The Hidden Cost of Cutting Medicaid

Medicaid was never intended to be the backbone of the U.S. public health system. But what started in 1965 as a limited health insurance option for a small group of low-income Americans has grown into a $900 billion program that funds everything from hospital care to housing support.  In this episode, Michael Sparer and Rebecca Sale trace the history of Medicaid and unpack the sweeping changes coming to the program under the “One Big Beautiful Bill.” The result won’t just be fewer people with insurance. It could also mean unexpected and harmful cuts to the country’s already fragile public health system. They also discuss whether a small, unexpected provision for rural health investment could point toward a better model for the future. Michael S. Sparer, J.D., Ph.D. is the William Henry Welch Professor of Public Health Systems at Columbia University's Mailman School of Public Health, where he has taught for over 30 years. He also directs the Center for Public Health Systems, which examines how America's fragmented public health infrastructure functions and how it can better serve communities. Professor Sparer’s research examines how policy shapes politics both in health insurance systems and in local health departments. He is particularly expert in Medicaid policy and in the inter-governmental dynamics that have shaped the evolution of that program. His work on public health has also focused on federalism and on the ways in which local health departments respond to changing political and fiscal environments. Before his academic career, he spent seven years as a litigator for the New York City Law Department. He is a three-time recipient of Columbia teaching excellence awards and former editor of the Journal of Health Politics, Policy and Law. The Center for Public Health Systems at Columbia's Mailman School of Public Health conducts needed research, facilitates public discussions, develops policy proposals, and provides educational programs, all with the goal of encouraging a better, more efficient, and more equitable public health system. This work builds on the recognition that the nation’s public health system is currently under-resourced, under-paid, and under-valued and that a stabilized and strengthened system would benefit all of us.