A Real Gully Washer 

If a rainstorm was sufficiently sudden and intense, my father would pronounce it “a real gully washer.” Peering through the window alongside him as a child, I would nod in agreement, not quite sure what it meant. 

Later, my geography and regional slang got better, and I came to understand that “gullies” were the small steep-sided ravines that scrape the sides of some hills. Whether the dry washes of my dad’s home in South Dakota or tree-lined chasms in the Pacific Northwest, the gullies drain water from the higher parts into the flats below. 

I also appreciated the impact of the gully washers. They could deliver needed moisture and clean out dead and rotting vegetation, but also overwhelm homes, communities, and farmlands at the ravine’s mouth with water and detritus. Intense rains in the hills of Vermont in 2011, western North Carolina last year and repeatedly in Kentucky in the last decade have wreaked havoc, destroying roads and homes and isolating individuals and whole towns. A gully washer in New York a few years ago swept my friend’s home off its foundations and into a lake. 

The new federal administration is implementing its strategy of, as one if its advisors Steve Bannon, likes to say, “flooding the zone.” Since the inauguration, it has released over 60 executive orders and taken administrative actions designed to abolish agencies, flush out a swath of the government workforce, and test the constitutional balance of powers. Collectively this is a real gully washer of executive branch activity. The state and local health officials that Milbank supports are leaders in the communities at the mouth of the gully who are dealing with all that is washing out to them.  

It is not an easy time. State officials are spending countless hours just trying to interpret directives and events, and understand how they affect their health and human services programs.   

To comply with executive orders such as “Ending Radical And Wasteful Government DEI Programs And Preferencing:” and “Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government,” agencies have issued stop work orders and terse policy directives to state governments, grantees, and contractors. Agency staff have been on “a communications lockdown” that forbids discussions with state partners to offer necessary explanation and interpretation. Chaos and confusion have ensued.  

Here are a few examples of how state public health and health financing efforts are being affected: 

• Access to select federal public health websites vanished. Contract lapses with the Centers for Disease Control and Prevention (CDC) compromised the National Electronic Disease Surveillance System Base System, a website relied upon by at least 24 states to report and access data on infectious diseases from bird flu to foodborne outbreaks. Access to surveillance data on HIV infections and behaviors that endanger the health of children, and guidance to clinicians on topics from immunizations to contraception were unavailable as officials implemented various executive orders. Although these sites are now coming back online in response to court orders — some with the following caveat: “This page does not reflect biological reality and therefore the Administration and this Department rejects it.” — the functionality of the website links and integrity of the data on the sites remain uncertain.  

• Before it was restrained by federal courts, the Office of Management and Budget’s efforts to withhold all federal payments to contractors and states jeopardized the financing of medical care. The resulting freeze on Medicaid funding forced them to consider withholding funds from providers who were owed payment for services. Under Federal Matching Assistance Percentage rules, providers in the poorest states stood the most to lose as a larger portion of their state’s Medicaid programs are federally funded. As of this writing, access to Medicaid drawdowns have been restored but states and their service providers are still dealing with uneven and inconsistent access to other federal funds. 

• Obligations to enforce federal statute became muddied. For example, state departments of health have responsibility for investigating complaints regarding the Emergency Medical Treatment and Active Labor Act (EMTALA), an almost 40-year-old federal statute requiring hospital emergency rooms to assess and stabilize anyone who presents for care. New guidance from the US Department of Health and Human Services appeared to direct states not to enforce the delivery of obstetrics services, including emergency abortions, under the EMTALA obligations, potentially eliminating federal pre-emption of more restrictive state laws. Calls for more consistency and clarity from the administration went unanswered for weeks before the Centers for Medicare and Medicaid Services reversed course and allowed states to resume their investigations of complaints. 

• Finally, reductions in federal workforce are already affecting vital functions in states. Among the estimated 750 layoffs to date at the Center for Disease Control are Fellows in the Laboratory Leadership Service program which investigates local disease outbreaks and the Public Health Associates program, which provides early career staff to state and local health departments. 

In our work supporting state and local public sector health leaders, we at Milbank see three broad categories of impact as they wrestle with new federal administrative initiatives. 

Public programs that demonstrably improve population health and reduce preventable health inequities are being threatened. When providers of medical care and social services like community health centers and homeless services providers can’t access federal funds, communities and their residents suffer. Likewise, when federal officials — be they air traffic controllers landing planes, public health epidemiologists surveilling infectious diseases, or federal program administrators giving guidance to their state partners — are unable to fulfill their essential functions, people will be harmed — from measles outbreaks in Texas to children enrolled in Head Start programs in Maine. State and local officials end up managing the consequences of the loss of the federal government’s capacity.  

Commenting on the suddenness and scope of workforce reduction measures, Margaret Murray, CEO for the Association for Community Affiliated Plans, said, “Staffing cuts of the level described in the President’s executive order will bring about a cascade of consequences for Medicare, Medicaid, and other publicly supported coverage programs — placing at risk the people who rely on those programs for coverage, including children, families, seniors, veterans and people with disabilities.” As community members, constituents, and voters, we must bear witness to the broad swath of harms that have resulted and work to address and prevent them.  

Leadership is overwhelmed. Time spent by state legislative and executive branch leaders on this kind of mitigation and recovery — verifying facts, chasing down the status of missing funds and programs, taking calls from aggrieved constituents, redeploying staff from existing functions and reportedly even setting up incident command centers as in a natural disaster — is time not spent meeting the other demands of their work and the people they serve. While every change in government administration brings uncertainty, one that generates exhaustion undermines government effectiveness.  

Trust in government is eroded. When the federal government is creating chaos and constitutional checks and balances are tested and ignored, trust in leadership diminishes. State and local officials will be blamed when government services weaken because of federal policies. The Trump administration will, in turn, learn that federal authority will suffer when states cannot trust their federal partners to be reliable, competent, and empathetic.  

President Trump was narrowly elected with a mandate of change — to respond to those who felt they were not being heard by government. His actions on his return to the White House have been sudden and intense — like a gully washer. Indeed, one of the earliest uses found for the term is in an 1870s prayer petition:   

“It was a dry time, when a union service was held to pray for rain; a brother of another denomination arose, and after telling the Lord how dry it was, said, “And now, Lord, send us rain: none of your drizzle-drozzle, but a regular grand soaker and gully washer.” 

The gully washer in Washington may indeed be the answer to the prayers of some, delivering refreshing reforms. But for communities down below, and their leaders, its breadth, speed, and, in some cases, apparent disregard for the law, is harmful to the health of communities and individuals. As floods sweep down, the sandbags of solidarity, outcry, and court challenges where appropriate are needed.     

And then, it is worth remembering all floods eventually recede. Disaster recovery may be time-consuming, exhausting and at times divisive, as we have also seen in North Carolina, but nature always recovers. Vegetation regrows. After a flood, as a fisherman colleague of mine says “the fish always come back.”  

The same can be said of communities. “We learn from every [flood],” said Kentucky Governor Andy Bashear last week, “and we try to rebuild so that the next one and the next one we lose fewer people.” Reflecting 14 years later on 500 miles of roads and 200 bridges repaired, a local history of Hurricane Irene in Vermont, states: “Hard times are challenging. But hard times can make us stronger when we work together.”    

Even as debates continue about whether and how to prevent this federal flooding now and in the future, state and local public sector officials are leading these efforts at protection and recovery.