The Algorithm Says No. Trump’s Medicaid Purge Is Cutting the Disabled Loose.
A secretive computer program has already stripped nearly 900 Nebraskans with developmental disabilities of the round-the-clock care that keeps them alive. Under the president’s One Big Beautiful Bill Act, it is only the beginning. Every state is next.
Susan Browne is 72 years old and terrified of what she has always feared most — not her breast cancer, but the day she will no longer be there for her sons. David is 47. John Michael is 45. Both have profound autism. Both need help eating without choking, dressing, bathing, using the bathroom. For decades, Susan and her husband asked themselves a question they could not answer aloud: who takes care of the boys after we are gone? Last year, they thought they had solved it. Using Medicaid funding for people with developmental disabilities, they created a nonprofit, hired a trusted team of caregivers, and built a home around round-the-clock, one-on-one support their sons would need for the rest of their lives.
Then a computer said no.
An algorithm called interRAI — adopted quietly by the Nebraska Department of Health and Human Services — determined that David and John Michael Browne did not, in fact, require the care their doctors, their aides, and their own mother said they needed. It cut their combined Medicaid funding by more than $220,000 a year. According to a nine-month NBC News investigation published this week, the state has used the same tool to slash funding for nearly 900 people with developmental disabilities, most of them with intellectual and behavioral needs so severe that any competent human assessor could see them from across a room. The algorithm cannot. And the appeals process, families told NBC, “appears to rubber-stamp whatever the algorithm decides.”
“I’m so terrified for my sons now,” Susan Browne told NBC. Her words are the first words of this story, but they are not really a Nebraska story at all. They are the sound of a policy machine that Congress and the Trump White House built together over the last fifteen months finally engaging its gears — and the sound of the first bodies falling into it.
I. The Machine in the Assessment Room
Nebraska adopted interRAI in 2025 as its new tool for determining how much Medicaid-funded home-and-community-based support each disabled resident would receive. State officials, quoted by both NBC News and the Flatwater Free Press, described the switch as a step toward fairness and consistency. In practice, the switch produced something quite different: a black box whose scoring logic the state will not fully disclose, whose assessment forms have — according to families — misrepresented profoundly disabled adults as being able to eat, bathe, and use the bathroom independently, and whose determinations reduced the service tier of roughly one in four recipients.
Susan Browne was in Houston receiving cancer treatment when her sons’ interRAI assessments were conducted. The state, she said, refused to reschedule. When she later reviewed the results, she found that more than half of the answers did not reflect reality. The Nebraska Department of Health and Human Services told reporters it “cannot comment on specific cases” and that assessors are trained to gather information from multiple sources. Nebraska lawmakers, alarmed by the growing scandal, passed a bill nearly unanimously on April 10 requiring training standards and supervisory review of any assessment that lowered a person’s service tier. As of last week, DHHS reversed course on the outside contractor it had hired to review the tool, after advocates pointed out that the firm employed the woman who had helped implement interRAI in the first place.
II. The One Big Beautiful Bill and the Fiscal Squeeze
Nebraska did not adopt interRAI because Nebraska is uniquely cruel. Nebraska adopted interRAI because every state Medicaid director in America is now staring at the same mathematical problem, and the algorithm is one of the few cost levers left. That problem has a signature at the bottom: Donald J. Trump, dated July 4, 2025.
The One Big Beautiful Bill Act, which the House passed 218–214 and the Senate passed 51–50 with Vice President J.D. Vance breaking the tie, is the largest reduction in Medicaid spending in the program’s history. The 940-page law affects more than 130 million Americans who rely on Medicaid and Medicare. It imposes 80-hour-per-month “community engagement” requirements on non-exempt enrollees beginning December 2026. It requires states to re-verify eligibility every six months instead of every twelve. It caps and phases down the provider-tax mechanism that states have used for decades to draw federal matching funds. It shortens retroactive coverage. And it imposes cost-sharing of up to $35 per service beginning October 2028.
