EARTH FUTURE ACTION

AMERICA'S STATE OF EMERGENCY

THE TIME FOR ACTION IS NOW

POOR PEOPLE ARE GETTING KILLED EVERY DAY

BECAUSE AMERICA REMAINS THE ONLY MODERN STATE

WITHOUT HEALTHCARE AS A RIGHT

THOUSANDS OF AMERICANS DIE EACH YEAR FROM A LACK OF HEALTH INSURANCE

America's healthcare system was in a state of disaster even before COVID. The pandemic exposed and intensified a system that was already failing, resulting in the United States recording one of the highest COVID death tolls in the world. Many studies show that this death toll could have been reduced by a universal healthcare system. More recent federal data confirm that millions remain uninsured or underinsured in 2025 and 2026, meaning preventable deaths are still occurring today.

In the first half of 2025, the Centers for Disease Control and Prevention reported that about 27.5 million Americans (roughly 8.2% of the population) were uninsured, according to the National Health Interview Survey. Among adults ages 18-64, more than 11% lacked coverage, leaving millions without reliable access to care. Research consistently shows that large-scale coverage losses translate into thousands of preventable deaths. A 2025 analysis published in Annals of Internal Medicine and reported by STAT News found that proposed Medicaid and ACA cuts could lead to more than 16,000 deaths per year.

A recent study by Yale epidemiologists showed that Medicare for All would save around 68,000 lives a year while reducing U.S. healthcare spending by around 13%, or $450 billion a year. In 2022, Yale researchers also found that more than 335,000 American deaths during the pandemic would have been prevented if there was universal health insurance. In addition, the U.S. would have saved $105 billion in COVID-19 hospitalization expenses alone.

A Lancet study in 2021 also showed that 40% of Covid deaths were preventable. The medical journal The Lancet came to this conclusion by comparing the pandemic in the United States with other high-income G7 nations, like Britain, France and Canada. One of the report's recommendations is a single-payer reform, like Medicare for All, that would, quote, "cover all residents under a single, federally financed plan providing comprehensive coverage," unquote. Read more about the study here at Democracy Now.

A March 2021 report by the progressive group Public Citizen also found that hundreds of thousands of U.S. COVID deaths could have been avoided under a single-payer system, noting that under such a system, hospitals would be better funded and providers would be better able to coordinate care for patients.

Americans are dying because they don't have health insurance or can't afford the out-of-pocket costs.

Immediate action is needed. An action agenda of what is needed is outlined at the end of this report.

MILLIONS OF AMERICANS WITH HEALTH INSURANCE ARE UNDERINSURED

Millions of Americans suffer under policies that provide little meaningful protection. High deductibles and cost-sharing force families to pay thousands of dollars before their insurance begins to cover care.

The Commonwealth Fund reports that nearly one-quarter of adults are underinsured, meaning they face serious financial barriers despite being insured.

Surveys by the Kaiser Family Foundation show that cost remains one of the main reasons insured Americans delay or skip care.

Rising premiums and deductibles are expected to worsen underinsurance through 2027 unless major reforms are enacted.

THE HIGH AMERICAN MORTALITY RATE COMPARED TO OTHER MODERN STATES

The United States continues to rank poorly among wealthy nations in basic health outcomes. Life expectancy rose modestly to about 79.0 years in 2024, following pandemic declines, but remains below most peer nations.

A 2025 analysis in JAMA Health Forum found that avoidable mortality remains significantly higher in the U.S. than in comparable countries.

OECD data confirm that the U.S. continues to lag behind other developed nations in health outcomes despite far higher spending.

Unless coverage stability and benefit protections are strengthened, 2027 is likely to reflect continued stagnation in U.S. life expectancy relative to peer nations.

THE U.S. HAS HIGHER SPENDING ON HEALTHCARE COMPARED TO THE REST OF THE DEVELOPED WORLD

The United States spends more on healthcare per person than any other developed nation, yet continues to produce poorer outcomes. U.S. healthcare spending far exceeds that of Europe, Canada, and Japan.

Despite this extraordinary spending, millions remain uninsured or underinsured, and medical debt continues to rise. Administrative waste, fragmented insurance systems, and profit extraction drive costs upward while resources are diverted away from direct patient care.

High spending without universal access is not a sign of strength. It is evidence of systemic inefficiency and inequality.

