Project 2025: Privatize Medicare, Criminalize Abortion, Punish Poor People
With a good dose of trans-sexism and bans on IVF and gay adoption
There are three pieces of a functioning democratic society that should never be subject to market forces: healthcare, education and journalism. You unleash the forces of your demise when you create circumstances in which only rich people can be free of disease, full of knowledge, and have the courage to tell the truth.
Most of what I have written in this Substack has to do with the demise of journalism. This week, as part of my bi-weekly series on Project 2025, I am focusing on the right’s intention to subject even more healthcare to market forces.
This should be a pretty easy thing to understand. The U.S. healthcare system has been stuck in the mire of trickle-down theory for the last few decades. And the one piece of forward progress - the Affordable Care Act - lacked the ability to give real subsidies until this year, 10 years after it was launched.
Former President Barack Obama calls this the slow work of turning around the ship of state. I call this the corrosiveness of low expectations.
Most people know that the ACA got rid of pre-existing conditions, let people keep their children insured through age 25, and provided a marketplace where we could weed through expensive insurance plans with high deductibles that didn’t tell us exactly what they would or wouldn’t cover.
What I didn’t realize until recently is that there were supposed to be bigger subsidies for those plans. But Congress rejected that. And, my gut tells me, Obama didn’t push.
President Biden’s Build Back Better plan expanded those subsidies, so - finally! - the Affordable Care Act lives up to its name.
If Roger Severino has his way, the ACA would go back to being the appendix of laws - flapping uselessly in our body of jurisprudence.
Severino - a former Trump HHS attorney who is a domestic policy advisor at the Heritage Foundation - wrote chapter 14 in Project 2025, which focuses on changes that would be made to healthcare with the election of “the next conservative president.”
(I will repeat that phrase in every P2025 piece I write, because this is not just about Trump. If Trump loses, this document will be lying in wait for the next conservative candidate.)
Severino wouldn’t actually get rid of the ACA. There have been so many failed attempts at this point, that would be futile. Rather, he wants to gut it from the inside, in a kind of sneak attack.
One would be forgiven if, after reading this 49-page euphemism of a chapter, you came away thinking there was nothing there. Severino wants you to think that. He doesn’t write anything that people will take offense at. But a closer examination - and days of researching every highlighted part of the chapter below - reveals that there is a lot of meaning in what Severino tries to avoid saying.
If I could rename this chapter on Health and Human Services, I would call it, “We Hate Poor People and Women,” with a subhead, “Especially Black poor people and trans women.”
And a sub-subhead of “We want to privatize Medicare, but we’re not telling you that.”
This is on page 41 of the 49-page chapter:
The Family Agenda. The Secretary’s anti-discrimination policy statements should never conflate sex with gender identity or sexual orientation. Rather, the Secretary should proudly state that men and women are biological realities that are crucial to the advancement of life sciences and medical care and that married men and women are the ideal, natural family structure because all children have a right to be raised by the men and women who conceived them.
Let’s be clear - this is one of the main agenda items in the whole of P2025. Every single chapter mentions or refers to trans rights and women’s rights. Most of them also refer to poor people. The greatest sin our government has committed, according to the august writers of this document, is the propagation of the idea of equity.
And abortion.
Click on the PDF above for an annotated look at my thinking as I analyzed this document.
Parsing It Out
But there are prescriptions in this HHS chapter that go beyond sexist and trans-sexist dog whistles. There are assumptions that would be laughable if they weren’t underpinning dangerous intentions to act.
Let’s start with the first paragraph, in which Severino writes that Under Trump, “HHS was focused on “all Americans from conception to natural death, including those individuals and families who face…economic and social well-being challenges.”
Biden, Severino says, changed HHS’ mission to “promoting equity in everything we do for the sake of populations sharing a particular characteristic, including race, sexuality, gender identification, ethnicity and a whole host of other categories.”
Because of that, Severino implies, white people are dying.
This one paragraph shows so much about the thinking of the Project 2025 oligarchs that it’s worth parsing with a bit of detail.
First, white people really are dying from more “deaths of despair,” as Anne Case and Angus Deaton realized in their research. This started in the 1990s, just as “trickle down economics” reached its zenith.
Deaths of despair include alcoholism, drug use, suicide. These numbers are absolutely up in communities whose only employer closed their plants and went overseas; who saw their unions busted or capitulate to a lower starting wage; who saw their main streets close and be replaced by lower-paying big box stores; who couldn’t afford healthcare. Who had lost hope.
Who bought the Shangri-la story of “morning in America” but then turned destructively inward when they realized the sun was rising only for a selected few.
In other words, the policies written in the 1980s Heritage Foundation version of Project 2025 led to the demoralization and premature deaths of people who were impacted.
But Severino wants to blame Black and Queer people.
This becomes clearer in Severino’s characterization of the different approaches of Trump and Biden.
Trump’s policies covered “All Americans from conception to natural death… including… those who face economic and social well-being challenges.”
Biden changed that to “promot[e] equity in everything we do for the sake of populations sharing a particular characteristic, including race, sexuality, gender identification, ethnicity and a whole host of other categories.”
For Severino - for all the libertarians who make up the “intellectual” wing of the conservative movement - promoting equity is harmful to the people who don’t fit into those categories, i.e. poor white people.
For them, it’s an either/or. If Brad gets 10 pieces of chocolate, and Marcus gets four pieces of chocolate, and to ensure they get the same amount you make more chocolate so they each get 10, Brad is not harmed.
But Brad - Roger Severino, in this case - feels slighted. He feels he should have more.