The result is the fiscal architecture inside which stories like the Brownes’ become inevitable. As the Center for American Progress noted in a joint analysis with The Arc, home-and-community-based services — the exact category that lets the Brownes’ sons live at home rather than in an institution — are Medicaid’s largest optional category, which means they are the first thing on the chopping block when the money contracts. States that lose federal matching funds have three real options: raise state taxes, kick people off the rolls, or cut what each remaining person is allowed to receive. The Republican governors and Republican-led legislatures now facing that trilemma are, unsurprisingly, choosing the last two.
“It reframes disabled people as costs to be contained rather than citizens entitled to equal access to care.”
— Matthew Hazlett, autistic disability policy analyst, quoted in Prism Reports, Sept. 2025
III. A National Timeline of Withdrawal
The OBBBA was designed — deliberately — so that its most punishing effects hit after the November 2026 midterms. Republican leadership initially set 2029 for the Medicaid revamp; conservatives pushed the timetable forward. But the phase-in has already begun. What follows is a partial chronology of the withdrawal now underway across all fifty states.
Beneath the timeline is a simpler picture. Federal Medicaid dollars are being withdrawn. States are being handed the political blame for the cuts that federal withdrawal forces on them. And the disabled Americans at the far end of the funding chain — who cannot organize a rally, cannot picket a governor’s mansion, cannot in some cases speak — are being asked to absorb the loss quietly.
IV. “Family Values,” Redefined
There is a hypocrisy at the heart of this policy that deserves to be named cleanly, because the men and women pushing these cuts still describe themselves as the party of the family. The Brownes are a family. They built a nonprofit, hired caregivers, and structured their sons’ entire adult lives so that David and John Michael would never have to be institutionalized. They did exactly what a “family values” politics purports to reward: they took responsibility, at enormous personal cost, for their own. And the response of a Republican-controlled Congress and a Republican White House was to sign a law engineered to strip their sons of the funding that makes that family possible.
The cruelty is not incidental. It is structural. The $1 trillion in Medicaid cuts exists to offset roughly $4.5 trillion in tax cuts weighted heavily toward the top of the income distribution. The math is not disputed by CBO, by KFF, or by the Urban Institute, whose August 2025 analysis concluded that the OBBBA’s Medicaid provisions “partially offset the cost of trillions of dollars in tax cuts.” That is the trade. The Brownes’ sons are the currency in which it is being paid.
Even inside the Republican caucus, that trade was not universally acceptable. Sen. Thom Tillis of North Carolina voted against the bill and warned that the Medicaid cuts were “inescapable” and could cost Republicans both chambers of Congress. Sen. Josh Hawley of Missouri called his party’s targeting of Medicaid “a mistake.” Rep. Brian Fitzpatrick of Pennsylvania, one of the last House Republicans in a competitive district, voted no, citing precisely these provisions. Rep. Don Bacon of Nebraska — representing the state now cutting its disabled residents by algorithm — publicly said he had once pledged never to support anything with more than $500 billion in Medicaid cuts, then voted for a bill with nearly twice that. He gave, as his reason, “other tax breaks.”
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V. Congress at a Standstill — and Democrats’ Attempt to Move It
House Democrats have not been idle, but they have been outvoted. On the first anniversary of the OBBBA’s signing, Rep. Brendan Boyle (D-PA), ranking member of the House Budget Committee, introduced the Protecting Americans’ Health Care Act, legislation designed to fully reverse the largest cut to Medicaid in American history. “One year later,” Boyle said, “Trump’s so-called ‘Big Beautiful Bill’ has proven to be anything but beautiful. More than 8 million Americans have already lost their health care, and millions more are seeing their costs rise — all to give billionaires the largest tax break they have ever received. It’s about to get worse.” Boyle also filed a discharge petition to force a floor vote on halting the cuts, and introduced a resolution demanding that CMS issue guidance to states before the December phase-in.
In the Senate, Democratic Leader Chuck Schumer spent the fall of 2025 warning Republicans that if they refused to extend the ACA premium subsidies, “there won’t be another chance to act.” He was correct. The subsidies expired. In December, the Senate rejected two competing bills to extend them. Sen. Jon Ossoff of Georgia, running for re-election in a state where 300,000 Georgians have already lost coverage, has said his opponents “own” the fallout. Rep. Ami Bera of California, involved in Democratic campaign operations, is targeting Republican-held districts where more than 60 percent of constituents rely on Medicaid.
