What that leaked HHS reorganization document actually is—and what to expect next.
What's a "passback," and how likely are these changes to occur? A former Acting Director of the CDC and other experts offer insights.
On Wednesday, Inside Medicine published a leaked draft of the Trump administration’s plans to majorly overhaul and deeply cut funding to HHS, beating out all the major news agencies (thanks to Inside Medicine readers). The plans, as reported by The Washington Post, include a $40 billion decrease in funding for HHS programs. If implemented, the proposal would eliminate many key and long-established components of the public health infrastructure that protect the American people from everything from pandemics to cancer.
Today’s piece zooms out a bit.
It provides a brief overview of what’s on the chopping block, and links to a few other more detailed analyses of this. But I think the value-add of today’s newsletter goes in a different direction than other coverage of this proposal by providing…
A primer on the US federal government’s funding cycle. Where does this leaked document fit in, and why does that concern me so much?
On-the-record analysis from an Inside Medicine interview with Dr. Anne Schuchat, a two-time former Acting Director of the CDC, with some additional comments from other experts, including a budget whiz, who needed to remain anonymous in order to provide the best analysis possible.
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An overview of targeted public health and safety programs.
What is included in the proposed cuts outlined in the leaked plan to slash and reorganize HHS? Here’s a rundown of some of the big-ticket items from Kristina Fiore at MedPage Today:
The NIH would go from a $47 billion-per-year agency down to $27 billion.
The CDC would go from a $9.2 billion-per-year agency down to $5.2 billion.
A new agency called the Administration for a Healthy America would receive $20 billion.
Another overview of the proposed cuts was posted on LinkedIn by Dr. Céline Gounder. Highlights include:
🔹Maternal and child health.
Newborn screening.
Childhood lead poisoning.
Head Start.
Maternal mortality.
🔹Chronic disease prevention.
Smoking cessation
🔹Environmental health.
🔹Public health surveillance.
🔹Primary care.
🔹Rural health.
🔹Mental health & addiction.
🔹HIV prevention & treatment services.
🔹Indian Health Service.
🔹Health disparities.
We’ll get more into the weeds on some of this soon, but for now, I want to keep it high-level so that we can delve into the wider context.
What’s a “passback”? Is this the legal version of the last three months?
What’s different about this news cycle is that the mechanics of these proposed sweeping cuts to our public health system are actually more-or-less conventional. That is, up until now, most of the administration’s often draconian actions against our public health assets have been through unilateral executive orders, which have been either highly unusual uses of that power, unlawful, or both. So, what I take from this—and what I think a lot of media coverage has glossed over, so far—is that what this proposal represents is a legal attempt to achieve what the Trump administration has been trying to do by testing the limits of its authority since January 20. That’s deeply troubling, because if this goes through, any resulting damage will be long-lasting, and approved by Congress.
A federal budget primer.
On Friday, I had the chance to review the steps of the US government’s budget and appropriations cycle with a highly knowledgeable former HHS budget official. I learned that the leaked document, known as a “passback,” is a routine part of the US federal government’s fiscal cycle.
The upshot is that each year, federal agencies submit a pie-in-the-sky funding wishlist to the Oval Office. The President (by way of the Office of Management and Budget, OMB) then creates what the administration believes to be a more “realistic” proposal, which is sent back to the agencies. This is the “OMB passback,” which is the document leaked this week. (Technically, what we saw was a draft. The final version could be different.) From there, the agencies have one more chance to lobby for changes before the final proposal is sent to Congress.
Once the OMB sends the final “President’s Budget” to Congress, both the House and the Senate have to make their own bills from scratch. While the President’s Budget is basically a guideline (rather than a binding legal document of any kind) the implication is that the President might veto anything that strays too far from the proposal. Obviously a lot of negotiations happen at that stage.
If agreements can’t be reached, then Congress can decide to just use last year’s bills for some period—and that’s a “continuing resolution”—which buys time to negotiate. For the current fiscal year (October 2024 through September 2025), the decision was made to just have the entire year repeat whatever was in last year’s cycle.
The former HHS budget official I spoke to said that the current House was likely to accept most of what the draft passback proposes. But he felt that the Senate would almost certainly not go for it—in part because many HHS projects on the chopping block have broad support on both sides of the aisle. (That and the fact that appropriations bills need 60 votes, and for that to happen, a number of Democrats would have to agree, which ain’t happening.) So, this means that a continuing resolution might be the only way to keep the government open this fall.
