minnesota data. That version did not make clear that while under the same umbrella, there are differences. An update emphasizes Medicaid and CHIP when noting Minnesota data. (8:45 a.m. MST, Jan. 16, 2025)
In their pursuit of slashing government spending, Congressional Republicans are taking a hard look at Medicaid. But a new report shows how this public health program is preventing care access from further eroding in rural Minnesota and elsewhere.
The incoming Trump administration promises major budget cuts, and a House GOP proposal floats a nearly $2.5 trillion Medicaid reduction. But findings from Georgetown University's Center for Children and Families show people in rural areas are more likely than metro populations to receive health coverage through Medicaid.
Katy Kozhimannil, associate professor in the University of Minnesota School of Public Health, said its providers rely on it, too.
"Medicaid is an absolutely essential source of revenue for those hospitals to keep operating and to provide different types of services and additional training and support for clinicians," she said.
A key Medicaid component is the Children's Health Insurance Program. At 7%, the Georgetown report says Minnesota is among the states with the largest difference in the share of kids covered by Medicaid and CHIP when comparing smaller towns to urban centers. Some House Republicans insist these programs need reform to avoid a fiscal collapse. But skeptics say drastic changes are a way to offset a planned extension of federal tax cuts.
Joan Alker, executive director and co-founder of the Center for Children and Families at Georgetown University, called these budget proposals "horrifying," while suggesting the public might be caught off guard because the program wasn't really discussed on the campaign trail last fall.
"There was complete silence about it, despite the fact that it is the largest source of public coverage by far in the United States," she said. "It's also a very popular program with the voters of all political stripes."
Report authors stress the timing of the proposed cuts is especially bad as rural areas continue to grapple with hospital closures. 120 facilities have either closed or ceased offering inpatient services over the past decade. Many rural hospitals opt to shutter less lucrative units such as maternity wards. And the experts say Medicaid covers a majority of pregnancy care in smaller communities where these units still operate.
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The Trump administration has frozen funds used for abandoned mine land cleanup.
Through the Bipartisan Infrastructure Law, Congress invested around $11 billion into a trust fund to help address the backlog of sites needing reclamation but the federal Office of Surface Mining Reclamation and Enforcement has stopped releasing the money.
Chelsea Barnes, director of government affairs and strategy for the advocacy group Appalachian Voices, said with ongoing flooding in eastern Kentucky, heavy rainfall can worsen problems on abandoned mine sites, triggering erosion, landslides and "blowout" events, leading to property damage.
"There's a buildup of water and then it all of a sudden, releases really fast," Barnes explained. "That can go downstream, down a mountainside and crash into homes, businesses, destroy roads."
In addition to tackling environmental hazards, research shows cleanup projects also create jobs. One analysis by the Sierra Club found investing in reclamation will create nearly 3,000 jobs and billions in economic growth in a handful of Appalachian states.
While some states have decided to operate business as usual, assuming federal funds will be unlocked soon, Barnes noted for others, the freeze has halted projects.
"Maybe they have enough money on hand to kind of keep things rolling for a little bit," Barnes acknowledged. "But the longer this goes on, the worse it's going to get."
She emphasized water polluted with metals and chemicals from mining can seep into waterways and kill fish and other aquatic life, and contaminate drinking water. She added federal funds are often used for acid mine drainage cleanup.
"A cleanup project for that might look like a water treatment facility to clean up an old acid mine drainage site," Barnes observed.
There are 12,000 acres of disturbed former mine land in eastern Kentucky which could be reclaimed to reduce environmental and safety hazards, according to a 2024 report by the Appalachian Citizens' Law Center.
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Minnesota is little less than a year away from launching its paid-leave law, but state lawmakers are debating whether to delay the start until 2027.
Paid leave was considered one of the crowning achievements of the 2023 legislative session, when Democrats controlled both chambers. But the GOP now has a slight edge in the House, so the policy is getting a second look.
Employers will be required to provide up to 20 weeks of paid time off each year to a worker dealing with a health issue, or caring for a loved one. During committee debate Thursday, Minnesota AFL-CIO president Bernie Burnham argued against pushing things back.
"Working Minnesotans are ready for the peace of mind that comes from knowing we will have the freedom to care for ourselves, and the people we love, without sacrificing a paycheck," she said.
Supporters of the later start date have said there's still uncertainty about the impact on businesses, especially smaller companies, as they prepare to comply. Others testified there aren't enough safeguards in place yet for the state to smoothly roll out the program. But Burnham said the effort has been vetted, and any kinks can be sorted out after the currently scheduled launch of January 2026.
Some voices in the education field testified in support of the bill calling for a one-year delay. Kim Lewis, associate director of government relations for the Minnesota School Boards Association, said the timing isn't good for school districts around the state.
"A significant number of the 331 districts are currently making staffing cuts to balance budgets," she said. "No one wants to do that, but the increased costs and the increased needs are a reality. Our biggest issue and question is, how do we pay for the paid leave benefit?"
But the Minnesota Association of Professional Employees, which represents more than 18-thousand state workers, has said not only would this halt a critical benefit they've fought for over the past decade, but also result in additional administrative costs for the state.
Minnesota set aside funds to help cover the program's launch. After that, benefits would be funded by payroll taxes shared by employers and workers.
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A lawsuit has been filed against the Trump administration over its budget-cutting plans targeting medical research led by colleges and universities.
Their allies warn of negative consequences for curing diseases, as well as local economies. The suit was brought by Minnesota and 21 other states after the National Institutes of Health said it would follow through on orders to cut $4 billion through a grant funding formula for indirect expenses.
North Dakota is not part of the legal case, but an analysis said the state could lose more than $3 million in research funds.
Ellie Dehoney, senior vice president of policy and advocacy for the group Research!America, said no matter the state, the pain will be quickly felt.
"The suddenness of it is one of the ways that you degrade your research capacity," Dehoney pointed out.
Beyond the effects on finding cures for diseases such as Alzheimer's, Dehoney warned of job losses at lab equipment makers and other supporting businesses. Trump advisers suggest too much grant money goes to overhead costs but advocates countered the argument misrepresents the facts. They said even indirect funds keep the lights on at university labs and support other key infrastructure such as data storage. A federal judge on Monday temporarily halted the cuts as the case proceeds.
Dehoney said medical research at the academic level needs to play out first because the private sector does not have the resources or patience to play the long game in advancing treatments. She also warned slowing scientific progress could keep more people dealing with chronic health issues from improving their quality of life and participating in the workforce.
"I know a person who is on Social Security disability," Dehoney observed. "She went on a biologic (drug), she has rheumatoid arthritis, and now she's working full-time."
Dehoney argued abruptly stalling important research work also benefits global competitors such as China. She feels there is room for groups like hers to work with the Trump administration on finding efficiencies but only if they actually boost research capacity, not reduce it.
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