Biden didn’t STOP serving people not in those categories Severino lists. He looked at the research and realized people in those categories are underserved, and he wanted to change that.
Also note Severino’s use of the phrase “gender identification” in place of “gender identity.” The first implies that it’s a choice, a piece of clothing one puts on. “I want to be a boy today…” This is how Severino and his team at P2025 see it. Don’t just gloss over words like this when you’re reading.
I also want to look at his wording “from conception to natural death.” Severino uses a variation of this phrase a few times in the chapter. He never says IVF or In Vitro. He just refers to conception. Then there’s this line on p. 451 (page 3 in the attached pdf):
“In the context of current and emerging reproductive technologies, HHS policies should never place the desires of adults over the right of children to be raised by the biological fathers and mothers who conceive them.”
So, no sperm and egg donors?
On page 461 (page 13 in the pdf) Severino says that “three-parent embryo creation and human cloning research should be banned.”
So… no sperm and egg donors.
Again, it’s what’s not said, it’s words they use that are purposefully not defined, that is the scariest part of Project 2025.
The thing that cracks me up most about this first paragraph is it’s a complete contradiction of the entire premise.
Severino argues later in this chapter - and other authors argue in other chapters - that the federal bureaucracy is too bloated, that they are full of “experts” who make decisions that don’t comport with the wishes of the president.
And yet, right here in this first paragraph, Severino laments that the Department of Health and Human Services changed it’s focus when Biden came to office.
Which is it? Do presidents direct the work of federal agencies? Or do agencies ignore the presidents?
And since Severino gives no examples of agencies ignoring Trump, I have to assume that he’s talking about things that he and his P2025 cohorts wanted to do in the Trump administration that were illegal.
Medicare and Medicaid
Severino says right on the top of page 465 (page 17 in the pdf) that Medicare Advantage would become the default option if Project 2025 is rolled out. That’s what people will automatically get when they turn 65.
Medicare Advantage is the private supplemental insurance that seniors can get to cover things Medicare doesn’t. And Medicare doesn’t cover everything, because Republicans have consistently vetoed improvements.
Making private insurance the default option for Medicare sure seems like privatizing Medicare to me.
Even worse, Severino wants to stop crackdowns on Medicare Advantage after some providers were sued or indicted for fraud in Medicare Advantage billing.
Severino will get rid of $35 insulin and other “price controls” which he sees as anti-free market.
He also wants to give “control” over health care spending to patients. We know how this works. “Control” equals “put the responsibility on the patient.” The ACA marketplace doesn’t give you minute details about what’s in their plans because it’s confusing and legalistic. People who buy insurance are not experts on insurance. They just want to be covered.
We shouldn’t make people shop for healthcare.
Severino wants to semi-privatize Medicaid, too. Really, he just wants to reduce coverage because he thinks that the people who get Medicaid are not “truly needy.” He doesn’t define that term. But for me, it evokes a Dickensian mindset.
He proposes to:
Lower payments states get from the federal government
Make it harder to qualify for Medicaid
Make people on Medicaid partly pay for their care
Implement work requirements
These read like punishments to me. But if your worldview is that some people are better than others, it makes a macabre kind of sense.
Other changes Severino wants to make:
Prioritize straight married families
Prohibit adoptions by gay families
Stop “mail order abortions” - which is the second reference I’ve seen in the six chapters I’ve annotated so far that refers to the Comstock Act of 1873
Get rid of the “no surprises” rule in medical billing. Remember, it’s all about consumer choice. If the consumer doesn’t go to an in-network doctor, then that’s their choice. Even if the consumer is in a car accident and is simply taken to the closest hospital, it’s still their choice for being unconscious and not telling their ambulance driver where to take them.
Contradictions
Surprisingly, there are some good ideas in this chapter, though Severino does not apply them consistently.
He writes about the revolving door and partnerships the Centers for Disease Control and the National Institutes of Health have with pharmaceutical companies. He argues that should stop. And yet, he argues later that Medicare Advantage audits are too stringent.
This is a contradiction. He doesn’t want the CDC to partner with Big Pharma, but he’s OK with letting doctors commit fraud.
He writes on page 455 (7 in the pdf) that “Miscarriage management or standard ectopic pregnancy treatments should never be conflated with abortion.”
But then he defines EMTALA (requiring doctors to treat anyone who comes to an ER) to mean saving aborted fetuses who he thinks are “born alive.”
He wants to get lower-cost generic drugs into the market faster. BUT he would also lower standards for making generic drugs, and leave it up to the marketplace. So if your pharmacy wants to buy lower cost drugs that have been less rigorously tested, that’s just the choice you make. Buyer beware, I guess.
There is one paragraph in this chapter that left me absolutely speechless. In a section on COVID lockdowns, Severino writes:
…how much risk mitigation is worth the price of shutting down churches on the holiest day of the Christian calendar and far beyond as happened in 2020? What is the proper balance of lives saved versus souls saved? The CDC has no business making such inherently political (and often unconstitutional) assessments and should be required by law to stay in its lane.
In other words, as long as Jesus is in your heart, you can kill anybody.
That pretty much sums up Project 2025.
I decided to analyze Project 2025 because it scared me. And I didn’t see anyone pointing out the things that scared me the most. It’s not just what they say they’ll do.
It’s what they imply they will do.
This takes a tremendous amount of time to read, annotate and write.
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Previously in this series:
Poor people are punished under both parties’ rule. Millions of migrants entering under an expanded asylum loophole hurts sanctuary cities and cripples poor communities therein.