Praying for the Dam to Hold 

Last weekend, the middle of the country was submerged by a storm that lasted for days and led to at least 25 deaths and untold property and infrastructure damage. Around 3:30 am Thursday morning, while in the basement with my family for the third time that night because of tornado warnings, I thought about a friend who had managed one of the flood control dams maintained by the Army Corps of Engineers until the prior week when he took the “fork in the road.” He trusts his team, but his position has not been filled because of a hiring freeze. That night in the basement, and as the rain continued over the following days, I prayed for the dam to hold. 

There’s an analogous reality in public health right now. On March 24 and 25, state and local public health and mental health agencies received notice that over $11 billion in federal funds would not be available to cover any costs after March 24. The time-limited funding had been appropriated by Congress and obligated via contract by state and local governments that had spent the last several years using those dollars to build a stronger public health and mental health infrastructure to weather future storms. The list of grant discontinuations now consumes 51 pages of small-print spreadsheets.  

Loss of State and Local Public Health Staff, Abrupt End of Projects  

In discussion with state leaders, we at Milbank have learned that most state health departments had to immediately fire between 50 and 250 employees and contract workers. The scramble also included termination of funding to local health departments and contractors, resulting in rippling layoffs estimated to be in the thousands. For funding that had been scheduled to end over 6 to 18 months, states and localities had been creating off ramps or sustainability plans for the people, services, and capital investments the grants had been supporting. These plans will no longer be implemented, leaving productive employees without paychecks and projects partially completed. (See a recap of an April 11 Milbank State Leadership Network briefing on the impact of the cuts.)

States had been using the funds to upgrade equipment, modernize data and IT infrastructure to improve reliability and efficiency, improve community emergency response, increase community access to routine immunizations, train staff, and even create temporary housing units for individuals exposed to threats like measles or tuberculosis. Taking a chainsaw to work midstream left purchases for major lab equipment in limbo, stopped construction on state public health laboratories and local health department facilities, and ended testing for diseases such as novel influenza.  

The abrupt termination of funding created significant waste, confusion, and inefficiency in addition to undermining trust and credibility with business partners and communities. Even the small faith-based clinic where I volunteer in Nashville lost funding for most of its community health worker program, and we have had to drop the sustainability planning we were doing with state and health care partners.  

Loss of Mental and Substance Use Disorder Treatment 

Tragically, the dam was cracking in state mental health agencies at the same time. The sudden termination of obligated funding for state mental health block grants immediately resulted in the loss of access to mental health and substance use disorder treatment for under- and uninsured individuals in all states. In Colorado alone, $30 million and over 60 mental health contracts were eliminated in a single day.  

This funding was also being used to seed new substance use treatment programs and to build the infrastructure for state-run 988 crisis lines. In Wisconsin, for example, the funding loss resulted in the shutdown of a successful “warmline” that, in March, had directed 4,000 calls to mental health services before callers reached a crisis point. While the state was going to take over funding in September, the warmline had to be closed April 5, resulting in lost jobs, trust, and care for thousands of patients a month.  

State/Local Impact of the Dismantling of HHS  

Just a few days after the funding rescission, its impact was compounded by the layoffs of 10,000 federal employees. The combination of these terminations and the nearly 10,000 workers who took the “fork in the road” voluntary exit has reduced the US Department of Health and Humans Services (HHS) workforce by 25%. As there is no official list of impacted areas of HHS — and the communications and human resources teams of the Centers for Disease Control and Prevention (CDC), Food and Drug Administration, Health Resources and Services Administration, and the National Institute of Health — were included in the layoffs, neither the federal teams nor the state staff that rely on them were informed of which programs or program personnel were affected. Furthermore, public announcements of recalls or grant notifications or clinical guidance from agencies could not be issued because staff was no longer in place to do so.  

Affected employees, many of whom discovered they had lost their job when their security pass no longer worked, took to crowdsourcing their current employment status. While my family was getting the news on flood damage from neighborhood social channels, governmental public health employees and their contractors were following Reddit to determine what divisions had been washed away and which ones were still operational.  

What has become clearer is that entire program teams at federal HHS agencies have been effectively dismantled either through outright dismissal of staff, including over 40% of CDC senior staff, or mandatory relocation of senior leadership to remote Indian Health Service locations. At the state and local public health levels, 3,400 workers lost their jobs at the FDA, 1,200 at the NIH, and 2,400 at CDC.  

The carnage at CDC alone includes programs that directly improve the health of millions of Americans: 

• Division of HIV Prevention – Approximately 161,800 Americans have HIV but do not know it. The center equips states with testing, data infrastructure, connection to treatment, and rapid response to HIV outbreaks. 
• National Institute for Occupational Safety and Health – The near total elimination of this agency will remove evaluation of personal protection equipment, miner’s health, health care worker safety, firefighter safety, and more.  
• Division of Reproductive Health – Staff terminations have included scientists and clinicians responsible for issuing clinical contraception guidance, the infertility team, and the teams that support states in caring for pregnant women during outbreaks such as Zika, COVID-19, and Ebola. Other terminated staff were responsible for the data that states and localities use to monitor pregnancy outcomes, access, and behaviors.  
• Division of STD Prevention and the Division of Viral Hepatitis lab closures – One of the two closed labs was responsible for testing new drug-resistant strains of STDs and developed national testing guidelines. The other lab was the world’s leading viral hepatitis laboratory and set hepatitis testing standards for all US labs. It was processing samples for an outbreak in Florida when it was shut down by staff terminations. 

Additional CDC program eliminations include most of the injury center (the leading cause of death for children), the Division of Oral Health, and the Division of Minority Health. The removal of core public health prevention, such as tobacco prevention and the Quitline from CDC, as well as all the tobacco regulatory staff at the FDA, is being hailed as “the greatest gift to the tobacco industry in the last half century.” Meanwhile, all of the block grant staff in the eastern part of the country who help states provide health care services for all women and children, particularly children with special needs, were let go.  

A Time to Speak Frankly and Across Party Lines and Government Branches 

Now is the time for state and local policymakers to speak frankly and frequently across the legislative and executive branches and across party divisions to understand the impact of federal funding cuts. Part of the difficulty of telling the story of impact for the recent funding recission is that it looks different in every state given the flexibility of the funding. State legislators and the public should ask the state and local public and mental health directors to clarify what was funded through the terminated grants; what work was paused; how many people and contracts were terminated; and what services will be lost that could otherwise have been completed or bridged to sustainability. All states have already had to make abrupt changes and terminations to prevent immediate state financial risk for funds spent after March 24, and uncertainly abounds even for the 23 states that issued a temporary restraining order to block the end of the payments that is now being challenged by HHS.  

Now is also the time for state legislators and the executive branch to communicate about the impact of federal staffing cuts. It is unlikely this funding for states will continue for long in program areas where federal staff has been eliminated unless state policymakers make their priorities known to their federal delegation and the public, especially in light of the rapidly approaching deadlines¹ for the President’s budget request and congressional appropriations.  

The United States relies on a complex infrastructure to support public health, which is the dam that holds back health threats from epidemics, injury, chronic disease, and bioterrorism. Local, state, and federal roles are inter-dependent and spread across multiple agencies. When some of the supports, and in this case entire embankments, in that infrastructure are removed without warning, the dam starts to break. It’s time to quickly shore up the dam of public health by communicating state needs to federal delegations. The storm is coming. 

¹ April 14: HHS reorganization plans to Office of Management and Budget; April 29: Federal agency spend plans to Congress; May 6: Authorizing committees report legislation to cut spending to budget committees to be compiled into reconciliation bill; May: President submits budget request