When federal health officials announced late last month what top officials called a “dramatic restructuring” of the U.S. Department of Health and Human Services, Robert F. Kennedy Jr., the department’s secretary, claimed: “Over time, bureaucracies like HHS become wasteful and inefficient even when most of their staff are dedicated and competent civil servants. This overhaul will be a win-win for taxpayers and for those that HHS serves.”
Many within the federal health agency, including division leadership, are waiting to hear Kennedy’s plan for the restructuring beyond initial reports that some DHHS offices will be combined in a new “Administration for a Healthy America.”
In North Carolina, the results are being felt in several ways. First, the federal government clawed back some $11 billion nationwide allocated to states for long-term responses to the COVID-19 pandemic. Officials at the state Department of Health and Human Services said this would result in the loss of 80 jobs and $230 million in federal funding for North Carolina. All of this on top of hundreds of millions in cuts to the state DHHS and university research in the state.
Then came last week’s personnel cuts at federal health agencies. Now North Carolina-based health officials, researchers, nonprofits, advocates for the aging, domestic violence victims, substance users and more are struggling with uncertainty about the slashing of workforces, blockages to counted-on funding streams and the delivery of care to some of the state’s most vulnerable.
“There have not been clear descriptions of what any of this consolidation would look like,” said a federal health employee from North Carolina working in Washington who wishes to stay anonymous. Many federal employees and grant recipients have been reluctant to speak out for fear of reprisal against themselves or their employers.
“In fact, without very well thought through plans for that, the only impact is going to be increased fraud, waste and abuse, because you can’t just throw everything into one pot with four people overseeing it and hope everything goes well,” they said.
The federal employee said their department staff was cut significantly, and co-workers were having conversations among themselves about which funding streams they will need to revert to Congress because they don’t have enough hands to administer the funds properly.
Cutting federal workers is penny wise and pound foolish, the federal health employee told NC Health News. Many federal DHHS workers are at the height of their careers and have expertise in certain subject matters while accepting less pay than what they could receive in the private sector.
And as the DHHS cuts take shape, advocates, federal employees and state officials in North Carolina are scrambling to understand the changes and make the necessary adjustments to their workflows and service delivery.
No one to answer the phone
“I feel like we lost so many good people … like the average of between 15-20 years of experience that were all let go,” said a North Carolina-based employee with the Centers for Disease Control and Prevention. NC Health News also granted them anonymity for fear of job loss.
Sara Howe, CEO of Addiction Professionals of North Carolina, was walking the halls of Capitol Hill last week to educate elected officials from North Carolina on the importance of a federal funding stream known as the Substance Use Prevention and Treatment Block Grant. While Medicaid will cover certain aspects of addiction treatment, the block grant funding fills the gaps to pay for those services that help sustain someone in recovery long term.
Addiction Professionals of North Carolina Director of Public Policy Jarrett Patrick and CEO Sara Howe went to Capitol Hill to advocate for continued funding of the Substance Use Prevention and Treatment Block Grant during a time of great uncertainty as federal health funds have been cut and federal health and human services employees have been fired. Beyond potential funding cuts to Medicaid or the block grant, Howe said she’s also concerned that in an attempt to increase efficiency, the federal health department will lose those who understand the needs of people with substance use. She also worried that with the changes, money initially designated for alleviating substance use could end up being spent elsewhere.
“If we homogenize this to one public health prevention model, you lose institutional knowledge and expertise,” Howe said. “My fear is there won’t be a focus on substance use.”
As Howe and her colleagues were meeting with staff on Capitol Hill last week, some of her fears were being realized across town where the staff at the Substance Abuse and Mental Health Services Administration, where staff was cut by one-third. It was already one of the smaller divisions within the federal DHHS.
As staff dwindles, Howe said, logistical concerns arise about federal grant renewals arriving on time, confusion about who will handle contracts and how money will get to the states, among other things.
If grant seekers have an issue, she wondered, would there even be someone at the federal DHHS offices to answer the phone? “When you take a hatchet so fast, you’re going to hit the main arteries and then you can’t bring it back,” Howe said.
Many of the federal grants go to nonprofit organizations or smaller county agencies that are the boots on the ground, she said. If checks are delayed or funding is cut, that will have real-world consequences in North Carolina.
Disruptions begin
In March, the state DHHS had to wrestle with the impact of a federal delay in the payment of $250 million in Medicaid funds. According to state officials, that delay postponed payments to local providers and organizations.
The loss of staff at the federal level can be disruptive to workflows and communication, said Kathleen Lockwood, policy director for the North Carolina Coalition Against Domestic Violence. The coalition is 90 percent federally funded — coming from a complex array of sources, including the CDC and the U.S. Department of Justice.
“We are concerned that even though the funds have been appropriated and our contracts are very much in place,” Lockwood said. “If there are no staff members to actually administer those funds, it will functionally turn into us not being able to receive them under our existing contracts.”
Carianne Fisher, the coalition’s executive director, explained that the organization is in year three of a five-year grant for domestic violence prevention through the CDC. Every year, an annual progress report is due that leads to a continuation application for the next year’s funding. Their year four budget is due in November, she said, but she’s now uncertain who will be reviewing it, as many of the staff they’ve worked with for years — and who were familiar with their work — have had their jobs eliminated.
“You build a relationship with your grant officer, and they know what the work looks like, so that when they review, they can ask questions based on the work that you’re doing … they know the big picture,” Fisher said. “New staff always have a learning curve, and this is particularly complicated work that folks are doing to prevent domestic violence.”
She worried it will be even more difficult for new people to step into the work when they are juggling new responsibilities taken on because of the downsizing.