The strategic problem is stark. The districts hurt worst by the Medicaid cuts are, in most cases, the districts Democrats have the hardest time flipping. CNN’s July 2025 analysis noted that only eight of the 64 House Republicans in above-average Medicaid-reliance districts appeared on the DCCC’s target list. The bill is a political liability. It is also, so far, an unpunished one. And the Republicans holding the majority in both chambers have shown no interest in reopening the question — even as their own Trump-aligned President has, according to the Hill, tried to quietly rebrand the OBBBA as the “Working Families Tax Cuts Act.”
“More than 8 million Americans have already lost their health care, and millions more are seeing their costs rise — all to give billionaires the largest tax break they have ever received. It’s about to get worse.”
— Rep. Brendan Boyle (D-PA), Ranking Member, House Budget Committee
VI. Trump’s Ongoing Campaign Against American Healthcare
The interRAI cuts, the OBBBA, and the expired ACA subsidies are not three separate stories. They are three instruments of the same campaign, and the president continues to conduct it. The White House’s insistence on letting the subsidies expire — even after moderate Republicans, including four House members who joined Democrats to force a discharge petition, publicly begged him to intervene — produced the largest single-year cost increase in ACA history. According to the Bipartisan Policy Center, some older enrollees are now paying between 25 and 30 percent of their annual income on marketplace premiums.
The pattern is consistent. Trump has demanded further work requirements. He has resisted every legislative attempt to restore protection for Medicaid HCBS waivers. He has personally rejected the moderate Republican effort to extend even a temporary subsidy fix. And when governors, providers, and disability advocates have warned in public that the cuts will kill people, the White House response has ranged from silence to open dismissal.
This is what his priorities look like when they are put in writing and enacted into law: tax reductions for the wealthiest Americans, financed by the withdrawal of care from the most vulnerable. It is not an accident of drafting. It is the design.
The 25th Amendment and a President Detached from the Consequences of His Own Signature
The Twenty-fifth Amendment, ratified in 1967, provides a mechanism — Section 4 — by which the Vice President, together with a majority of the principal officers of the executive departments, may declare in writing to Congress that the President “is unable to discharge the powers and duties of his office.” Upon that declaration, the Vice President becomes Acting President. The clause was drafted to address exactly the scenario in which a chief executive continues to occupy the office while being fundamentally unable to perform its judgment-bearing functions.
In April 2026, House Judiciary Ranking Member Jamie Raskin (D-MD) formally demanded a full cognitive and neurological evaluation of President Trump by the White House Physician, citing “increasingly volatile, incoherent, and alarming public statements” and “urgent concerns about his mental fitness across the political spectrum.” Days later, Raskin introduced a bill that would activate the Section 4 review process. More than 50 House Democrats have publicly joined the call, including Sen. Ed Markey of Massachusetts, Rep. Yassamin Ansari of Arizona, Reps. Eric Swalwell and Sydney Kamlager-Dove of California, and Sen. Andy Kim of New Jersey, who said flatly: “he is unfit for office. I think the 25th Amendment, and if not, then impeachment.” Speaker Emerita Nancy Pelosi has renewed her own call. A group of psychiatrists cited by The Hill in June 2026 warned of Trump’s “rapidly worsening, reality-untethered, increasingly dangerous decline.”
The Medicaid crisis is not, in itself, evidence of medical unfitness. But it is evidence of something the 25th Amendment was written to address: a President who does not appear to understand, or care to understand, what his own signature has set in motion. The Brownes’ story is not obscure — it was the lead investigative piece on the NBC Nightly News. The president has said nothing. Eight million Americans have lost coverage, ACA premiums have doubled, and every state is now planning cuts to HCBS waivers, and the president continues to insist the law is beautiful. When a chief executive cannot, or will not, engage with the human consequences of laws he signed — when his response to disabled Americans losing their care is to rebrand the bill that took it — the constitutional question is no longer whether he is a bad president. It is whether he is capable of being a president at all.
