DC residents and their political leaders are understandably anxious about Donald Trump’s second presidential term. They are also disturbed by the fact that the Republican Party has gained control, albeit narrow, of the Senate and House. That trifecta is exacerbated by the reality that so few conservatives on Capitol Hill have the courage to stand up to Trump and his potential cabinet members, many of whom are unqualified or outright corrupt.
Local citizens with whom I have spoken during the past week have expressed concern that Republicans might repeal the city’s Home Rule Charter, depriving it of its quasi-independence; that a control board might be imposed to manage the overall operations of the District government; or that the city’s police force might be merged with federal law enforcement, placing the Metropolitan Police Department under the Department of Justice. Already the DC Superior Court is technically a federal agency.
Given the city’s unavoidable connection to the federal government, its interactions with the first Trump administration and recent actions by congressional Republicans — such as repealing the DC Council’s revised criminal justice code — don’t think such predictions of mayhem and madness are hyperbole.
The havoc could be more direct, affecting hundreds of thousands of low-income residents who desperately depend on the government for their quality of life. Consider, for example, that the foundational funding for the DC Healthy Families and several other health care programs comes principally from the federal government.
The District government finances a health insurance program that serves as many as 300,000 low-income adults and children. For context, DC has a population of nearly 680,000 people, according to the U.S. Census Bureau. In fiscal year 2024, the city-approved total budget for health care of District residents was about $5 billion, according to DC Council documents.
More specifically, nearly $4 billion went to Medicaid providers; 70% of the money the city spends for Medicaid recipients comes from the federal government, while 30% comes from local tax revenue.
In 2024, the city also budgeted nearly $119 million of its own money to provide health insurance through the DC Health Care Alliance to immigrant residents who because of federal rules and regulations do not qualify for Medicaid.
The health care of all these individuals could be at risk depending on what changes are implemented by the federal government during this next Trump administration. One thing is clear: With its current fiscal challenges, the DC government couldn’t possibly eat the costs currently being borne by the feds.
Wayne Turnage, the District’s deputy mayor for health and human services and the director of the DC Department of Health Care Finance, did not respond to my request for a comment.
However, Adrian Jordan, president of Amerigroup DC, a managed-care organization that contracts with the District to ensure Medicaid-eligible low-income residents, among others, receive health care, said the future is unknown.
“It’s a matter of what [changes] the city is willing to make, and what it can afford,” said Jordan, adding that his company, which is a division of Anthem, is “prepared for anything.”
“We can be helpful to the city because [our parent company] operates in deep red states,” he added.
When Trump announced his intention to nominate Robert F. Kennedy Jr. as secretary of the Department of Health and Human Services (HHS), he said he would let Kennedy “go wild” on health, food and medicine. A massive agency, HHS includes a number of operating divisions with expansive portfolios — including the Centers for Disease Control and Prevention, the National Institutes of Health, the Federal Drug Administration, and the Centers for Medicare and Medicaid (CMS).
Trump has named Dr. Mehmet Oz to be administrator of CMS. Kennedy’s position is predicated on Senate confirmation; Oz’s is not. While the latter does have a medical degree, both lack the experience necessary for their assignments.
“I definitely think that there is area for concern. Mehmet Oz is not what I would call an expert for CMS purposes,” at-large DC Councilmember Christina Henderson told me during a recent interview about the potential federal changes under Kennedy and Trump.
Henderson, who serves as chair of the legislature’s Committee on Health, acknowledged that Oz is a practicing physician but offered that dealing with the administrative, regulatory and policy demands of CMS “is very complicated. There are a lot of moving pieces. Layer RFK on top of that, who we know doesn’t know very much about CMS policies and procedures.”
She noted that DC, like many states, recently submitted an “1115 waiver” application. “Our hopes were to be able to do some pretty innovative things with Medicaid dollars. I think there’s lots of concern that these waivers are going to sit for months.”
“If the political folks want to slow things down, then that’s really going to put us in a pickle in terms of some of the more innovative work that we have been able to do,” Henderson added.
