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This is a KFF Health News story. When President Donald Trump posted a satirical music video on social media in early October depicting his budget director, Russell Vought, as the Grim Reaper lording over Democrats in Congress, public health workers recognized a kernel of truth. Vought has exerted extraordinary control over government spending this year, usurping congressional decisions on how the nation's money is used. His push for more layoffs during the government shutdown is only the latest blow, following months of firings, canceled grants and withheld funds. By cutting and freezing public health funds, in particular, the Trump administration has already begun to undercut efforts to provide medical care, outbreak response, housing assistance and research across the U.S., according to health officials, nonprofit directors and federal agency staffers interviewed by KFF Health News. Since most federal funds for public health flow to states, Vought is rivaling the Department of Health and Human Services secretary, Robert F. Kennedy Jr., in his ability to upend government-led efforts to keep Americans healthy. In Texas, Centers for Disease Control and Prevention funds to stem a measles outbreak weren't available until after the crisis had subsided and two children had died. A project to protect Alabamans from raw sewage and hookworm was abandoned. People with HIV have had to delay medical care as clinics scale back hours. Time-dependent surveys on HIV and maternal mortality were halted. Food banks have canceled events. Tobacco prevention programs lapsed. Initiatives to protect older adults at risk of falling have been harried. No matter what budget Congress ultimately passes for next year, the Trump administration may continue to thwart financial support for such programs in ways that will harm people's health. "The White House has shown that they are willing to unilaterally exert control over funding," said Gillian Metzger, a constitutional law professor at Columbia University. "This is a huge deal," she added, "because the power of the purse is central to Congress' ability to shape and direct policy." Before he was appointed to lead the White House's Office of Management and Budget this year, Vought outlined budgetary strategies the executive branch could deploy to wrest power from Congress and federal agencies in Project 2025, the Heritage Foundation's conservative blueprint. Vought's tactics unfolded this year, often below the radar. They include abrupt grant cancellations, extraordinary constraints on how funds can be spent and excessive layers of review, agency officials say, at every step in the grantmaking process. Getting money out the door has been further complicated by layoffs that have gutted offices overseeing grants on chronic disease prevention, HIV, maternal mortality and more. Government employees have described these tactics to members of Congress, said Abigail Tighe, executive director of the National Public Health Coalition, a group that includes current and former staffers at 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 said. "If they don't have capacity, we all collectively suffer." Democrats on the House Appropriations Committee have pushed for transparency, but the extent to which money Congress appropriated for public health in 2024 and 2025 has gone unspent because of the administration's disruptions is not yet known. "This is a sophisticated strategy to cause money to lapse and then say, 'If they can't spend it, they don't need it,'" said Robert Gordon, a public policy specialist at Georgetown University and a former assistant finance secretary at HHS. "No one thought this was possible or legal, but that is what's happening," he said. Details on how the administration has subverted health spending have received little attention because many changes have been made quietly -- and people who rely on federal funds fear retribution. The Trump administration has defunded and threatened federal offices that hold the government accountable and fired whistleblowers. It has abruptly revoked funds for local governments and organizations. Vought and spokespeople at the White House and the OMB did not respond to queries from KFF Health News. However, Vought described his intentions in a Sept. 3 speech. He said that federal agencies and Congress had gained more power over spending since the 1970s and that their control became "woke and weaponized" under Presidents Barack Obama and Joe Biden. "Thankfully, President Trump won," he said. "And we have now been embarked on deconstructing this administrative state." Many parts, many malfunctions Like a car, the federal budget process has many components that can break down. Through the OMB and its partner, Trump's Department of Government Efficiency, or DOGE, the administration has intervened at various junctures. "There are so many ways in which money is not operating in the way it is supposed to operate," said Bobby Kogan, the senior director of federal budget policy at the Center for American Progress, a left-leaning think tank, and a former OMB adviser. Typically, Congress passes a budget that appropriates money for the next fiscal year to federal agencies. For many public health programs, ranging from housing assistance to cancer screening, agencies then post open calls online for states, local governments, and organizations to apply for funding. Agency experts select winners and send notices of awards -- or notices of ongoing funding to groups that previously won multiyear awards. Next, the OMB, which administers the federal budget, activates money for agencies, like a bank activates a credit card, so that grantees can spend and get reimbursed rapidly. Auditors keep an eye on spending, but the government has in the past limited interruptions so that programs run smoothly. Early on, the Trump administration canceled billions of dollars in awards granted in 2024 and early 2025 for research and global health. In March, it clawed back $11.4 billion in COVID-era funds that Congress had earmarked for health departments that were using the money for disease surveillance, vaccinations and more. Although some funds have been restored because of lawsuits, the Supreme Court has allowed other cuts by the administration to stand while the cases move through the courts. Beyond these "shotgun" cancellations, the administration has taken a quieter, "in-the-weeds, slowing, cutting, conditioning" approach that's frozen funds for public health, said Matthew Lawrence, a law professor specializing in health policy at Emory University. By August, the CDC's center for HIV and tuberculosis prevention had doled out $167 million less than the historical average, according to an analysis by the Center on Budget and Policy Priorities, a think tank focused on