ACA CHANGES AND COVERAGE LOSSES IN 2026

Enhanced Affordable Care Act premium tax credits expired at the end of 2025. These credits had lowered premiums for millions of families since 2021.

Without them, premiums rose sharply in 2026. The Urban Institute estimates that up to 4.8 million people could lose coverage as a result.

The Kaiser Family Foundation reports that average marketplace premium payments could more than double for some families.

Enrollment declines are already visible in 2026.

NO PAID SICK LEAVE IN THE U.S.

Currently, there are no federal legal requirements for paid sick leave in the U.S. Some states and local jurisdictions require it, but it needs to be a national requirement. Many employees, especially in low-wage sectors, must choose between income and health.

The United States is one of the few countries in the world that does not require paid sick leave for its workers. Of United Nation member countries, 181 provide paid sick leave in some form while 11 do not, including the U.S. So this places the U.S. along with nations like Tonga, Tuvalu, Nauru, and Somalia.

Bureau of Labor Statistics data show that a large share of private-sector workers lack paid sick leave.

International labor standards demonstrate how unusual this is among developed nations.

As healthcare access weakens and out-of-pocket costs rise, lack of paid sick leave in 2026 will further increase health risks.

MEDICAID CUTS, AND COVERAGE LOSSES

For decades, Medicaid has operated under divided federal and state control, a structure that has produced chronic instability and weak accountability. When costs rise, responsibility is routinely shifted rather than resolved. Congress limits spending growth, states impose cost controls, and hospitals, physicians, and patients absorb the consequences. Instead of building a durable financing and administrative system, policymakers have relied on indirect cost containment (payment freezes, benefit limits, eligibility tightening, and administrative barriers) that reduce access without appearing as formal "cuts."

One of the most persistent failures has been chronic underpayment of providers. The Medicaid and CHIP Payment and Access Commission reports that Medicaid physician payments average about two-thirds of Medicare rates, discouraging participation and shrinking provider networks. The Commonwealth Fund has documented that these low rates are associated with longer wait times, fewer specialists, and delayed treatment. Hospitals face similar structural underpayment. The American Hospital Association reports that hospitals absorbed more than $130 billion in combined Medicare and Medicaid underpayments in 2023, continuing a long pattern of public programs paying below the cost of care. Rather than correcting these imbalances, policymakers have allowed underpayment to become a permanent feature of the system.

The Affordable Care Act expanded Medicaid in 2010 and significantly reduced uninsured rates in participating states, yet political resistance delayed expansion in several states for years. At the same time, Congress repeatedly debated proposals to cap Medicaid spending through block grants and per-capita limits. The Kaiser Family Foundation warned that these approaches would reduce federal support over time and force states toward coverage and payment cuts. Even when these proposals failed, they reinforced fiscal uncertainty and discouraged long-term investment in staffing, infrastructure, and service expansion.

During the COVID-19 pandemic, Medicaid was temporarily stabilized through continuous coverage rules that prevented disenrollment. Enrollment rose to historic levels, and coverage gaps narrowed. Expanded ACA premium tax credits further reduced coverage loss during transitions between Medicaid and private insurance. These protections, however, were treated as emergency measures rather than the foundation for lasting reform. When continuous coverage ended in 2023, states resumed eligibility reviews at scale. By 2025, more than 25 million people had been disenrolled, many for procedural reasons rather than income changes. Congress also allowed enhanced ACA tax credits to expire at the end of 2025, increasing premiums and weakening coverage transitions. The unwinding exposed major management failures, including outdated systems, understaffed eligibility offices, and inconsistent outreach.

THE DISASTROUS TRUMP TAX BILL OF 2025 IS A DEATH SENTENCE FOR MANY

On July 4, 2025, President Donald Trump signed H.R. 1 into law, embedding supposed cost controls into Medicaid. Rather than strengthening administrative capacity or reimbursement levels, H.R. 1 tightened eligibility oversight, restricted state financing tools such as provider taxes, reduced retroactive coverage protections, and established new work-reporting requirements. The Kaiser Family Foundation has noted that restrictions on provider taxes reduce states' ability to stabilize Medicaid without cutting payments or services. The law formalized a shift toward managed contraction rather than structural repair.

