By Amy Maxmen, illustration by Oona Zenda, for KFF
When President Donald Trump posted a satirical music video on social media in early October depicting his finances director, Russell Vought, because the Grim Reaper lording over Democrats in Congress, public well being employees acknowledged a kernel of reality.
Vought has exerted extraordinary management over authorities spending this yr, usurping congressional choices on how the nation’s cash is used. His push for extra layoffs throughout the federal government shutdown is just the newest blow, following months of firings, canceled grants, and withheld funds.
Russell Vought, Workplace of Administration and Finances director, on the White Home on Sept. 29.
Since most federal funds for public well being movement to states, Vought is rivaling the Division of Well being and Human Providers secretary, Robert F. Kennedy Jr., in his potential to upend government-led efforts to maintain People wholesome. In Texas, Facilities for Illness Management and Prevention funds to stem a measles outbreak weren’t out there till after the disaster had subsided and two kids had died. A undertaking to guard Alabamans from uncooked sewage and hookworm was deserted. Individuals with HIV have needed to delay medical care as clinics reduce hours. Time-dependent surveys on HIV and maternal mortality have been halted. Meals banks have canceled occasions. Tobacco prevention applications lapsed. Initiatives to guard older adults liable to falling have been harried.
It doesn’t matter what finances Congress finally passes for subsequent yr, the Trump administration could proceed to thwart monetary assist for such applications in methods that may hurt folks’s well being. “The White House has shown that they are willing to unilaterally exert control over funding,” mentioned Gillian Metzger, a constitutional legislation professor at Columbia College.
“This is a huge deal,” she added, “because the power of the purse is central to Congress’ ability to shape and direct policy.”
Earlier than he was appointed to guide the White Home’s Workplace of Administration and Finances this yr, Vought outlined budgetary methods the chief department might deploy to wrest energy from Congress and federal companies in Venture 2025, the Heritage Basis’s conservative blueprint.
Vought’s ways unfolded this yr, typically under the radar. They embody abrupt grant cancellations, extraordinary constraints on how funds will be spent, and extreme layers of assessment, company officers say, at each step within the grantmaking course of. Getting cash out the door has been additional sophisticated by layoffs which have gutted places of work overseeing grants on continual illness prevention, HIV, maternal mortality, and extra.
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Authorities workers have described these ways to members of Congress, mentioned Abigail Tighe, govt director of the Nationwide Public Well being Coalition, a gaggle that features present and former staffers on the CDC and HHS. “We want Congress to act, because this is preventing states and communities from doing critical public health work to keep our country safe,” she mentioned. “If they don’t have capacity, we all collectively suffer.”
Democrats on the Home and Senate appropriations committees have pushed for transparency, however the extent to which cash Congress appropriated for public well being in 2024 and 2025 has gone unspent due to the administration’s disruptions will not be but identified. “This is a sophisticated strategy to cause money to lapse and then say, ‘If they can’t spend it, they don’t need it,’” mentioned Robert Gordon, a public coverage specialist at Georgetown College and a former assistant finance secretary at HHS.
“No one thought this was possible or legal, but that is what’s happening,” he mentioned.
Particulars on how the administration has subverted well being spending have acquired little consideration as a result of many adjustments have been made quietly — and individuals who depend on federal funds concern retribution. The Trump administration has defunded and threatened federal places of work that maintain the federal government accountable and fired whistleblowers. It has abruptly revoked funds for native governments and organizations.
“Thankfully, President Trump won,” he mentioned. “And we have now been embarked on deconstructing this administrative state.”
Many Components, Many Malfunctions
Like a automobile, the federal finances course of has many parts that may break down. By the OMB and its companion, Trump’s Division of Authorities Effectivity, or DOGE, the administration has intervened at varied junctures. “There are so many ways in which money is not operating in the way it is supposed to operate,” mentioned Bobby Kogan, the senior director of federal finances coverage on the Heart for American Progress, a left-leaning assume tank, and a former OMB adviser.
The Trump administration delayed requires functions for 2025 funding, leaving many nonprofits and native governments with solely a few weeks to place collectively detailed functions for multimillion-dollar grants.
Usually, Congress passes a finances that appropriates cash for the following fiscal yr to federal companies. For a lot of public well being applications, starting from housing help to most cancers screening, companies then publish open calls on-line for states, native governments, and organizations to use for funding. Company specialists choose winners and ship notices of awards — or notices of ongoing funding to teams that beforehand received multiyear awards.
Subsequent, the OMB, which administers the federal finances, prompts cash for companies, like a financial institution prompts a bank card, in order that grantees can spend and get reimbursed quickly. Auditors regulate spending, however the authorities has up to now restricted interruptions in order that applications run easily.
Early on, the Trump administration canceled billions of {dollars} in awards granted in 2024 and early 2025 for analysis and international well being. In March, it clawed again $11.4 billion in covid-era funds that Congress had earmarked for well being departments that have been utilizing the cash for illness surveillance, vaccinations, and extra.
Though some funds have been restored due to lawsuits, the Supreme Court docket has allowed different cuts by the administration to face whereas the circumstances transfer by way of the courts.
Past these “shotgun” cancellations, the administration has taken a quieter, “in-the-weeds, slowing, cutting, conditioning” strategy that’s frozen funds for public well being, mentioned Matthew Lawrence, a legislation professor specializing in well being coverage at Emory College.