A constipated bureaucracy may be the least of the city’s worries, especially since by most standards the current CMS hasn’t been a paragon of speed or efficiency. During an examination of the District’s health care delivery system I conducted in 2023, I learned that CMS officials provided little to no direct oversight of DC, save an annual report.
Despite a purposeful stream of mixed messages, it’s no secret what Republicans want: repeal of the Affordable Care Act, commonly called Obamacare; an end to federal financing of gender-affirming treatment; new conditions for receipt of fertility treatment; and adjustments to the financing formula used to reimburse states, among others.
Earlier this week, the U.S. Supreme Court heard arguments in U.S. v. Skrmetti, which revolves around whether states can ban gender-affirming treatment for children and teens.
Project 2025’s “Mandate for Leadership: The Conservative Promise” — a document published by the Heritage Foundation as a transition framework but at least nominally rebuffed by Trump during the campaign — includes a number of recommendations for HHS and its subordinate agencies. Roger Severino, one of the authors, called for CMS to reissue “a stronger transgender national coverage determination. CMS should repromulgate its 2016 decision that CMS could not issue a National Coverage Determination (NCD) regarding ‘gender reassignment surgery’ for Medicare beneficiaries,” pushing the issue onto the states, which undoubtedly would have to foot the bill if they decided to provide such coverage.
Severino also argued that one of CMS’ goals should be “promoting stable and flourishing married families,” which he described as being “comprised of a married mother, father, and their children.”
“Unfortunately, family policies and programs under President Biden’s HHS are fraught with agenda items focusing on ‘LGBTQ+ equity,’ subsidizing single-motherhood, disincentivizing work, and penalizing marriage. These policies should be repealed and replaced by policies that support the formation of stable, married, nuclear families.”
Further, “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,” added Severino.
He also advocated for putting Medicaid on a “fiscally predictable budget” by adjusting payments to hospitals, reforming managed care and adding a work requirement.
It’s hard to believe that Republicans can successfully repeal Obamacare given their past failures when they’ve tried to do so. But they can do plenty of harm in other areas as Severino’s recommendations suggest.
Even Democrats in the House and Senate may go along with some of these ideas. Don’t forget that Democratic President Bill Clinton joined with the Republican House under then-Speaker Newt Gingrich to end “welfare as we have come to know it,” forcing states to adopt employment requirements in order for them to receive federal funds. It wasn’t all bad. But those who didn’t go along with the plan lost some benefits.
Henderson told me that there aren’t 60 votes in the Senate to “get rid of ACA” but posed another scenario: “Can you squeeze Medicaid on the federal side so much that you’re actually kicking people off health care?”
Absolutely.
District officials will be forced to play a carrot or stick game — with far more sticks than carrots being used to impose the federal will. People I spoke with believe the biggest stick may not even be inside the health arena but instead aligned with Trump’s signature immigration program, which includes mass deportations.
A longtime sanctuary city, DC has provided aid and comfort to tens of thousands of immigrants, many from Central America. Thousands of the residents enrolled in the city’s Health Care Alliance program are from those communities. Henderson told me that the number of people with that coverage has declined over the years. However, the city could still be pressured to provide information for those deportation efforts or risk losing funding for various federal programs, including health care.
What happens if Tom Homan, Trump’s designated border czar, comes calling for the names of individuals who are members of the Health Care Alliance?
If District officials or contractors decline to provide such information, what will happen to the city’s Medicaid funding?
Henderson said that Trump cannot change Medicaid rates by executive order. Does he have to with Republican majorities in the House and Senate?
The train may be late leaving the station, but eventually it will leave.
“We are having conversations with our partners in government to get very clear on the legal protocols and requirements around protecting personally identifiable information,” said Henderson, adding that she hopes private philanthropy can come to the rescue if programs and health care take a hit during this Trump administration.
“We can’t afford to just pull everything back,” she said. “I would certainly challenge the private philanthropy world to be paying attention and using this opportunity to plug holes, particularly in the public health space where the federal government has said ‘no more.’ ”
That’s a tall order.
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