This bill creates a bureaucratic nightmare for poor people who need healthcare.

Medicare and Medicaid Underpaid Hospitals by $100 Billion

Protect Medicaid

MEDICARE UNDERFUNDED: SIXTY YEARS OF PATCHES INSTEAD OF PERMANENT SOLUTIONS

Since its creation in 1965, Medicare has been governed less by long-term financial planning than by political avoidance and short-term budget management. Rather than establishing a stable, dedicated funding structure capable of keeping pace with rising medical costs and a rapidly aging population, Congress has repeatedly relied on temporary fixes, payment suppression, budget caps, and fiscal maneuvers to postpone difficult decisions. From early hospital payment limits and the Balanced Budget Act of 1997 to decades of physician "doc fixes," sequestration cuts, and shifting payment formulas, lawmakers have preserved Medicare's appearance of stability by transferring financial risk onto providers and beneficiaries. By 2026-2027, this six-decade dependence on stopgaps has left the program legally intact but operationally strained: marked by chronic underpayment, uneven access to care, and unresolved long-term solvency risks.

Medicare's financial fragility was built into its original structure. Part A (Hospital Insurance) relies primarily on payroll taxes and a trust fund, while Parts B and D depend heavily on general federal revenues and beneficiary premiums that rise automatically with costs. This fragmented model avoided politically difficult tax increases but ensured that Medicare would be perpetually exposed to budget politics. Instead of aligning revenues with long-term obligations, Congress chose a system that requires continuous intervention (creating a permanent cycle of short-term "fixes" rather than durable financing).

By 2026-2027, the cumulative impact of Medicare's long reliance on payment restraint and temporary fixes is increasingly reflected in measurable system stress. MedPAC reports that many hospitals, skilled nursing facilities, home health agencies, and physician practices continue to face sustained financial pressure when serving Medicare patients, particularly as labor, supply, and compliance costs remain elevated. The American Hospital Association similarly documents that Medicare payments frequently fail to cover the full cost of care, forcing hospitals (especially rural and safety-net institutions) to rely on cross-subsidization or service reductions to remain solvent. These financial gaps are magnified by ongoing sequestration reductions and uneven annual payment updates, leaving many providers with limited capacity to expand services, invest in staffing, or absorb future shocks.

Provider participation and service availability suffer when persistent Medicare payment constraints reduce providers' willingness to accept patients, limit appointments, and discourage investment in high-cost specialties and rural facilities that depend heavily on Medicare revenue. Chronic underfunding strains the workforce by limiting hospitals' and practices' ability to offer competitive wages, retain specialized staff, and maintain adequate staffing ratios, resulting in longer wait times, reduced services, and clinician burnout (with under-resourced facilities least able to respond). When Medicare payments fall short, providers compensate by negotiating higher private insurance rates, increasing fees, or consolidating for pricing power, effectively spreading Medicare's financing shortfalls across the system through higher premiums and out-of-pocket costs. For beneficiaries, these structural pressures create practical barriers: while Medicare's benefit package remains intact, access to timely appointments, specialized care, and nearby facilities increasingly depends on provider participation and local capacity, with a growing share experiencing difficulty finding providers in certain specialties and regions (not due to benefit cuts, but to financing policies that fail to sustain provider networks over time).

Taken together, these outcomes demonstrate that Medicare's underfunding in 2026-2027 is no longer merely a budgetary abstraction. It manifests in workforce instability, service reductions, regional access gaps, and cost shifting throughout the healthcare economy. Decades of reliance on payment suppression and temporary fiscal fixes have produced a system that functions, but only by operating under continuous strain. Without structural reform to align revenues with long-term obligations, Medicare's future will continue to be shaped less by deliberate stewardship than by managed scarcity.

End Medicare's Underpayments To Physicians

Medicare and Medicaid Underpaid Hospitals by $100 Billion

BIDEN'S CUTS TO SOCIAL BENEFITS AND PUBLIC HEALTH

Many key relief programs were put in place when the government declared a federal Public Health Emergency at the beginning of the Covid pandemic. These programs provided a lifeline for the poor, and many other struggling Americans. But now that the federal Public Health Emergency has been declared over in 2023, these relief programs have been rolled back and ended. There also is no more new funding for Covid. At the end of 2022, Biden and Congress failed to include Covid funding in the 2023 budget. Zero dollars were appropriated for Covid in the fiscal year 2024 budget, which was released on March 9th, 2023.

