Can Rural Hospitals Survive Billions in Medicaid Cuts?

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President Donald Trump: Entered his second term with a net worth of $5.2 billion, according to Forbes. That alone made him the wealthiest president in American history—by a factor of ten.

But Trump wasn’t content to be the only billionaire in the room. He surrounded himself with people who swim in the same financial waters.

The list reads like a Forbes 400 convention program:

Elon Musk: The world’s richest person, worth an estimated $431 billion. 

Howard Lutnick: Commerce Secretary, net worth $3 billion

Linda McMahon: Education Secretary, net worth $3 billion.

Stephen Feinberg: Deputy Defense Secretary, net worth $5 billion.

Steve Witkoff: Ambassador‑at‑Large, net worth $2 billion. 

Kelly Loeffler: Small Business Administration Administrator, net worth $1 billion. 

Warren Stephens: Ambassador to the United Kingdom, net worth undisclosed but billionaire status confirmed. 

Tilman Fertitta: Ambassador to Italy, net worth undisclosed but billionaire status confirmed. 

Add it all up, and the combined wealth of the “Trump Nine” approaches 460 billion. To put that in perspective: If these nine people pooled their resources, they’d have enough money to buy Denmark outright (GDP 450 million).

Neither Greenland nor Denmark is for sale, of course, because countries aren’t bought and sold. But it’s characteristic of billionaires to presume that everything is for sale—including, now, the government of the United States.

And here’s the kicker: This doesn’t even include Treasury Secretary Scott Bessent, often described in news accounts as a billionaire, though his declared net worth is only about half a billion. In any other administration, a $500 million Treasury secretary would be the headline. Here, he’s barely a footnote.

The Price of Admission

How do you get one of these jobs? It helps to be a billionaire. It helps more to be a donor.

Let’s follow the money.

In the 2024 election cycle, Elon Musk donated or directed approximately 291 million to support Trump and other Republicans. He was rewarded with billions in new federal contracts and subsidies.

Howard Lutnick kicked in 14 millions. Linda McMahon added $12 million. Combined, the Trump Nine donated roughly one‑third of a billion dollars to secure Trump’s return to the White House.

But the giving didn’t stop on Election Day.

Trump’s 2025 inaugural committee raised a staggering $239 million—four times what President Biden raised in 2021. The biggest billionaire donors, not coincidentally, scored the highest‑ranking billionaire appointments. 

Musk, Lutnick, and McMahon—the top three donors—became the top three billionaire officials.

This is not how democracy is supposed to work. In a functioning democracy, you earn a Cabinet position through expertise, experience, and a demonstrated commitment to public service. In Trump’s Washington, you buy it.

“We’re in uncharted waters,” Michael Waldman, president of the Brennan Center for Justice, told The New York Times in January 2025. “It’s tempting to liken this to the Gilded Age.

 But John D. Rockefeller didn’t actually run McKinley’s campaign or move into the White House.”

Waldman might have added that the Gilded Age never gave us a president who issued his own currency (as Trump has done no fewer than four times) or owned a majority stake in the private company (Truth Social) that informs the nation of his policies.

 At the end of Trump’s first term, the nonprofit Citizens for Responsibility and Ethics in Washington (CREW) tallied nearly 4,000 financial conflicts of interest. Those conflicts haven’t diminished in his second term—they’ve multiplied.

There are Trump Bibles (Trump doesn’t attend church). Trump wine tumblers (Trump doesn’t drink). Trump key chains, hoodies, wrapping paper, umbrellas, golf balls, beach towels, sneakers, and pajamas. 

Most of these are available at www.trumpstore.com, and the proceeds go not to some campaign fund but to the Trump Organization—a privately held corporation owned by the president and run by his two oldest sons.

Everything’s for sale. Including, it seems, the government.

From the Gilded Age to the Platinum Age

To understand how we got here, we need to understand how we got anywhere—because the concentration of wealth we’re witnessing today isn’t normal. It isn’t inevitable. It’s the result of policy choices made over five decades.

In his farewell address, President Joe Biden warned that “an oligarchy is taking shape in America of extreme wealth, power, and influence that literally threatens our entire democracy, our basic rights and freedoms, and a fair shot for everyone to get ahead.” 

Biden was talking about Trump, and he was right. But the problem predates Trump—and will outlast him if we don’t understand its roots.

Let’s start with some perspective on what a billion dollars actually means.

Most of us can conceptualize a million dollars. The median home price in America is about 400,000; in California, it’s approaching.

But billionaires? That’s different.

Consider the difference between one million and one billion. It’s not just the next large number—it’s the next large number by a factor of one thousand. 

If you wanted to count to one million out loud, at one number per second with no breaks, you’d be done in about 11.5 days. A man in Birmingham, Alabama, actually did this in 2007, counting into a webcam every day, and reached one million in 89 days.

But counting to one billion? That would take 31 years and 8 months with no breaks—and if you worked at the same pace as the Birmingham counter, it would take more than 244 years. That’s twice the longest human lifespan ever recorded.

To own $1 billion is to possess more dollars than you’ll ever count. It’s to possess more dollars than you could reasonably spend in ten lifetimes. 

And yet, in Trump’s America, we’ve put a dozen people with that kind of wealth in charge of writing the rules for everyone else.

