Yes. People Will Die.
Joni Ernst’s cringey videos were wrong. They also reveal a lot about the GOP’s desperately dishonest sales job.
BY NOW, YOU HAVE PROBABLY SEEN or heard about the clips of Senator Joni Ernst trying to defend proposed health care cuts in the “Big Beautiful Bill” Republicans are rushing through Congress.
If you haven’t, by all means check them out, and not simply because they are so bizarre. Ernst’s comments are also among the best illustrations yet of how dishonestly Donald Trump and the Republicans are trying to defend their legislation—and how desperately they want to hide its potential impact, which includes real harm to many millions of people.
The saga started last Friday at a town hall meeting where the Iowa Republican fielded questions about the bill, which the House passed late last month and Ernst and her Senate colleagues are taking up now. In the form that passed the House, the bill would slash spending on Medicaid and the Affordable Care Act’s health insurance subsidies by hundreds of billions of dollars over the next decade, with nearly 11 million people likely to become uninsured as a result.
When angry audience members shouted that some of those people losing coverage would die, an exasperated Ernst said, “Well, we are all going to die.” The resulting clip reverberated across the country. The next day, Ernst doubled down by posting an Instagram video—filmed as she walked through a cemetery—in which she said she wanted to “apologize” for revealing that human beings are mortal. “I’m really, really glad I did not have to bring up the subject of the tooth fairy as well,” Ernst said in an attempted deadpan. That video went viral, too.
It was a distinctly Trumpian, never-say-sorry approach, though it didn’t seem to be helping her much politically. By Monday, the Des Moines Register had given most of their front page to her quote, a famous Iowa retailer was selling t-shirts mocking it, and a Democratic state representative had announced a bid to challenge Ernst in the 2026 midterms, saying the senator had been “disrespectful” to Iowans.
Disrespectful, yes. Deceptive, too.
As scrutiny over the Republican legislation has intensified, Trump and GOP leaders have deployed three main arguments in their defense: that the bill won’t cause coverage losses, that it will affect only able-bodied Americans who could be working but aren’t, and that it won’t cause anybody to suffer real financial or physical harm. None of these arguments holds up and it’s not even close.
Just a few weeks ago, a new paper that’s been the talk of the health economics field demonstrated the very point Ernst was denying at her town hall—namely, that the difference between having or losing government-provided health insurance really can be the difference between life and death.
But you don’t need to read fancypants academic journals to understand what this legislation would do if it became law. All you need to do is to talk to some people who know about Medicaid first hand, including some from right in Ernst’s backyard.
HEATHER SANDERS LIVES IN ANKENY, a small suburb north of Des Moines. She taught science to middle and high schoolers in the public schools for more than two decades, until 2023 when she became a nearly full-time caregiver to her elderly mother following a series of medical complications and injuries.
Sanders, 55, says she has had trouble finding steady work to fit around the caregiving—or that could offset the cost of getting care for her mother. “It doesn’t make sense for me to work at McDonald’s when I’d have to pay more to put my mom in a program or a home,” she told me in a phone interview on Monday.
So while she hasn’t stopped looking for work, Sanders said, she’s been leaning on savings and odd jobs to pay her bills. She’s also been leaning on Medicaid for health insurance. That’s possible because Iowa is a Medicaid expansion state, meaning it opened the program to all residents with income below or just above the poverty line.
Roughly 180,000 Iowans are among the 20 million Americans nationwide getting coverage through that expansion. They are also the ones Republicans in Washington are targeting directly with the bill’s biggest single change: a set of “work requirements” that would force states to deny insurance to anybody who couldn’t demonstrate they had employment, were looking for work, or were volunteering for at least eighty hours a month.
The legislation includes an exemption for caregiving, but it doesn’t specify what would qualify and what wouldn’t—or how prospective beneficiaries would satisfy those requirements. It also includes a lookback provision, so that failing to document activities for the past six months or year could disqualify someone from coverage.1
As it happens, Iowa’s Republican governor and GOP leaders of the legislature have been pushing to create a similar state-level requirement for the past few months. It prompted Sanders to speak out at a public hearing, where she talked about her mother and her own struggles to get a job—and pushed back on the idea that people who might not fit into the narrow exemptions, or be able to document them, are somehow undeserving of health care.