The federal Public Health Emergency was ended in the Spring of 2023. What this means is up to 18 million Americans (including millions of children) were tossed off Medicaid.

As of March 1st, 2023, the food stamp benefits added during Covid were taken away from 32 states. Recipient households had their monthly grocery allocations reduced by at least $95. (NBC News)

One of the most damaging consequences was the mass termination of Medicaid coverage. Beginning in 2023, states resumed eligibility "redeterminations," triggering the largest coverage purge in program history. By 2024, more than 18 million people (including millions of children) had lost Medicaid, often due to paperwork barriers rather than true ineligibility. Many of these individuals remained uninsured or underinsured through 2025 and 2026.

At the same time, enhanced nutrition assistance ended. In March 2023, emergency Supplemental Nutrition Assistance Program (SNAP) benefits were eliminated nationwide, cutting monthly grocery support by $90 to $250 for many households. These reductions intensified food insecurity as inflation and housing costs rose. By 2025 and 2026, food banks and community pantries reported sustained crisis-level demand.

Housing protections also expired. Federal eviction moratoriums and emergency rental assistance programs wound down without adequate long-term replacements. Homelessness and housing instability increased through 2024 and 2025. Families pushed off Medicaid and food assistance often faced compounding risks: untreated illness, medical debt, eviction, and job loss.

Looking ahead, the 2027 outlook remains fragile. Medicaid financing pressures, workforce shortages, and rising healthcare costs threaten to deepen access gaps. Without renewed federal investment, coverage losses and service reductions are likely to continue compounding beyond 2027.

DISASTROUS CUTS IN SOCIAL SECURITY OPERATING BUDGET

Social Security is often described as a protected, self-funded program supported by payroll taxes. In reality, its ability to function depends on yearly funding decisions made by Congress. For Fiscal Year 2025, SSA received about $14.3 billion (nearly $2 billion less than it said was needed to meet rising demand). For FY2026, funding rose only slightly to about $14.8 billion, still below long-term needs. Once inflation and workload growth are considered, this amounts to a real cut.

This chronic underfunding has weakened customer service and reduced public access. Between 2010 and 2019, SSA's workforce declined by about 15 percent. Staffing fell another 10 percent in 2025 alone. Field offices in most states have experienced double-digit staff losses, while in-person visits are being cut by roughly 50 percent.

At the same time, policy changes are narrowing access to benefits. Proposed rules could reduce Supplemental Security Income eligibility for hundreds of thousands of low-income and disabled people, while tighter disability standards make it harder for seriously ill people to qualify. These are indirect benefit cuts carried out through regulation rather than legislation.

In 2023, around 30,000 people died while waiting for disability payments. With the cuts to SSA by the Department of Government Efficiency, the number of deaths could increase to more than 67,000, according to projections made by the Subcommittee on Social Security, Pensions, and Family Policy in March 2025.

Cost-of-living increases offer limited protection. SSA announced a 2.8 percent COLA for 2026, with early estimates pointing to a similar increase for 2027. These increases often lag behind rising housing, medical, and food costs.

Additionally, cutting the operating budget for the SSA also impacts Medicare enrollment because the SSA provides information and support to Medicare beneficiaries, helping them understand their benefits and navigate the complexities of the Medicare system.

With the passing of President Trump's H.R.1 bill, the Congressional Budget Office predicts that due to the Statutory Pay-As-You-Go Act, medicare faces significant payment reductions up to $45 billion in cuts in 2026, with total cuts projected to reach $536 billion by 2034. This will be a disaster for millions on medicare, causing beneficiaries to face limited access to doctors, higher out-of-pocket costs, and increased difficulty while accessing long-term care. These cuts threaten to accelerate the insolvency of the Medicare trust fund while endangering rural hospitals, which face potential closures due to reduced funding.

While Medicare is a separate program administered by the Centers for Medicare & Medicaid Services (CMS), the Social Security Administration plays a pivotal role in determining eligibility, facilitating enrollment, and managing the financial aspects of Medicare.