By August, the CDC’s heart for HIV and tuberculosis prevention had doled out $167 million lower than the historic common, based on an evaluation by the Heart on Finances and Coverage Priorities, a assume tank centered on decreasing inequality. The CDC’s funding for continual illness prevention lagged by $259 million, the Ryan White HIV/AIDS Program had underspent by $105 million, and funds for psychological well being on the Substance Abuse and Psychological Well being Providers Administration have been greater than $860 million behind what was anticipated.
An unknown quantity of Congress’ 2025 funding for analysis and public well being has but to be awarded and can most likely lapse this yr, mentioned Joe Carlile, an creator of the middle’s evaluation and an affiliate OMB director through the Biden administration. The obstructions look like concentrated in areas the place the White Home proposed reducing the federal finances subsequent yr. “The administration may be executing their 2026 budget request through administrative controls,” Carlile mentioned.
“This is boring but crazy-high stakes,” he added. “A one-branch veto of spending neuters the power of the purse in the Constitution that Madison said was the fundamental check on the executive branch.”
Incremental Chaos
A key tactic Vought described in Venture 2025 happens when the OMB prompts funds for companies in installments, referred to as apportionments. Vought wrote that “apportioned funding” might “ensure consistency with the President’s agenda.”
Below Vought, the OMB shrank the dimensions of apportionments, HHS and CDC staffers mentioned. It’s unlawful for companies to let grantees withdraw cash earlier than the overall quantity is within the metaphorical financial institution, in order that delayed companies’ potential to greenlight spending.
The OMB and DOGE additionally positioned situations on apportionments by way of memos, footnotes, and spoken directives telling companies to make sure that spending “aligns with Administration priorities,” based on reviews and HHS workers who mentioned that notices of funding alternatives and awards required extreme layers of sign-off. The CDC and different companies circulated lists of priorities that replicate White Home stances, together with these concentrating on range, fairness, and inclusion efforts; immigration; and transgender rights. Public well being efforts have been particularly caught up in crimson tape, since many concentrate on populations bearing an unequal burden of loss of life, illness, and harm.
When federal funds have been delayed, Tamachia Davenport, program director on the St. John AIDS outreach ministry in New Orleans, needed to determine between reducing workers or forgoing provides that stop the unfold of HIV and different sexually transmitted infections.
Teams that depend on federal funds have largely been unaware of the explanations grants have been held up, however they’ve fielded what they considered as unsettling queries. For instance, Kathy Garner, the pinnacle of a Mississippi nonprofit, mentioned officers requested her to defend the exclusion of males from a program to shelter ladies who skilled home violence.
Delays have been made worse by uncertainty. Grantees mentioned they’ve been unable to succeed in program officers as a result of tens of 1000’s of federal employees have been laid off. Company officers mentioned firings gradual funding additional.
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Lauren Richey, medical director at College Medical Heart’s HIV clinic in New Orleans, backed out of hiring a sorely wanted dentist she had recruited. “I was afraid to tell someone to move across the country for a job when I wasn’t sure if or when we’d get the funding for their salary,” she mentioned. “The wait is now three to four months for dental services, when it was usually a couple of weeks at most.”
Tamachia Davenport, program director on the St. John AIDS outreach ministry in New Orleans, mentioned that “a lot of us are having to rob Peter to pay Paul.”
When the group didn’t get CDC funds it anticipated this summer time, Davenport needed to determine between reducing workers or provides. Involved her prime workers would take jobs elsewhere, she stopped shopping for the condoms they distribute all through town to stop the unfold of sexually transmitted infections.
Louisiana already has one of many highest charges of HIV, chlamydia, and gonorrhea within the nation. Condoms price far lower than treating these ailments. For an individual contaminated by HIV at age 35, such prices exceed $326,000.
Teams centered on most cancers, diabetes, and coronary heart illness additionally report lasting repercussions from delays, in addition to ongoing fears that they are going to occur once more. Louisiana State College’s Wholesome Growing old Analysis Heart canceled a few of its workshops to coach well being employees on caring for folks with dementia. “There may be fewer people who have this very specific expertise next year in Louisiana and Mississippi,” mentioned Scott Wilks, the director of the middle. “That’s on top of the big shortage we have already.”
Nationwide surveys tallying maternal and toddler mortality froze for about 5 months due to funding delays, inflicting an irrecoverable hole in knowledge that had been collected constantly since 1987, CDC officers say.
“We are seeing the administration get their way with or without an approved budget,” one mentioned. “It’s such a terrible shame to play with people’s health this way.”
DOGE posted on its web site expense reviews overlaying a few month’s span from April to Might. Almost 230 of the person bills filed to federal companies throughout that interval are for $1 or much less. Different entries break down month-to-month salaries for particular person workers and petty prices for postage or month-to-month subscriptions.
“Public funds deserve scrutiny, but this is different from audit practices I’ve been a part of,” Carlile mentioned.
DOGE additionally stalled requires functions for 2025 funding — and a few calls by no means appeared because the fiscal yr got here to a detailed on Sept. 30. Amongst them are applications for teams that present housing help. Individuals will probably be evicted when these organizations run out of cash left over from 2024, mentioned Steve Berg, chief coverage officer on the Nationwide Alliance to Finish Homelessness.
Different solicitations got here out months not on time, leaving teams with a couple of weeks to place collectively sophisticated functions for multimillion-dollar awards, together with for Alzheimer’s care, dependancy restoration, senior assist, and continual illness administration.
“They’ve set projects up to fail,” one HHS official mentioned.