reducing inequality. The CDC's funding for chronic disease prevention lagged by $259 million, the Ryan White HIV/AIDS Program had underspent by $105 million, and funds for mental health at the Substance Abuse and Mental Health Services Administration were more than $860 million behind what was expected. An unknown amount of Congress' 2025 funding for research and public health has yet to be awarded and will probably lapse this year, said Joe Carlile, an author of the center's analysis and an associate OMB director during the Biden administration. The obstructions appear to be concentrated in areas where the White House proposed cutting the federal budget next year. "The administration may be executing their 2026 budget request through administrative controls," Carlile said. "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 Project 2025 occurs when the OMB activates funds for agencies in installments, called apportionments. Vought wrote that "apportioned funding" could "ensure consistency with the President's agenda." Under Vought, the OMB shrank the size of apportionments, HHS and CDC staffers said. It's illegal for agencies to let grantees withdraw money before the total amount is in the metaphorical bank, so that delayed agencies' ability to greenlight spending. The OMB and DOGE also placed conditions on apportionments through memos, footnotes and spoken directives telling agencies to ensure that spending "aligns with Administration priorities," according to reports and HHS employees who said that notices of funding opportunities and awards required excessive layers of sign-off. The CDC and other agencies circulated lists of priorities that reflect White House stances, including those targeting diversity, equity and inclusion efforts; immigration; and transgender rights. Public health efforts have been especially caught up in red tape, since many focus on populations bearing an unequal burden of death, disease and injury. Groups that rely on federal funds have largely been unaware of the reasons grants were held up, but they've fielded what they viewed as unsettling queries. For example, Kathy Garner, the head of a Mississippi nonprofit, said officials asked her to defend the exclusion of men from a program to shelter women who experienced domestic violence. Delays were made worse by uncertainty. Grantees said they've been unable to reach program officers, because tens of thousands of federal workers have been laid off. Agency officials said firings slow funding further. "Everyone's inbox is full of letters from grant recipients asking, 'How do we proceed?'" one high-ranking CDC official told KFF Health News, which granted agency officials anonymity because of their fears of retaliation. "We just say, 'Please wait.'" Time was critical as a measles outbreak surged in West Texas early this year. The state asked for federal funding for the response in March, but it didn't arrive until May, after the outbreak had largely faded in Texas, according to an investigation by KFF Health News. Apportionment control was a key reason, CDC staffers said. In July, 81 HIV organizations sent a letter to Kennedy. "With every day of delayed FY2025 funding release, the delivery of essential HIV services is compromised," said the letter, which was reviewed by KFF Health News. Because of delays and uncertainty, it said, HIV clinics had laid off case managers and reduced clinician hours, closed sites, and pared down hotlines that patients call with urgent questions. The funds arrived about a month later, but HIV providers remain shaken. Lauren Richey, medical director at University Medical Center's HIV clinic in New Orleans, backed out of hiring a sorely needed 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 said. "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 at the St. John AIDS outreach ministry in New Orleans, said that "a lot of us are having to rob Peter to pay Paul." When the group didn't get CDC funds it expected this summer, Davenport had to decide between cutting staff or supplies. Concerned her top employees would take jobs elsewhere, she stopped buying the condoms they distribute throughout the city to prevent the spread of sexually transmitted infections. Louisiana already has one of the highest rates of HIV, chlamydia and gonorrhea in the country. Condoms cost far less than treating these diseases. For a person infected by HIV at age 35, such costs exceed $326,000. Groups focused on cancer, diabetes and heart disease also report lasting repercussions from delays, as well as ongoing fears that they will happen again. Louisiana State University's Healthy Aging Research Center canceled some of its workshops to train health workers on caring for people with dementia. "There may be fewer people who have this very specific expertise next year in Louisiana and Mississippi," said Scott Wilks, the director of the center. "That's on top of the big shortage we have already." Nationwide surveys tallying maternal and infant mortality froze for about five months because of funding delays, causing an irrecoverable gap in data that had been collected continuously since 1987, CDC officials say. "We are seeing the administration get their way with or without an approved budget," one said. "It's such a terrible shame to play with people's health this way." DOGE also inserted itself into grant reimbursements this year, stalling the rapid turnaround that public health groups typically expect to cover salaries, rent, and other monthly costs outlined in budgets that have already been approved. In what's now labeled Departmental Efficiency Review, itemized expenses must be regularly justified by multiple government officials, according to documents reviewed by KFF Health News. DOGE posted on its website expense reports covering about a month's span from April to May. Nearly 230 of the individual expenses filed to federal agencies during that period are for $1 or less. Other entries break down monthly salaries for individual employees and petty costs for postage or monthly subscriptions. "Public funds deserve scrutiny, but this is different from audit practices I've been a part of," Carlile said. DOGE also stalled calls for applications for 2025 funding -- and some calls never appeared as the fiscal year came to a close on Sept. 30. Among them are programs for groups that provide housing assistance. People will be evicted when these organizations run out of money left over from 2024, said Steve Berg, chief policy officer at the National Alliance to End Homelessness. Other solicitations came out months behind schedule, leaving groups with a few weeks to put together complicated applications for multimillion-dollar awards , including for Alzheimer's care, addiction recovery, senior support and chronic disease management. "They've set projects up to fail," one HHS official said.