The consequences are predictable—and predicted.

After Trump’s 2017 tax cut, the combined wealth of America’s billionaires doubled to $6 trillion, according to a July 2024 report by Americans for Tax Fairness. 

Going back to the start of the twenty‑first century, American billionaire wealth has increased ninefold. There aren’t enough billionaires in America to fill Carnegie Hall, but they now own 3.8% of the nation’s total wealth.

During that same quarter‑century, the bottom half of the income distribution—about 66 million families—increased their collective wealth not ninefold but twofold, thanks largely to COVID stimulus checks. 

Those 66 million families own not 3.8% of America’s wealth, but just 2.5%.

The Foxes Guarding the Henhouse

So what happens when you put billionaires in charge of the government? You get policies that benefit billionaires.

Consider the “Big Beautiful Bill” itself. Its primary purpose was to make the 2017 tax cuts permanent—locking in trillions of dollars in giveaways for the wealthy and corporations. 

The estate tax exemption was raised to 15 million per person (30 millions for couples),  ensuring that billionaire dynasties can pass their fortunes to heirs without paying a dime in taxes. 

The qualified business income deduction—a massive loophole that lets wealthy business owners treat their income as “business income” to avoid higher tax rates—was made permanent and expanded.

These provisions didn’t write themselves. They were written by people who benefit from them—or whose donors benefit from them.

This is what happens when billionaires run the government. They don’t suddenly develop working‑class sympathies. They don’t forget how they made their money. They don’t start prioritizing the needs of rural hospitals over the interests of corporate donors.

They do what they’ve always done: look out for themselves and people like them.

The Billionaire Tax Rate: A Preview

Which brings us to a fundamental question: If billionaires are running the government, why would they ever raise taxes on themselves?

They wouldn’t. And they haven’t.

According to a recent study from University of California, Berkeley economists, the individuals on the Forbes 400 list—including Elon Musk, Jeff Bezos, and their peers—paid an average effective tax rate of just 24% between 2018 and 2020. 

That’s six percentage points lower than the 30% rate paid by other taxpayers.

How is this possible? The wealthy structure their income differently.

Your paycheck is taxed as “ordinary income” at rates up to 37%, plus another 7.65% for Social Security and Medicare. But the wealthy don’t live on paychecks. 

They live on investments—capital gains from selling stocks, bonds, real estate, and other assets. And capital gains are taxed at a maximum rate of just 23.8%.

Even better (for them), they don’t have to pay taxes on wealth they haven’t “realized” by selling. If Elon Musk’s Tesla stock goes up by $10 billion in a year, he owes zero taxes on that gain—until he sells. 

He can borrow against that stock to fund his lifestyle, and the loans aren’t taxable income.

This is the “buy, borrow, die” strategy that allows billionaires to avoid taxes indefinitely. They buy assets that appreciate. They borrow against those assets to fund their spending. 

And when they die, their heirs inherit the assets with a “step‑up in basis,” meaning the capital gains taxes that were never paid are wiped out entirely.

The “Big Beautiful Bill” didn’t close this loophole. It expanded it—by making the estate tax exemption permanent and raising it to $15 million per person.

In 2022, the top 0.001% of earners—just 1,538 households—each made at least $85.5 million and paid an average federal tax rate of only 23.5%. 

That’s roughly the same effective rate paid by an iron and steel worker or a high school special education teacher in Pennsylvania.

Let that sink in. The people who make $85 million a year pay the same tax rate as a special education teacher. And under the “Big Beautiful Bill,” that arrangement is now permanent.

The Swamp They Promised to Drain

Remember the promise? “Drain the swamp.”

It was the central metaphor of Trump’s 2016 campaign—a pledge to rid Washington of the lobbyists, insiders, and special interests who profit at the expense of ordinary Americans.

The reality, nine years later, is a swamp that has been dredged, expanded, and repopulated with creatures far more exotic than anything that existed before.

Trump’s first‑term Cabinet had only one confirmed billionaire—Education Secretary Betsy DeVos. But there were enough multi‑millionaires to boost the Cabinet’s combined wealth to $6.2 billion—a record at that time.

Today’s Cabinet, excluding Elon Musk, is worth $14 billion—more than twice the combined net worth of Trump’s first‑term Cabinet. With Musk included, the number approaches half a trillion dollars.

This is not draining the swamp. This is stocking the swamp with alligators and charging admission.

The cynicism of it all is breathtaking. Trump campaigned as a populist, wearing aprons and riding garbage trucks, promising to fight for the forgotten man and woman. 

He posed with coal miners, hung his face from the Department of Labor building, and talked endlessly about bringing back manufacturing jobs.

But when it came time to govern, he surrounded himself with people whose entire existence depends on the systems that keep working people down. 

People who made their fortunes by minimizing labor costs, maximizing government contracts, and structuring their affairs to avoid taxes.

The “Big Beautiful Bill” is the proof. It delivers permanent tax cuts for billionaires and temporary crumbs for everyone else. It cuts Medicaid by hundreds of billions while expanding estate tax exemptions. It makes the wealthy wealthier and calls it a win for the working class.

And the billionaires who wrote it, who funded it, who now occupy the highest offices in the land—they’re not even pretending to apologize.

They’re building a ballroom.

But that’s a story for another chapter.

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