Program cuts will affect services
Other advocates are concerned that without federal funding or oversight, agreements with the federal government will not move forward.
The Administration for Community Living, which oversees programs intended to help older adults and people with disabilities live independently, was dissolved into other offices of DHHS on March 27. If the administration’s services suffer, older adults and people with disabilities could be forced into institutions, according to a statement from Justice in Aging, a legal advocacy organization focused on fighting senior poverty.
Money for home-delivered meals, in-home aide services, transportation assistance, housing and home improvements that allow people to remain in their communities, long-term care ombudsmen and congregate nutrition sites all flowed through the Administration for Community Living, said Mary Bethel, chair of the board of directors for the North Carolina Coalition on Aging.
Now, the remaining federal workers — likely without expertise — will have to take on the administration’s responsibilities. Bethel said farming out the work is troubling, as other agencies already have a huge burden and won’t have the focus or knowledge needed to run them as smoothly.
While no cuts to funding for those services have been announced yet, Bethel said she’s concerned that essential services will get lost in the mix. And even if the funding isn’t cut, the situation is daunting, she said. North Carolina’s demographer estimated last year that from 2021 to 2041, the state’s 65-and-older population is expected to grow from 1.8 million people to 2.7 million.
“With our older adult population increasing at such a fast rate, even if funding stays the same as it is today, then we’re still taking a cut,” Bethel said.
At the local level, Bethel said she’s heard concerns from some counties about continuing to provide services amid uncertainty of whether they’ll be reimbursed by the federal government.
“I’ve been in this business 50 years, and I have never seen people as anxious and stressed as they are now,” Bethel said.
Looming uncertainty
Uncertainty about what cuts could be coming next has put organizations on edge, in particular for those that rely primarily on federal funds. Part of the challenge is that the information that once flowed from trusted federal DHHS staff has been turned off.
The situation makes long-term planning impossible, such as for the 93 local domestic violence service providers across the state, said Lockwood from the NC Coalition Against Domestic Violence.
“All we can tell them is there is a disruption going on that we foresee could impact our access to federal funding,” she said. “We are all hands on deck asking for congressional action and asking for our state legislature to recognize the trouble to come.”
For domestic violence shelters in particular, the threat of DHHS funding cuts comes at a time where one source of federal funds — the federal Victims of Crime Act — has been decreasing over the past several years, already constraining capacity.
Lockwood’s organization surveyed all of the 93 domestic violence programs in the state to understand the stakes of potential federal cuts. Of the 43 programs that answered by early March, most reported they could only operate for an average of 60 days without federal funding.
“Their budgets are so razor-thin already that by the time they start to see or have actual funding impacts, we are already going to be looking at the potential of programs closing,” Lockwood said. “It will be too late at that point to reverse course without irreparable damage to at least a lapse in availability of services in communities across the state.”
For example, Lockwood said federal funding provides the foundation for domestic violence service providers to be able to offer 24/7 hotlines and emergency shelter for people fleeing an abusive partner, among other services.
Additionally, if the coalition lost all its federal funding, coalition executive director Fisher said she would have to reduce her staff from 19 full-time employees to just two.
She also said that many program leaders are turning to foundations and other private funders for support.
“It’s more competitive to receive funding from other funding sources because everyone’s scrambling,” Fisher said. “It feels like we’re in competition with our partners to provide services across the state. None of us want to do that. We know that everyone needs a menu of services, and a lot of the survivors of domestic violence have also experienced child abuse or have experienced sexual assault, and all victims and survivors deserve the services they need.”
‘Feels like a slap in the face’
Adding to uncertainty is the status of lawsuits over the cuts to funds and staffing. Jeff Jackson, North Carolina’s attorney general, joined 22 other states and the District of Columbia in filing a lawsuit last week in federal court in Rhode Island over the $11 billion in cuts to funding to states. Additionally, a federal judge said she will temporarily block billions in federal health cuts.
“There are legal ways to improve how tax dollars are used, but this wasn’t one of them,” Jackson added. “Immediately halting critical health care programs across the state without legal authority isn’t just wrong — it puts lives at risk. That’s why we’re going to court.”
But the courts move slowly, and the back and forth has taken a toll on service providers and on the federal DHHS employees themselves.
The anonymous CDC worker who spoke to NC Health News described being terminated in mid-March with a late-night email saying her dismissal was due to poor performance, even as her latest performance review said she achieved outstanding results. A second notice came to her personal email days later, saying she had been reinstated and should report to work the following day. Her supervisor had not been made aware of either action before they took place.
So far, though, she said she’s been lucky, as last week, more than 20 percent of workers were cut from the CDC and she was not among them.
“It is insulting, and it feels kind of like a slap in the face to say that we’re not qualified,” she said. “Especially that email that said we need to leave the unproductive public sector to live the American Dream by working in the productive private sector. It just felt like such an insult.”
“We know we’re making less money here than we could be making somewhere else. But that’s not why we’re doing it. We’re doing it to help people and to help people live healthier and better lives.”
NC Health News spoke to other federal health employees who said they feel underappreciated, sad and scared as their DHHS colleagues have been haphazardly fired. They anxiously wonder if they are next.
“This has happened so fast and so furiously that we’ve all been trying to sort of wrap our minds around what the heck is happening,” said Jane, one of the federal health employees based in North Carolina.
“We really need to shine a light on what looks to me like a tinder keg with federal employees’ health and well-being,” she said. “We’ve already seen suicide attempts, completion of suicide and someone who’s in the hospital with heart attack … not to mention mental health impacts for workers and their families.
“We’ve seen people starting to, sort of, melt down in the workplace.”
This article first appeared on North Carolina Health News and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.