Now, Sanders told me, she wants people across the country to hear the same message.
“Previously, I would never have thought I needed Medicaid,” she said. “But then you realize, hey, the people on Medicaid—they’re not just sitting around eating bon bons. It’s a lot of people who have had bad luck—their house caught on fire, or they have a disease and they can’t work, or they work in a job that doesn’t pay for insurance.”
Sanders’s appearance got some local press, and it inspired her friend and former teaching colleague Tim Garner to write his own letter to the state, protesting the cuts. In a phone interview, Garner told me that he, too, has been following the national debate—and he couldn’t help but notice that Republicans want to use money now going to health care to help offset the cost of their big tax cuts for the wealthy.
“It just feels like we’re comforting the comfortable and afflicting the afflicted,” Garner said.
SANDERS IS JUST ONE IOWAN. But it wasn’t hard to find others with firsthand knowledge of how the kinds of health care cuts now under consideration would likely harm them or their loved ones.
• Karen Maass, a retired physical therapist who worked with special needs children, told me she’s seen time and again how documentation requirements prevent even savvy, persistent people from getting help they need. And new documentation requirements are a big part of the Republican bill, which through myriad, technical-sounding modifications would make it more difficult to enroll and stay on Medicaid—and to get the Affordable Care Act’s private subsidies, too.
“I don’t think the average person has any conception of how difficult it can be to fill out the forms you are required to fill out in order to apply for these programs,” Maass said.
• Lori Hunt of Des Moines is trying to find a new job, following layoffs at the advocacy organization where she worked previously. She has been getting private coverage through HealthCare.gov, with the help of those Obamacare subsidies.
But the GOP bill would make those subsidies less valuable—once again, through a set of technical changes. And then there’s the separate possibility that Republicans refuse to renew a temporary funding boost that has made the subsidies even more valuable. “That tax credit covers basically all of my monthly bill,” Hunt said. “Without it, it would cost almost as much as my mortgage payment.”2
• Terry Anderson, 67, is a retired veteran also living in Ankeny. He worries what Medicaid cuts would mean for his adult son, who has severe physical disabilities from cerebral palsy and who depends on Medicaid to pay for the in-home care that allows him to live independently.
Republicans say it’s precisely for people like Anderson’s son that they want to limit Medicaid elsewhere—that is, they’re reducing the rolls in order to ensure that coverage is available for the “truly vulnerable.” Anderson isn’t buying it. Partly, that’s because he used to work on information and data systems for the state, and he has seen how they ensnare people who don’t have the experience dealing with bureaucratic systems: “It’s basically meant to be a picket fence to get rid of people,” he said in a phone interview. “They’re just getting people off the system.”
The changes being proposed by Republicans have particular resonance for Iowa because the state has a relatively high number of people who are self-employed (frequently as farmers) or working in small businesses. That makes them even more dependent on the kind of help that Medicaid and Obamacare provide, according to Mary Nelle Trefz, advocacy network director for the Iowa nonprofit called ACES 360.
Trefz went on to note that the money flowing through these programs ends up helping Iowa economically—in part, by allowing small businesses to compete financially with larger companies that offer benefits. But the broader effects will be felt in Iowa’s rural hospitals, which are always just barely scraping by.
“The conversations I’ve had with hospital executives, they tell me they feel like Medicaid expansion has been a lifeline,” Adam Zabner, a Democratic state representative who works on health care issues, told me. “Before they were operating with maybe 10 or 20 percent of their patients who didn’t have health insurance, and they don’t think they can go back to that.”
The CEO of one rural Iowa hospital system wrote something along those lines in a recent column for the Register: “Cuts to Medicaid . . . force decisions about whether we can keep our maternity ward open, retain emergency services, or offer mental health care,” wrote Todd Patterson, CEO of Washington County Hospitals and Clinics. “These aren’t just services—they are lifelines.”
And the challenge to rural hospitals represents just one way cuts in the federal bill could have broader consequences than most people realize.