The Practical Barriers
Invocation under Section 4 requires the Vice President and a majority of the Cabinet — that is, Vice President Vance and a body of principal officers appointed by, and loyal to, the president himself. Congressional action, absent that predicate, has no operative force under the amendment’s plain text. Raskin’s bill would set up a disability-review body that Congress can constitute independently, but under Section 4 that body still requires majority agreement with the Vice President’s determination. No serious analyst believes those thresholds will be met in this term.
Why the Barriers Do Not Erase the Case
The 25th Amendment is not merely a mechanism. It is a standard. It states, in the plainest constitutional language, what the country should demand of a President: the capacity to discharge the powers and duties of the office. That standard exists whether or not it is politically enforceable in a given moment. To say that Section 4 is dormant is not to say the constitutional case is unmade. It is to say that the political system has not yet caught up to what the Constitution already presumes: that a chief executive who cannot process, or refuses to acknowledge, the direct human consequences of his signature has abdicated the essential function of the office. The Brownes’ sons are the evidence entering the record.
Editorial Conclusion
This is not a budget dispute. It is a moral disqualification. A government that will spend $4.5 trillion to widen the wealth of its richest citizens, and then reclaim the money by letting an unaccountable algorithm decide which profoundly autistic sons still deserve to be fed, has surrendered any claim to represent the country as a whole. David and John Michael Browne did nothing to earn what is being done to them. Neither did the 900 Nebraskans behind them, nor the 8 million Americans already stripped of coverage, nor the 7.5 million more the CBO says are coming. The Constitution provides mechanisms — the 25th Amendment, impeachment, the ballot — for a nation to correct a President who cannot, or will not, meet the minimum threshold of care his office demands. It is now the duty of Congress, of the electorate, and of every American who still believes that disability is not a disqualification from citizenship, to use them.
Sources & References
- NBC NewsNebraska is using an algorithm called interRAI to take Medicaid funding from disabled people (Sept. 8, 2026)
- Flatwater Free PressBenefits slashed, appeals denied: Nebraska disability change leaves hundreds desperate for more help
- Omaha Daily RecordBenefits Slashed: Nebraska Disability Switch Leaves Hundreds Desperate for Help
- KSNB Local 4DHHS reverses course, will seek bids from new contractors for interRAI review
- Center for American ProgressThe Truth About the One Big Beautiful Bill Act’s Cuts to Medicaid and Medicare
- Disability ScoopCongress Approves Nearly $1 Trillion In Cuts To Medicaid Threatening Disability Services
- Prism ReportsPeople with disabilities are bracing for the impacts of Trump’s ‘Big Beautiful Bill’
- Urban InstituteMedicaid Cuts in the One Big Beautiful Bill Act Leave 3 in 10 Young Adults Vulnerable
- KFFMedicaid: What to Watch in 2026
- KFFMedicaid and Upcoming State Budget Debates
- Disability BelongsMedicaid Changes States are Rolling Out in 2026
- GovFactsHow the ‘One Big, Beautiful Bill’ Targets Medicare and Medicaid
- Berkeley Public HealthWhat do the looming cuts to Medicaid really mean?
- House Budget Committee DemocratsBoyle Announces Protecting Americans’ Health Care Act
- House Judiciary DemocratsRaskin Demands Cognitive Evaluation of President, Calls to Invoke 25th Amendment
- The Daily BeastTrump, 79, Faces Congressional Bid to Invoke 25th Amendment
- The Hill (Opinion)Concerns Grow Over Trump’s Mental Fitness for Presidency
- The HillDemocrats target Republicans over ‘big, beautiful bill’ on campaign trail
- CNNHow Trump’s ‘big, beautiful bill’ frames the defining debate for 2026
- PBS NewsHourSenate rejects both bills on ACA subsidies, all but ensuring premium hike in 2026
- Talking Points Memo5 Points on the Impact of Congress Letting ACA Subsidies Expire
- Caring Across GenerationsFederal Cuts, State Choices, and the Future of Aging and Disability Care
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