Does that mean that the President’s proposal as seen in the leaked document is dead in the water? No, and for two reasons. First, apparently the rules of continuing resolutions make some of what the President wants to do easier, for the time being, at least. (I’m not entirely certain why or how, but several experts I spoke to agreed with that take, and I’ll try to get more follow-up on that.) Second, the Trump administration has already tried to contradict Congress by failing to spend money that the government by literal Congressional law is obligated to spend. Turns out that there are ways the administration could legally “hide” the money instead of spending it in the short-term, but I’ll also leave this for another time.
Long story short, under normal circumstances, a lot of this proposal would be expected to die in the Senate—even with this Senate! But the Trump administration’s bizarre view of its own power over spending may mean that we could see a return to its earlier tactics and attempts to circumvent the usual processes by ignoring the law and seeing if anyone will bother to try and stop them. The overall showdown—that is, whether Congress has much of a job at all—may all end up in a massive Supreme Court case that would adjudicate who really has the power to spend taxpayer dollars.
Former top CDC official Dr. Anne Schuchat and others weigh in.
To get a sense of how this OMB passback compares to previous ones, I spoke to Dr. Anne Schuchat, a former Principal Deputy Director of the CDC who twice served as Acting Director of the agency during the first Trump administration.
On whether this draft passback will become reality:
“The most important factor is Congress, because the final outcome depends on what Congress passes—not on what the Office of Management and Budget (OMB) includes in the proposed budget. There is usually a difference between the OMB’s proposed budget and the final budget enacted by Congress. The key question is whether Congress will defend the programs and priorities it previously supported."
On how extreme this particular passback is:
“A lot of proposals are made each year, but they are typically not as drastic as this. Organizational changes are not unusual, but this situation is unusually chaotic and costly.”
On unusual details in this passback:
“Reorganizations usually require detailed justifications.” For example, the passback proposes eliminating an existing chronic disease program but would create a new one in its place. “Normally, changes require time, justification, and stakeholder buy-in if you are following the standard rules. What’s happening now appears to be unprecedented, both in terms of its speed and disregard for those norms.”
Other experts chime in…
Another former CDC official told me that these drafts can change quickly, and that much could change at this stage, even before it is officially sent around to the agency stakeholders. The former HHS budget official I spoke to agreed, pointing out that some of the massive changes proposed in the passback would likely be unpopular among key members of Congress, including among some Republican senators who have, for example, long supported the Administration for Strategic Preparedness and Response (ASPR), the first program on the alphabetical list of programs slated for elimination in the leaked document.
Another source, a current CDC employee, said that the process leading to the leaked OMB passback document was more typical of “business as usual” for funding cycles in at least one way. Unlike the sudden DOGE cuts (including deep and sudden cuts in personnel, programs, grants, and more) during the Trump administration—which were done with zero input and without specifics prior to their announcements—this OMB passback reflects at least some input and feedback from agencies like the CDC. So, the agencies did make their usual appeals, like they would in any year. Moreover, the draft is not finalized. “There could be some shifts,” the source told Inside Medicine, “but I would guess it isn’t going to be major shifts, at least to top lines.”
That means that the big-ticket item—the $40 billion in cuts to HHS—is unlikely to vanish. My interpretation of that is that the pain is almost certainly coming, but the details of how and where are still in play. For example, it’s likely that further reductions in force (RIF) are coming, only this time clearly legal ones, rubber-stamped by Congress.
The implication, the source said is that “once this thing is all set in June, agencies [would need to] enact plans to get workforce in line with policy priorities…which I read as RIFs.” Losing more HHS employees sounds like a bad idea to me, not to mention an unrealistic way to make a meaningful dent in our annual budget deficit.
Bottom line.
Above all, the experts and stakeholders all said that unlike the administration’s previous actions attacking US public health and biomedical infrastructure, the annual funding process by which decisions on US government spending are made is playing out in accordance with the usual order of operations (albeit, much later than usual). That is, this is—and this alarms me—the legit version of what DOGE has been trying to do by testing the limits of our system to enforce the separation of powers as directed by the US Constitution. That said, nobody I spoke to could remember an OMB passback that had cuts and changes of this magnitude. If implemented, our nation’s public health and emergency preparedness systems would likely be dramatically reduced by this plan.
I’ll delve more into some of the specifics of what that could like this week. For now, what do you think? Do you questions for my HHS sources? Join the conversation in the Comments section.
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Thanks for explaining this pretty painlessly. New sausage making vocabulary, made tolerable.
Superb!! Not the cuts but the reporting & clear explanation! Understanding this is critical to planning resistance.