“People might have the inclination to think, ‘Well, I’m not on Medicaid, this doesn’t apply to me,’ but I really see these proposals as fundamental threats to our health care system,” said Trefz, adding later that “I think whenever we’re talking about health care, it’s important to think about the ripple effects that can have on our economy and our community—this is going to impact all of us.”
OVERALL, 93,000 IOWANS COULD END UP losing insurance if something like the House bill passes and those temporary Obamacare subsidies lapse. That’s according to an estimate from the Democratic staff of the Joint Economic Committee, but their figure isn’t much higher than an estimate from the nonpartisan research organization KFF, which in its state-by-state breakdown predicted coverage losses in Iowa of 83,000.
Newly updated projections the CBO released on Wednesday suggest coverage losses are probably going to be even higher in Iowa, and in the rest of the country as well.3 And losing insurance is no small matter. It’s certainly not a subject that deserves to be treated as fodder for bizarre selfie videos filmed in cemeteries questioning why people are so bothered by reminders of their mortality.
On Tuesday, researchers from Yale and the University of Pennsylvania calculated the effects of all the cuts in the GOP legislation, including reductions in spending on food assistance. Their conclusion: 51,000 more people dying annually.
These projections are hard to get right, and that’s an awfully big number. But the general idea that people could die because they lose health insurance is fully consistent with that new, much-discussed paper that came out last month—and a bunch of other, highly regarded studies that preceded it.
“Joni Ernst is correct that we will all someday die,” University of Michigan economist Helen Levy, coauthor of a recent Brookings Institution essay on the subject, told me in a phone interview. “But how soon that happens depends a lot on what your access to medical care is, and having insurance gives you better access to medical care.”
Republicans who believe in this bill have their reasons. They see lots of upside in smaller government and big tax breaks for the wealthy, more than enough to justify whatever downsides come from cutting health insurance for poor people.
That’s a perfectly defensible proposition, one that’s been part of debates about the size and scope of government for as long as those debates have been taking place. But it doesn’t play well politically, as Republicans have learned every time voters have punished them for such cuts.
That is why House Speaker Mike Johnson was on NBC Sunday vowing that the bill “strengthens” Medicaid while budget director Russell Vought was claiming on CNN that “no one will lose coverage as a result of this bill.” And it’s why Trump himself keeps insisting—as he did on Truth Social this week—that “there will be NO CUTS” to Medicaid.
In other words, they can’t win the political fight on the merits, so they’re lying. Whether they get away with it will depend, in part, on how many people realize what the Republican bill would really do—and whether they speak out against it, as they did at that Iowa town hall with Ernst.
“People don’t appreciate the full scale and scope of what’s at stake here,” Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities, told me. Lueck happens to be a native Iowan with family still in the state, and said she thinks a lot about what the bill would mean for people back home. “People need to pay attention now, before it becomes reality.”
Edwin Park, research professor at Georgetown’s Center for Children and Families, said interpretations would be left to HHS and the states—with “no requirement that states provide this exemption automatically.” As a result, Park said, “it is certain that those who would be eligible for this exemption (including parents of dependent children more generally) would be at serious risk of ending up unable to obtain the exemption.”
The expiration of those subsidies would have a massive effect of their own, leading 5 million more people to become uninsured, according to CBO.
If the projections are right, the percentage of Americans without coverage would reach its highest level since before the Affordable Care Act took effect, according to calculations by Bobby Kogan, senior director for budget policy at the Center for American Progress.
So, here's another good example: me. I'm 35, and I make around 2000 to 2800 a month. But I'm not a w2 employee; I'm a 1099 employee, meaning that my employer doesn't have to give me benefits or anything. Now, I get my health insurance through the state of MD, and yes, Medicaid. Despite the fact that I'm a healthy, able bodied adult who works, I am on medicaid because of my income.
It isn't that I'm lazy; I work more than 40 hours a week as it is. It's that there aren't a lot of W2 jobs that I can do in the part of the state I'm in, and so I make do with the 1099 jobs. I pay my taxes too, at the self employment 30% rate too.
The reality is, most people who are on medicaid work; and the ones that don't are disabled or old. Simply put, cutting it is just kicking poor people.
Ernst’s defense would be equally valuable to any accused murderer. The victim was going to die anyway, so no harm and no foul.