By 2026 and 2027, Social Security's problems are no longer warnings, they are daily realities. Underfunded offices, missing staff, reduced in-person service, long delays, aggressive debt collection, tighter eligibility, and looming benefit cuts now define the system. These failures are not unavoidable. They are the direct result of repeated political choices to delay reforms, underfund administration, and treat the nation's most important retirement and disability program as a budget problem rather than a public obligation. Unless this pattern changes, beneficiaries will continue paying the price for Congress's inaction and neglect.

Social Security is in Crisis

Social Security's Potential Service Cuts And the Silence Around Them

The Decline of Real Social Security Benefits

AMERICA'S RECORD LEVEL HOMELESSNESS CRISIS

Homelessness in the United States has become a full-scale emergency: one that is visibly worsening in many communities even as official national reporting lags far behind the reality on the ground. The most recent confirmed nationwide count shows 771,480 people experiencing homelessness on a single night in January 2024, an 18% jump from 2023 and the highest level recorded since modern HUD reporting began. That number is not just "high," it is a record that signals system-wide breakdown: rents and basic costs have climbed, affordable housing supply has failed to keep up, and the margin for financial survival for millions of households has thinned to almost nothing.

What makes this crisis harder to confront (and easier for leaders to evade) is that the federal government's national homelessness reporting moves at a glacial pace. The Point-in-Time (PIT) count happens every January, but the most recent national results available in early 2026 still reflect January 2024, because HUD has not yet released finalized nationwide totals for the 2025 or 2026 counts. This is not a minor bureaucratic issue; it means the country is routinely asked to debate funding and policy using numbers that can be more than a year out of date during a rapidly changing housing market. When homelessness is accelerating, delayed national data becomes a form of delayed accountability.

Meanwhile, the shortage of meaningful prevention remains baked into federal housing policy itself. Even in normal economic times, federal rental assistance functions like a rationed benefit rather than a basic protection against displacement: only about one in four eligible households receives federal rental assistance because funding is capped. In other words, the federal system is structured to leave many eligible people without help (even before a crisis pushes them over the edge).

Recent budget and administrative signals show how close to the line this infrastructure has been running. In 2024, HUD issued guidance tightening requirements connected to voucher "shortfall" funding, including more stringent restrictions on the issuance of vouchers: a concrete sign that the system was under pressure and trying to prevent funding from running out. And for FY2026, Congress approved a major HUD funding package totaling $77.3 billion (an increase advocates describe as a hard-won reversal from earlier proposals that risked deep cuts). The same final FY2026 package analysis reports $4.4 billion for Homeless Assistance Grants and $38.4 billion for Tenant-Based Rental Assistance (vouchers) real money, but still operating within a system where assistance is not guaranteed and need can outpace appropriations overnight. Even supportive-housing and homelessness groups noted FY2026 funding as an increase over a yearlong continuing resolution for FY2025, which is another way housing policy gets stuck in maintenance mode while homelessness grows.

State-by-state comparisons reinforce what people can already see: homelessness is heavily concentrated in large states like California and New York, but the problem is widespread and persistent across the country, not a localized anomaly. Taken together, the record 2024 count, the built-in rationing of rental assistance, and the chronic delays in national reporting paint a bleak picture: homelessness has gotten exceptionally bad, and the public is being asked to accept slow-moving data and piecemeal solutions while conditions continue to deteriorate.

THE STUDENT LOAN SYSTEM IN COLLAPSE

The student debt situation in America is nothing short of a disaster.

Nearly one in four borrowers with payments due are now behind on their loans, a rate nearly triple what it was before the pandemic. This dramatic surge represents a fundamental breakdown in the student loan system that affects 45 million Americans carrying over $1.75 trillion in debt. In 2025 alone, 3.6 million borrowers defaulted on their loans. As of early 2026, approximately 9 million borrowers are in default status, defined as being 270 or more days past due on payments. Nearly 10% of all student loan balances are now more than 90 days delinquent, and experts project that defaults could reach 13 million by year's end if current trends continue.

What makes this crisis harder to solve, and easier for policymakers to ignore, is that the structural protections that once existed have been systematically dismantled. The end of pandemic-era payment pauses and relief programs removed critical safeguards that had helped borrowers stay current. The elimination of borrower support programs under the Trump administration left millions without the assistance they had relied upon. Meanwhile, broader economic pressures (including inflation, higher interest rates, and increased living costs) have squeezed household budgets to the breaking point, making it increasingly difficult for borrowers to keep up with their loan payments.

The consequences extend far beyond missed payments: 32% of borrowers have delayed purchasing a home because of their student debt, with that figure rising to 37% among Gen Z and 36% among Millennials. An overwhelming 71% of current borrowers already regret taking out their loans.

The consequences of default are severe, long-lasting, and punitive in ways that go beyond financial hardship. Borrowers in default face wage garnishment of up to 15% of their earnings, seizure of tax refunds, and severely damaged credit scores that can affect housing, employment, and financial opportunities for years. What began as an investment in education has become, for millions, a source of enduring financial hardship that policymakers have yet to address. What we need immediately is student loan bankruptcy protection. It's the only way to stop financial ruin for millions.

THE ASSAULT ON THE FEDERAL GOVERNMENT - DOGE

Though the Department of Government Efficiency (DOGE) has effectively been dissolved as of November 2025, the impact it had the federal government and Social Security still permeates to this day.

Despite being sold as a way to cut down on unnecessary government spending and to streamline the government, independent investigations such as one by the Partnership for Public Service called "Cost of DOGE" revealed that DOGE would cost taxpayers over $135 billion in 2025 due to productivity losses, paid leave, and the costs of dismissing and re-hiring employees. Additionally, Treasury Department and IRS officials predicted a decrease of more than ten percent in tax receipts by the April 15 deadline in 2025 (more than $500 billion in lost federal revenue), noting that "DOGE-driven workforce reductions" were a factor. Federal workers are essential to the operations of the federal government. Without them, the bureaucracy will crumble.

DOGE attacked the federal government by forcing mass layoffs, cancelling government contracts and grants, and by obtaining senstitive data from government information systems. It been linked to nearly 300,000 job reductions in the federal sector, including both employees and contractors. Though some employees were rehired, the vast majority of them were not, and the damage had already been done to the federal government bureaucracy.

As of January 2026, the Department of Justice and court filings confirmed that members of the Department of Government Efficiency (DOGE) improperly accessed, shared, and mishandled sensitive, non-anonymized Social Security data. Despite initial restrictions, DOGE personnel retained access to this private information for 83 days, including through unauthorized, unsecured cloud servers.

DOGE's attacks on the federal government have made the already underfunded and overburdened bureaucracy less effective. With the addition of intense budget cuts, it's clear that the millions dependent on the federal government to survive are more at risk than ever.

POVERTY KILLS IN THE U.S.

A study published in JAMA Network Open found that roughly 183,000 deaths per year are associated with poverty.

U.S. Census data show that millions remain economically vulnerable despite modest income gains.

Low wages, food insecurity, housing instability, and medical debt continue to undermine health. Pandemic-era supports were largely dismantled after 2023, increasing hardship.

Entering 2027, rising housing costs, benefit erosion, and healthcare access losses threaten to deepen poverty-related mortality.

WE NEED ACTION NOW

It is morally unacceptable to say that today's health emergency is over. We need to treat an emergency like an emergency. Should a million more people have to die before the government takes serious action?

ACT NOW TO SAVE LIVES!

We must keep poor people alive. The following steps need to be done right now.

HERE IS AN ACTION AGENDA:

- Healthcare should be given to all who need it. This should include the immediate reduction or elimination of sky-high deductibles. - The Public Health Insurance Option should be made available to everyone

- The so called "open enrollment" system for health insurance and Medicare drug insurance should be abolished. It's absolute madness to ban people from buying health insurance for most of the year. The healthcare exchanges must stay open throughout the year. The current deadline for open enrollment is January 15th. That needs to change.

- Medicare needs to be properly funded. Cuts in payments to doctors and hospitals must end.

- We must immediately enact paid sick leave for all workers.

- The budget cuts in the Social Security operating budget must be restored.

- We must immediately instate student debt bankruptcy protections.

In every other modern state healthcare is a right. It should be a right here.

RELATED EARTH FUTURE ACTION REPORTS

Social Disaster USA - Millions of Americans Face Starvation and Poverty

Dead or Alive in Modern America - The Right to Exist

Life and Death in America (Audio)

The Need for Paid Sick Leave

American Citizens Aren't Getting Their Benefits

The Urgent Need for Protective Masks During Covid Crisis